HospitalInspections.org

Based on employee file review, employee handbook and staff interview, the Critical Access Hospital (CAH) failed to assure staff are certified to provide services to patients for one of eleven staff requiring a license or certification for their position.

Findings include:

- The CAH's employee handbook reviewed on 10/9/14 at 1:20pm directed, "...Each employee is responsible for determining that licenses/registrations/certifications are current and effective..."

- Review of employee personnel files on 10/9/14 revealed the hospital failed to ensure staff L a Medical Laboratory Technician hired on 8/12/14 had a current and effective certification for their position.

Human Resource staff K interviewed on 10/9/14 at 1:20pm verified staff L's employee file failed to have a current and effective certification as a Medical Laboratory Technician.

The Critical Access Hospital (CAH) reported a census of three skilled swing bed patients. Based on observation, policy review and interview the hospital failed to develop a system to monitor for outdated emergency supplies in one of one emergency room.

Findings include:

The CAH's policy for "Supply/Stock Rotation and Managing Outdates for Supplies" reviewed on 10/9/14 at 8:00am directed "...Any supply/stock items discovered that have reached or are near expiration will be pulled and processed according to policy..."

- Observation in the emergency room on 10/2/14 at 1:25pm revealed a Broselow Pediatric Emergency Kit with the following outdated supplies:

1. Five Intravenous (IV) delivery modules with an expiration date of 9/2012
2. One intubation (a kit to provide an emergency airway) module with an expiration date of 3/2013.
3. One 20-gauge Jelco IV needle with an expiration date of 11/2012.
4. One 24-gauge Jelco IV needle with an expiration date of 10/2013.
5. Six intubation (a kit to provide an emergency airway) module with an expiration date of 5/2013.

Administrative staff A interviewed on 10/2/14 at 1:25pm in the emergency room, acknowledged the outdated supplies in the Broselow pediatric emergency kit.

Based on credential file review, Medical Staff Bylaws and staff interview the CAH (Critical Access Hospital) governing body failed to followed the CAH's Medical Staff By-laws, for delineation (description) of privileges for two of seven physicians credential files reviewed (Physicians B and C ) and two of seven mid-level practitioners credential files reviewed (Staff D and E).


Findings include:

- The CAH's Medical Staff Bylaws reviewed on 10/2/14 at 2:00pm revealed section 5.1, Exercise of Privileges directed, "...a member providing clinical services at this hospital shall be entitled to exercise only those clinical privileges specifically granted..." 5.2, Delineation of Privileges directed, "...Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. Such requests must be accompanied by documentation of training..."


Review of two physician credential files and two mid-level practitioner credentials on 10/2/14 lacked approval of their delineation (description) of privileges and approval by the Governing Body. For example:


- Physician B's credential file revealed a temporary medical staff privileges dated 6/16/14 which lacked a delineation of privileges approved by the governing body for specific privileges Physician B could perform.

- Physician C's credential file revealed a temporary medical staff privileges dated 6/27/14 which lacked a delineation of privileges approved by the governing body for specific privileges Physician C could perform.

- Advanced Practice Registered Nurse (APRN) D's credential file revealed a temporary medical staff privileges dated 10/10/13 which lacked a delineation of privileges approved by the governing body for specific privileges APRN D could perform.

- APRN E's credential file revealed a temporary medical staff privileges dated 10/11/13 which lacked a delineation of privileges approved by the governing body for specific privileges APRN E could perform.

Credentialing Staff F interviewed on 10/2/14 at 2:45pm in the conference room acknowledged Medical Staff B, C, D, and E's credential files lacked delineation of privileges approved by the governing body.

Based on observation, staff interview, medical record review and document review, the Critical Access Hospital failed to ensure a complete history and physical were in the patient's chart within 24 hours (refer to C-0271) and the Critical Access Hospital's infection control officer failed to: develop an active infection control system (refer to C-0278).


The cumulative effect of the systematic failure to ensure a complete history and physical were in the patient's chart within 24 hours and develop an active infection control system resulted in the hospitals inability to provide care in a safe and effective manner.

The Critical Assess Hospital (CAH) reported a census of three swing bed patients. Based on medical record review, Medical Staff Bylaws review and staff interview the CAH failed to ensure a complete history and physical were in the patients chart as required by the CAH's Medical Staff Bylaws for one of twenty sampled patients requiring a history and physical (patient #'s 17). This deficient practice had the potential to affect the patient's planned course of care.
Findings include:

- The CAH's Medical Staff Bylaws Rules and Regulations reviewed on 10/2/14 at 2:00pm directed, "...A complete history and physical examination shall in all cases be written within 24 hours after admission of the patient..."

