HospitalInspections.org

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the physical therapy (PT) and occupational therapy (OT) departments were appropriately disinfecting equipment between patients by utilizing an EPA approved product to prevent the transmission of hepatitis B and HIV.
Findings include:
On 8/20/14, at 1:35 p.m. physical therapy assistant (PTA)-A confirmed the treatment tables and exercise equipment were wiped down with disposable disinfecting cloths between patients. The label on the container of disposable disinfecting wipes revealed the product was bleach free and the list of covered organisms did not include hepatitis B and HIV.
On 8/20/14, at 3:05 p.m. patient (P1) was observed during his physical therapy session. P1 had used the parallel bars, ankle weights, ball and a lowered exercise table. At 3:20 p.m. the physical therapist (PT)-A went to the cupboard in the physical therapy area and gathered some disposable disinfecting cloths. PT-A proceeded to wipe down the surface areas of the ankle weights, exercise table, ball and parallel bars.
On 8/20/14, at 3:25 p.m. PT-A verified that she utilized the disposable disinfecting cloths to wipe down the patient care equipment which P1 had touched during his therapy session. She confirmed her practice was to disinfect patient care equipment after each patient session.
The infection control representative of the CAH was a medical technologist and was interviewed on 8/21/14, at 10:10 a.m. and confirmed that the PT and OT department was not using the correct product to disinfect equipment between patients.

Based on interview and record review, the CAH failed to provide specialized training for the radiation safety officer. This had the potential to affect all current and future patients of the Critical Access Hospital (CAH).


The radiology department manger, interviewed on 8/20/14, at 2:30 p.m., stated that specialized training had not been provided for the Radiation Safety Officer (RSO) who was a radiology technician. The RSO was interviewed on 8/20/14, at 3:00 p.m. and stated all nuclear medicine was handled by DMS (contracted imaging service), they brought all radioactive doses for imaging, handled the material, and took it away with them for disposal. The RSO stated that she had not received specialized training.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated into the CAH's quality improvement program for radiology and dietary. This had the potential to affect all current and future patients of the CAH.

Findings include:

On 8/20/14, at 2:30 p.m. the radiology manager (RM) stated their quality tracking consisted of a retake/repeat analysis, the goal was less than 10% and the department had been ranging between 4-7% retakes over the last year. The RM stated that they were also tracking the turn around time for STAT and routine images. When asked for the written quality assurance (QA) action plan related to the review the process and goal for the QA project the RM stated that one had not been developed that it was just an idea of a project that was going to be implemented. The RM confirmed there was no written QA action plans developed or implemented.

On 8/21/14, at 11:40 a.m. the dietary manager (DM) was interviewed and stated the dietary department did not have a quality assurance (QA) or process improvement (PI) project currently in place. The DM stated that she had an idea for a QA project which included measuring for patient satisfaction with meals. The DM verified she did not have a written action plan developed for any current QA/PI activities at this time.

On 8/21/14, at 11:50 a.m. the chief executive officer (CEO) was interviewed and stated she was unaware of a current quality improvement project being completed in the areas of radiology and dietary.