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Based on observations, staff interview, and policy review, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel. The hospital Infection Control Officer failed to ensure the infection control practices were followed for three hand hygiene opportunities observed (Staff F and Staff T), to dispose expired food for one of one inpatient kitchenette cabinet and refrigerator, failed to keep stored product packaging securely closed, to separate patient food from staff food and failed to provide scheduled care and cleaning to the physical therapy hydrocullator (thermostatically controlled water bath for placing cloth heating pads) and paraffin bath (melted wax). This deficient practice has the potential to expose all patients and healthcare workers to infectious diseases and expose all patients to bacterial contamination and cross contamination resulting in foodborne illness.

Findings include:


- Medication pass observed on 5/2/2017 at 7:50 AM revealed Staff T leaving medication room and entering Patient # 3 room 101 without performing hand hygiene. Staff.T approached patient # 3's bedside and handed the medications to the patient.

LPN Staff T interviewed on 5/2/2017 at 8:00 AM acknowledged he did not performed hand hygiene prior to entering the patient's room.

- LPN Staff F observed at the nursing station on 5/3/2017 at 3:05 PM revealed Staff F handling a clipboard placed it on the counter and entered in Patient # 28's room 120 and walked directly to patient's bed to pull him up without performing hand hygiene.

LPN Staff F interviewed on 5/3/2017 at 4:00 PM acknowledged he entered the patient's room and stated he thought he did perform the hand hygiene. This surveyor was directly behind Staff F entering the patient's room walked to patient's bed and pulled him up, no hand hygiene performed.

- Inpatient kitchenette observed on 5/1/2017 at 3:00 PM revealed the following expired food in the cabinet above the coffee maker and refrigerator:

1) Triscuit Cracker box open 90 ounce with expiration date of 10/13/2015.
2) Xylitol Sweetener box with expiration date of 9/2016.
3) Grape jelly in a jar, one fourth full, with no name and what the item is and when it was opened.
4) Truvia Sweetener 1 box with expiration dates of 3/2017.
5) Hershey's Strawberry syrup 18.5 ounce with expiration date of 11/2016.

DON Staff A interviewed on 5/1/2017 at 3:30 PM acknowledged the food was expired in the inpatient kitchenette and should have been disposed. Staff A stated the cabinet with the expired food is staff food only. This surveyor explained the cabinet is not marked for staff food only.

- Kitchen pantry observed on 5/1/2017 at 2:00 pm revealed the following outdated food:
2-Gerber Mixed vegetables, outdated 4/2017.

1-2 ounce box Jell-O, outdated 4/2014
3-2 ounce box Jell-O, outdated 6/2016
2-2 ounce box Jell-O, outdated 7/2016
1-2 ounce box Jell-O, outdated 5/2016
1-4 ounce box Pudding mix, outdated 3/2015
1-4 ounce box Pudding mix, outdated 1/2017
1-4 ounce box Pudding mix, outdated 3/2017

Located in Freezer One:

1 open cardboard box of frozen fish fillets, inner plastic torn open and not resealed leaving the fish exposed
1 open cardboard box of beef patties, inner plastic torn open and not resealed leaving the patties exposed

Located in Refrigerator One:

1 container of employee food in the patient refrigerator

Dietary Manager Staff Q acknowledged all of the outdated food and removed it from the shelves, resealed the frozen food products, and disposed of the employee food in the refrigerator. S/he stated that the food products are to be checked for outdates monthly and food is to be rotated at the time the shelves are stocked. S/he acknowledged that no employee food should be in the same refrigerator as patient food. A separate refrigerator is available to employees in the cafeteria.

- Policy "Infection Control" directs "...Specific refrigerators are designated for employee food, in patient food refrigerators ...Nourishments are discarded when expired ..."

No policy was available for food rotation, disposal, or keeping open food products sealed.

The Kansas Food Handlers Code 3-202.15 Package Integrity directs "FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants."

- Policy titled "Hand washing/Hand Hygiene" reviewed on 5/2/2017 directed staff "...Decontaminate hands before having direct contact with patients ..."

- Observation on 5/3/2017 at 9:30 AM revealed the hydrocullator temperature log documentation monthly with all temperatures within required range. The log revealed the hydrocullator was last cleaned in September, 2016.

Interview with PTA Staff L stated the water is changed if it has a scum on the surface or visually appears dirty. S/he stated the hydrocullator is used "about every other day".

Policy "Interdepartmental Care of Equipment" directs "... the Hot Pack Unit (hydrocullator) should be cleaned once a month depending on usage ..."

- Observation on 5/3/2017 at 9:30 AM revealed the paraffin bath temperature log documentation monthly with all temperatures within the required range. The log revealed the lacked evidence of cleaning.

