HospitalInspections.org

Based on observation and staff interview, the Critical Access Hospital failed to ensure maintenance of equipment in 1 of 1 laundry department. Failure to ensure cleanliness of fans in the laundry department resulted in fans blowing dust on areas with clean linen, and failure to ensure daily cleaning of the lint collection area in clothes dryers has the potential to result in equipment not functioning properly and/or a fire risk.

Findings include:

Observation of the laundry department occurred on 04/19/23 at 11:45 a.m. with an administrative environmental services staff member (#8). Observation showed the following:
* Washing Machine Room - Two fans with accumulation of dust on fan blades and blade cage/grate.
* Dryer Machine Room - Three fans with heavy accumulation of dust on fan blades and blade cage/grate blowing on clean linen. Two dryers with large accumulation of lint in the lint collection area. During interview on 04/19/23 at 11:55 a.m., the staff member (#8) verified staff should remove the lint from the dryers daily and stated it looks like the lint had not been removed "since last week."
* Folding/Sorting Room - Two fans with accumulation of dust on fan blades and blade cage/grate blowing on clean linen. During interview on 04/19/23 at 12:00 p.m., the staff member (#8) confirmed staff needed to clean the fans, and the fans were not on a cleaning schedule.

Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff stored drugs and biologicals in accordance with professional principles on 2 of 3 days of survey (April 17-18, 2023). Failure to properly store drugs and biologicals limited the CAH's ability to prevent unauthorized use of medications and maintain control of medications.

Findings include:

Review of the facility policy and procedure titled "Medication Accountability and Security" occurred 04/19/23. This policy, revised 08/01/12, stated, ". . . All medications must be stored in a secure or locked area . . . Acute Nursing: . . . Medication carts . . . must be kept locked . . . "

- Observation on 04/17/23 at 4:10 p.m., showed a nurse (#1) prepare medications for administration to Patient #1. The nurse (#1) prepared a Sanctura 20 milligram (a medication for overactive bladder) tablet from a bottle. The nurse left the bottle of Sanctura tablets on the top of the medication cart and entered Patient #1's room to administer the medications. The nurse failed to place the medication bottle back into the medication cart prior to entering the patient's room.

- Observation on 04/17/23 at 4:49 p.m., showed a medication cart in the hallway with several medications in blister packs on top of it. No staff were present in the hallway. Nursing staff failed to place the medications in the medication cart when unattended.

- Observation on 04/18/23 at 3:42 p.m., showed a nurse (#2) prepare an IV antibiotic Rocephin for Patient #1 at the medication cart. The nurse failed to lock the medication cart prior to entering Patient #1's room.

During interview on 04/19/23 at 09:05 a.m., an administrative nurse (#5) stated she expected staff to store medications in the medication carts and to lock the medication carts.

Based on review of personnel files, review of professional reference, review of North Dakota Administrative Code (NDAC), and staff interview, the Critical Access Hospital failed to ensure all nursing staff possessed the specialized qualifications and competence needed to meet patient needs for 1 of 1 certified nurse aide (CNA) (#3) observed performing blood glucose monitoring. Failure to ensure all nursing staff receive the training necessary to perform their clinical duties may result in unmet patient needs.

Findings include:

Kozier & Erb's "Fundamentals of Nursing, Concepts, Process and Practice," 11th Edition e-Text, 2021, Pearson, Boston, Massachusetts, page 50, stated, ". . . Delegation is 'allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee's traditional role and not routinely performed. A delegatee may be . . . assistive personnel' . . . To perform the delegated care, the delegatee must have acquired the additional knowledge and training and validated competence to perform the delegated responsibility . . ."

NDAC, Section 33-43-01-12: "Supervision and delegation of nursing interventions" states, ". . . An individual on the department's nurse aide registry may perform nursing interventions which have been delegated by a licensed nurse. . . ."

NDAC, Section 54-05-02-07: "Standards related to registered nurse responsibility to organize, manage, and supervise the practice of nursing" states, " . . . In the administration and management of nursing care, registered nurses may assign and delegate the responsibility for performance of nursing interventions to other persons. . . . The registered nurse shall: . . . 2. Delegate to another only those nursing interventions for which that person has the necessary skills and competence to accomplish safely. . . ."

- Observation on 04/17/23 at 4:55 p.m., showed a certified nurse aide (CNA) (#3) performed a blood glucose test on Patient #4.

- Observation on 04/17/23 at 5:00 p.m., showed a CNA (#3) performed a blood glucose test on Patient #3.

Review of the CNA's (#3) personnel file occurred on the afternoon of 04/19/23 and lacked evidence of blood glucose monitoring training or annual competency validation.

During interview on 04/19/23 at 11:00 a.m., an administrative nurse (#5) stated the facility nurses trained the CNAs to perform blood glucose monitoring as they are hired but lacked documentation of the training. The administrative nurse (#5) stated they do not perform annual competencies for blood glucose monitoring for the CNAs.