Interview with PTA Staff L stated s/he could not remember the last time the bath was used, but it is kept on all of the time so it would be ready in case it was needed. The paraffin bath is used by occupational therapy (OT), not physical therapy, but the physical therapy is really responsible for maintaining it since OT is only available on an as needed basis.

Policy "Interdepartmental Care of Equipment" directs "...Most paraffin baths should be sterilized once a month depending on usage and cleaned regularly to remove the moisture and sediment that collect at the bottom..."


Infection Control Officer Staff W interviewed on 5/2/2017 at 8:00 AM indicated they do identify, monitor and collect all the culture reports and Clostridium Difficile (bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) every month and the reports are given to Staff A for PI (Performance Improvement). Staff W had been doing surveillance on hand washing in each department except the OR (Operating Room) department. Staff W indicated the last handwashing compliance surveys that were done were August 2016. Staff W was not able to produce to the surveyor an Infection Control Plan that they follow.

CNO Staff A interviewed on 5/3/2017 at 2:10 PM indicated that Staff W has not been doing the handwashing compliance surveys for some time. Staff A has spoken to Staff W many times regarding this issue.

CEO Staff B stated they are sending Staff W to an infection control class next Saturday. Staff B stated they are definitely looking into the Infection Control program and do all that we need to do to improve the program.

Policy reviewed on 5/2/2017 revealed the CAH failed to have an Infection Control Plan.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure all supplies are maintained to safely meet patients' needs for the day-to-day operations for one of one Emergency Department (ED) crash carts, one of two ED patient rooms (#1), one of one surgical ante-rooms, one of one procedure rooms, one of one surgical anesthesia carts, for one of one CT scan room, and one of one inpatient Emergency Crash Cart. The deficient practice of failing to dispose of expired supplies by the facility places all patients at risk for receiving ineffective, unsafe supplies leading to harmful treatment.


Findings include:


- Emergency Department (ED) room observed on 5/2/2017 at 8:00 am revealed the following opened packages and outdated medical supplies:

1-22g., 1 ½" Pediatric Lumbar Puncture Tray (needle inserted into the spinal canal), outdated 4/30/2017

1-10 Fr Bard Silicone Foley (tube inserted into bladder), outdated 9/2016

2-36 Fr Thoracic catheters (tube inserted into the space around the lung to drain fluid), outdated 11/2016

2-28 Fr Thoracic Catheters, outdated 10/2016

1-32 Fr Thoracic Catheters, outdated 8/2016

1- Sterile Half Drape (sterile covering), outdated 2/2017

5-3 swab Betadine packs (antiseptic), outdated 2/2017

1-6.5 mm Nasopharyngeal airway (tube placed in the nose and airway), outdated 3/2015

1-6.5 mm nasopharyngeal airway, outdated 4/2016

1-8.0mm nasopharyngeal airway, outdated 12/2014

1-CO2 Detector (Carbon monoxide detector), outdated 12/2016

1-36 Fr Endotracheal Tube (tube inserted into the airway), outdated 3/2014

1-22 Fr Endotracheal Tube, outdated 1/2014

1-20 Fr Endotracheal Tube, outdated 9/2014

1-16 Fr Endotracheal Tube, outdated 12/2014

85-Amniocentesis Test Swabs (swab used to test for leaking of amnio fluid), outdated 5/2016

2-Size 6 ½ Sterile Gloves, outdated 4/2017

1-19g Gripper Plus Port Needle (needle inserted into IV ports), outdated 4/2017

1-Ear Wick, outdated 10/2016

3-23g Butterfly blood collection needles, outdated 7/2016


Located in Crash Cart:

2-Intubating Stylets (guide used in the insertion of endotracheal tubes), outdated 10/2016

2-Lab collection tubes, outdated 4/2017


Located in ENT Box:

1-Skin Affix (Topical skin adhesive), outdated 12/2016

1-5.5cm Rapid Rhino (used in the treatment of nose bleeds), outdated 2/2016


Located in Pediatric Box:

4-Intubating Stylets, outdated 10/2016


Located in GYN Box:

2-Size 7 ½ Sterile Gloves, outdated 1/2017

3-Swab Collector lab tubes, outdated 10/2016

4-Amniocentisis Test Swabs, outdated 5/2016


Located in Broselow Bag (Pediatric):

1-6.5mm endotracheal tube, outdated 4/2017

1-5.5mm endotracheal tube, outdated 4/2017

1-4.5mm endotracheal tube, outdated 3/2017



- Surgical procedure room observed on 5/1/2017 at 3:00 pm revealed the following outdated medical supplies:

1-Percutaneous epigastric (PEG) tube (surgically inserted tube used to provide nutritional support), outdated 8/2016

2-Size 6 ½ Sterile gloves, outdated 4/2017


All outdated supplies were confirmed and removed by DON Staff A.