TRANSMISSION BASED PRECAUTIONS

1. Based on observation, review of facility policy, review of professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed standard infection control practices for 1 of 1 patients (Patient #2) observed in transmission based precautions. Failure to follow transmission based precautions, properly remove personal protective equipment (PPE), perform hand hygiene after removal of gloves, and when moving from one area of the CAH to another has the potential to spread infection to other patients, staff, and visitors.

Findings include:

Review of the facility policy titled "Standard Precautions" occurred on 04/19/23. This policy, revised November 2014, stated, ". . . Hand Hygiene with the use of an alcohol-based hand rub (ABHR) or by washing hands with soap and water should be performed: . . . after the removal of gloves . . . remove gloves promptly after use, before touching non-contaminated items and environmental surfaces . . . remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients . . . Reusable equipment should be properly cleaned and disinfected or sterilized before use on another patient . . . "

Review of the facility policy "Methicillin Resistant Staphylococcus Aureus (MRSA)" occurred on 04/19/23. This undated policy stated, ". . . Methicillin Resistant Staphylococcus Aureus may present as colonization or an infection. Colonization means that MRSA is present in the body without causing illness . . . MRSA can spread among other patients who are often very sick, and have weak immune systems, that may not be able to fight off infections. MRSA is almost always spread by physical contact . . . Hospitals usually take special steps to prevent the spread of MRSA. Patients will be placed on contact precautions. . . . Always wash hands after removing gloves. Remove gown and gloves before leaving the room . . . Items which are shared . . . need to be cleaned and disinfected between patients. . . ."

Review of The Centers for Disease Control and Prevention (CDC) guidance for PPE use, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, stated, ". . . How to Take Off (Doff) PPE Gear . . . Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. . . . "

Observation on 04/17/23 at 4:06 p.m. showed Patient #2's door contained a sign that stated "Contact Precautions" and an isolation cart containing reusable isolation gowns and gloves stood outside the door. A covered soiled linen basket and garbage can were also present outside the door.

Review of Patient #2's medical record occurred on all days of survey. Diagnosis included MRSA colonization in the lungs. An alert in the record stated, "Contact Precautions".

Observation on 04/17/23 at 4:49 p.m. showed a nurse (#1) exited Patient #2's room wearing a reusable isolation gown and gloves and carrying a portable medication scanner. Without removing the PPE, the nurse set the scanner on the medication cart (located outside the room), prepared several medications for administration, and re-entered Patient #2's room. The nurse exited the room again, removed the gloves, disposed of them in the garbage can in the hallway, removed the isolation gown by pulling it over his/her head, and put it in the dirty linen basket in the hallway. Without performing hand hygiene, the nurse pushed the medication cart to the nurse's station.

The nurse failed to adhere to proper transmission-based precautions, disinfect the medication scanner and medication cart, properly remove PPE after exiting Patient #2's room, and perform hand hygiene after removing PPE/gloves.

During interview on 04/18/23 at 10:00 a.m., an administrative nurse (#4) confirmed she expected staff to adhere to proper transmission-based precautions, properly remove PPE, perform hand hygiene after removal of gloves, and disinfect shared medical equipment.

DISINFECTING BLOOD GLUCOSE MONITOR

2. Based on observation, review of manufacturer instructions for use, review of facility policy, and staff interview the Critical Access Hospital failed to ensure staff follow standard infection control practices for 2 of 2 patients (Patient #1 and #2) observed for blood glucose monitoring. Failure to follow manufacturer instructions for use and properly disinfect the blood glucose monitor between patients has the potential to lead to the spread of blood borne pathogens.

Findings include:

Review of the Manufacturer Instructions for Use for the Accu-Chek Guide Blood Glucose Monitoring System stated, ". . . is intended to be used by a single person and should not be shared. . . . The following product has been approved for cleaning and disinfecting the meter . . . Super Sani.Cloth . . . Turn the meter off and wipe the entire meter surface with a Super Sani.Cloth. Carefully wipe around the test strip slot and other openings. . . . A separate Super Sani.Cloth should be used for cleaning and disinfection. For disinfecting the meter, get a new cloth and repeat step 2, making sure the surface stays wet for 2 minutes. . . ."

Review of the facility policy titled "Standard Precautions" occurred on 04/19/23. This policy, revised November 2014, stated, ". . . Reusable equipment should be properly cleaned and disinfected or sterilized before use on another patient . . . "

- Observation on 04/17/23 at 4:55 p.m., showed a certified nurse aide (CNA) (#3) performed a blood glucose test on Patient #4. The CNA wiped the blood glucose monitor with a single Super Sani Cloth, collected supplies, and entered another patient room.

- Observation on 04/17/23 at 5:00 p.m., showed a CNA (#3) performed a blood glucose test on Patient #3. The CNA wiped the blood glucose monitor with a single Super Sani Cloth and placed the monitor back into the medication room.

The CNA (#3) failed to wipe the blood glucose machine with a second Super Sani Cloth each time to ensure disinfection of the machine.

During interview on 04/18/23 at 10:00 a.m., an administrative nurse (#4) confirmed staff failed to disinfect the blood glucose monitor per the manufacturer instructions for use.