- Surgical ante-room and anesthesia cart observed on 5/2/2017 at 8:00 am revealed the following opened packages and outdated medical supplies:


1-Yankauer tip, open and attached to suction device

1-Yankauer tip, torn package in anesthesia cart drawer

10-Size 6 ½ Sterile gloves, outdated 4/2017


All outdated supplies were confirmed and removed by DON Staff A.


- CT scan room observed on 5/1/2017 at 2:30 PM revealed one open bottle Isopropyl 70% Alcohol with expiration date 6/2014.


Radiology Technician Staff V interviewed on 5/1/2017 at 2:30 PM acknowledged the Isopropyl bottle should have been disposed. Staff V stated they were not sure who uses this bottle, we usually use an alcohol pad.


- Inpatient Emergency Crash Cart observed on 5/3/2017 at 3:00 PM revealed the following expired supplies:

Pediatric Colorimetric CO2 detector (useful indicators of proper endotracheal tube-placed into the windpipe through the mouth) placement with expiration date of 7/2016.

Adult Colorimetric CO2 detector with expiration of date of 7/2016.

- Nursing station observed on 5/3/2017 at 2:45 PM revealed one sterile suction catheter 10 French package opened next to the suction machine.


RN Staff C interviewed on 5/3/2017 at 3:00 PM acknowledged the sterile catheter was opened and no longer sterile and the detector packages were expired and should have been replaced. Staff C disposed the catheter and detectors.


Policy "Crash Cart Checks/Emergency Boxes" directs " ...The crash carts red tags are checked once each shift by the nursing staff. Checks for outdated supplies and drugs are conducted on a monthly basis by the nursing staff and pharmacy staff ... ...Documentation of the checks is performed on the Crash Cart Schedule Sheet ..."

Based on observation, staff interview and policy review the facility failed to promote patient and staff safety by ensuring the generator had a remote safety stop station available. This failure has the potential to cause injury or death to patients or staff.


Findings include:

- Maintenance Room observed on 5/2/2017 at 11:30 AM revealed no remote manual stop stations located away from the generator location. The generator is located outside of the emergency entrance.


Maintenance Staff R interviewed on 5/2/2017 at 11:30 AM verified no remote stop had been installed for the generator. Maintenance Staff R acknowledged s/he was not aware of any regulations requiring a remote stop be installed.


NFPA 110, 5.6.5.6 regulation reviewed on 10/13/2016 at 12:15 PM states: "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building." An appendix item at A-5.6.5.6 suggests: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified."

Based on medical record review, staff interview, and policy review, the Critical Access Hospital (CAH) failed to perform annual review and update of Swing Bed Policies with Medical Staff approval. Four closed Swing Bed medical records were reviewed (Patient #6, #7, #9, #12). The deficient practice can lead to all Swing Bed patients receiving unsafe, inappropriate care.


- Observation of the Swing Bed Policies and Procedures manual revealed the manual was last reviewed and updated in 2012.


DON Staff A confirmed the review and update had not been completed annually. S/he stated the policy is to review and update the policies annually with medical staff approval. Currently, the policy review is to be presented at the May 2017 Medical Staff meeting.


The CAH staff was not able to provide a policy directing annual policy reviews, updates, and approvals.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure outdated, unusable medications were removed and made unavailable for patient use in one of one Emergency (ED) Department Crash Carts and one of one ED treatment rooms. The deficient practice or failure by the CAH to remove outdated medications places all patients at risk for receiving ineffective medications resulting in unsafe care.


Findings include:


- Emergency Department (ED) room observed on 5/2/2017 at 8:00 am revealed the following outdated medications:

1-9% Sodium Chloride (electrolyte solution), 1000ml, pour solution, outdated 4/2017

1-1000ml Lactated Ringers IV solution (electrolyte solution), outdated 3/2017

1-20ml vial Lidocaine multi dose vial (numbing medication), opened, unlabeled with date of opening, expiration date, or initials

1-4mg/4ml Norepinephrine Vial (medication used to treat low blood pressure and heart failure), outdated 4/2017

1-3.5 G Neomycin Ointment (antibiotic), outdated 12/2016

1-Sodium Chloride Inhalation, outdated 1/2017

1-Multi dose 20ml. vial of Lidocaine. Vial was open with no documentation of date opened or employee initials.


All outdated and open medications were confirmed and removed by DON Staff A.


Policy "Crash Cart Checks/Emergency Boxes" directs" ...Checks for outdated supplies and drugs are conducted on a monthly basis by the nursing staff and pharmacy staff ... ...Documentation of the checks is performed on the Crash Cart Schedule Sheet ..."


Policy "Multi-Dose Vials and Single-Dose Vials, Use and Labeling" directs " ...When a new multi-dose vial is opened, it will be dated and initialed by the person opening that vial ... ...Multi-dose vials with preservative will carry a 30 day expiration date from the date it was opened ... ...they may be reused as long as they are not taken into patient care areas ..."

Based on medical record review, staff interview, and policy review the Critical Access Hospital (CAH) failed to provide patient education to one of twenty-seven charts reviewed (Patient #20). Failure to fully educate patients regarding health status, goals and anticipated outcomes and risks places all patients at risk of failure to achieve desired health status.

Findings Include:

- Medical record review on 5/2/2017 at 2:00 PM revealed Patient #20 was admitted as an inpatient on 12/16/2016 and dismissed to home on 12/20/16. The admitting diagnosis was Urinary tract infection (UTI), Sepsis (infection affecting all body systems), chronic obstructive pulmonary disease (inability to efficiently move oxygen into the lungs and carbon dioxide out) (COPD) and insulin dependent diabetes. During the hospitalization the patient had an elevated temperature and experienced loose stools. A stool specimen was obtained for Clostridium Difficile (a transmittable bacterial infection of the colon) on 12/19/2016 with nursing staff notified of positive results on 12/20/2016. The medical record dismissal instruction sheet lacks documentation of patient education regarding the diagnosis and precautions to prevent transmission of Clostridium Difficile at home.

DON Staff A interviewed 5/3/2017 confirmed the documentation lacks patient education regarding the precautions and diagnosis.

Policy "Patient-Family Education Program" directs " ...Patient needs are assessed and education provided based on assessment including when applicable: safe and effective use of medications, potential drug interactions, nutrition interventions, self-care activities, personal hygiene and grooming, patient safety initiatives, ... ...information regarding any discharge instructions given to the patient/family are provided to the individual or organization responsible for the continuing care of the patient ..."

Based on medical record review, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure the patient signed the medical record informed consent prior to going to the OR (Operating Room) for 1 of 4 outpatient surgical patients reviewed (Patient #14).


Findings include:


- Patients #14's medical record reviewed on 5/3/2017 revealed an Outpatient procedure date of 3/16/2017 for Laparoscopic Cholecystectomy (gallbladder removed) and discharged the same day. The CAH failed to ensure Patient #14 signed their informed consent for their Colonoscopy with possible biopsy or removal of polyps.

- Director of Medical Records Staff S interviewed on 5/3/2017 at 3:00 PM acknowledged the patient did not sign their informed consent. Staff S mentioned they cannot believe they did not catch that.

- Policy titled "Informed Consent" reviewed on 5/3/2017 directed staff "...Prior to initiation of any procedure and/or surgery all clients of the Horton Community Hospital shall have the right to full explanation of: 1. The diagnosis 2. The nature of proposed treatment 3. Any risks and consequences of proposed procedure and/or surgery 4. Expected outcome of procedure and/or surgery 5. Possible treatment alternatives ... ...The nurse who acts as witness to the signature shall be responsible for insuring that the patient and/or legal guardian has received the indicated information prior to signing the consent..."

Based on medical record review, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure medical records are closed within 30 days of patients discharged for one of twenty-seven discharged patients (patient #13).

Findings include:

- Patients #13's medical record review on 5/3/2017 revealed an Outpatient procedure date of 3/16/2017 for Laparoscopic Cholecystectomy (gallbladder removal) and discharged the same day. The CAH failed to ensure the Physician Staff U signed their records within thirty days after the patient was discharged from the hospital.

- Director of Medical Records Staff S interviewed on 5/2/2017 at 3:00 PM acknowledged the physician did not sign the medical operative report. Staff S mentioned they cannot believe they did not catch that.

- Medical Staff Rules and Regulations of the Medical Staff NEK Center for Health and Wellness reviewed on 5/3/2017 directed the CAH Providers "...Section 13. Medical Records Completion. (a) Completion. It is the consensus of the Medical Staff that good medical records are essential in good medical care. The patient's medical records shall be completed and filed within a period consistent with good medical practice and not longer than 72 hours following discharge..."

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to maintain medical records storage in an organized/safe manner for one of two storage rooms (Medical record department). This practice has the potential for damage and destruction of the patient's records.


Findings include:


- The Medical Record room on the main floor of the CAH observed on 5/1/2017 at 11:30 AM revealed approximately 117 medical records stored on a bottom shelf that was less than an inch from the floor and could be destroyed if a flood occurs. The lack of arrangement prevented an accurate accounting of the records.


Director of Medical Records Staff S interviewed on 5/1/2017 at 11:30 AM acknowledged the lower shelf where the patient files lay are very close to the floor and could possibly get wet. Staff S stated she just did not look close enough to realize the files could potentially get wet.


- Policy review on 5/1/2017 revealed the CAH failed to ensure there was a policy to protect medical records from being destroyed.

Based on medical record review, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure they provided their swing bed patients their patient rights on admission, verbally and in written notice, for one of twenty-seven medical records reviewed (patient #7) and failed to ensure verbal and written patient rights are presented to Swing Bed patients in a language each patient can understand which impacted all swing bed patients. The CAH failure to provide the verbal and written patient rights could jeopardize the patient's understanding of their rights and responsibilities for making better decisions about their healthcare.


Findings include:


- Patient #7's closed medical record review on 5/3/2017 revealed an admission date of 12/16/2016 for swing bed services. Patient #7 medical record lacked evidence of the patient receiving their patient rights or their representative at admission.

Director of Medical Records Staff S interviewed on 5/3/2016 at 3:00 PM acknowledged the patient rights documentation sheet was not given and explained to the patient.

- Policy titled "Patient Rights and Responsibilities Swing bed Addendum" reviewed on 5/4/2017 directed staff "...The "Horton Community Hospital Patient Rights and Responsibilities" provides basic information for all patients to understand their rights and responsibilities while being cared for at Horton Community Hospital ...The patient's rights ensure that the patient or significant other ... Is fully informed, prior to or at the time of admissions and during the stay of these rights and of all the rules and regulations governing patient's conduct and responsibilities, facility responsibilities, and services available..."

- Observation on 5/2/2017 at 2:00 PM of the Swing Bed Patient Rights document that is presented to patients admitted to the CAH Swing Bed revealed the document does not state the patient rights will be presented to the patients in an understandable language regarding their health status and medical condition.


Interview with DON Staff A on 5/3/2017 acknowledged the document lacked the right of communication between staff and the patient in an understandable language. Review of the document provided to Swing Bed patients revealed the document is incomplete of information. Further review by DON Staff A confirmed the document currently given to Swing Bed patients is not the correct document and the correct document found in the Swing Bed policy manual with the correct wording will replace what is current patient rights document.

Based on medical record review, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure they provided their patients with the patient advance directives information, verbally and in written notice, for one of twenty-seven medical records reviewed (patient #7). The CAH failure to provide the written patient advance directives information could jeopardize the patient to understand their rights and responsibilities for making better decisions about their healthcare.

Findings include:

- Patient #7's closed medical record review on 5/3/2017 revealed an admission date of 12/16/2016 for swing bed services. Patient #7's medical record lacked evidence of receiving the patient advance directives information to the patient or their representative at admission.

Director of Medical Records Staff S interviewed on 5/3/2016 at 3:00 PM acknowledged the patient's advance directive information documentation sheet was not given to the patient.

- Policy titled "Patient Rights and Responsibilities Swing bed Addendum" reviewed on 5/4/2017 directed staff "...The "Horton Community Hospital Patient Rights and Responsibilities" provides basic information for all patients to understand their rights and responsibilities while being cared for at Horton Community Hospital ...The patient's rights ensure that the patient or significant other ... Is fully informed, prior to or at the time of admissions and during the stay of these rights and of all the rules and regulations governing patient ' s conduct and responsibilities, facility responsibilities, and services available... ...may formulate an advance directive..."

Based on staff interview and policy review, the Critical Access Hospital (CAH) failed to inform Swing Bed patients of their right to receive visitors at any time and the choice to exclude any visitors. Failure to inform Swing Bed patients of their right to have visitors of their choice at any time denies patients the opportunity to act on all of their rights.


Findings Include:

- Observation on 5/2/2017 at 2:00 PM of the Swing Bed Patient Rights document that is presented to patients admitted to the CAH Swing Bed revealed the document does not state the patient has the right to receive visitors as the patient desires. The patient rights do not state the patient has the right to restrict their own visitors.


Interview with DON Staff A on 5/3/2017 acknowledged the document lacked the right of communication between staff and the patient in an understandable language. Review of the document provided to Swing Bed patients revealed the document is incomplete of information. Further review by DON Staff A confirmed the document currently given to Swing Bed patients is not the correct document and the correct document found in the Swing Bed policy manual with the correct wording will replace the current patient rights document.