- Patient #17's closed medical record reviewed on 10/7/14 revealed an admission date of 9/16/14 and discharged on 9/17/14 with a diagnosis of congestive heart failure. The medical record contained a history and physical transcribed on 10/2/14 (16 days after admission).

Medical Records staff F interviewed on 10/8/14 at 4:00pm, acknowledged the CAH failed to complete the patient's history and physical according to the CAH's bylaws and rules within 24 hours of admission.

The Critical Access Hospital (CAH) reported a census of three swing bed patients. Based on observation, staff interview, and document 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. Observations included one staff not performing hand hygiene after wiping their nose, one terminal cleaning of a discharged patient room, two patients with a dressing change, one patient with a blood draw, five patient rooms, and one end of the day cleaning of a surgical room. The CAH's failure to identify failures with infection control practices created the potential for healthcare acquired infections.

Findings include:

- The CAH's policy "Infection Prevention and Control Surveillance Activities" reviewed on 10/8/14 at 3:25pm directed, "...It is the policy and practice of this hospital to have a well-structured surveillance system to assess the quality of patient care and hospital support activities to promote effective infection control practices..."

- Infection Control Officer staff M interviewed on 10/8/14 at 11:00am verified they were responsible for the management of the infection control program. Staff M indicated they have a formal surveillance for hand hygiene and monitor patient rooms after cleaning. Staff M acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control practices.

- Observations during the survey process revealed the following breaches in infection control practices.

- The manufacturer's information sheet for "Re-Juv-Nal" disinfectant cleaner reviewed on 10/8/14 at 11:45am directed "...To disinfect inanimate hard non-porous surfaces...allow to remain wet for 10 minutes..."

- The CAH's policy for hand hygiene reviewed on 10/6/14 at 4:30pm directed "...Hospital personnel shall perform hand hygiene, to prevent the spread of infections: After sneezing, coughing, blowing or wiping the nose or mouth...After removal of gloves and before placing another pair of gloves on...After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings..."

- The CAH's policy "Terminal Clean Patient Room Procedure" reviewed on 10/8/14 at 11:45am directed, "...Follow pre-determined facility guidelines for cleaning path (clockwise, top to bottom, restrooms should always be cleaned last...Turn down the mattress and wipe the bed frame and back of mattress working from top and repeat at the bottom...Begin a terminal bathroom clean by giving special attention to the order in which items are cleaned. It is best to start with the highest surfaces and leaving the commode/toilet for last..."

- Nursing staff N observed on 10/1/14 at 1:05pm blew their nose, disposed of the Kleenex and returned to work. Staff N failed to perform hand hygiene after blowing their nose.

- Housekeeping staff O observed on 10/2/14 between 9:05am and 11:07am cleaning room 105, a discharged patient room revealed the following breaches in infection control practices regarding manufacturers guidelines, hand hygiene and cleaning from dirty areas to a less dirty area. For example:

Staff O, wearing gloves applied "Tuff Stuff" descaler to the room sink. Staff O returned to the cleaning cart, removed their glove, reapplied gloves and failed to perform hand hygiene. Staff O went to the bathroom cleared the water from the toilet bowl, applied disinfectant, returned to the cleaning cart, removed their gloves, reapplied gloves without performing hand hygiene and obtained a duster and dusted the ceiling lights. Staff O using "Re-Juv-Nal" cleaned the bathroom shower bench, grab bars, changed gloves without performing hand hygiene, returned to the bathroom and using "Re-Juv-Nal" cleaned the toilet seat and base. The surfaces remained wet for five minutes not the required ten minutes for disinfection. Staff O changed their gloves without performing hand hygiene, cleaned the bed near the outside wall, and cleaned the mattress that rested on the floor with "Re-Juv-Nal". The mattress remained wet for seven minutes not the required ten minutes for disinfection. Staff O returned to the cleaning cart, changed gloves without performing hand hygiene, cleaned the second bed and mattress that had rested on the floor.

Staff O left the room, went to the cleaning closet in the hallway, refilled the cleaning bucket with "Re-Juv-Nal", returned to the room, and failed to change their gloves. Staff O, using "Re-Juv-Nal" cleaned the counter. two over-the-bed tables, two chairs and a recliner. The surfaces remained wet for three to six minutes, not the required ten minutes for total disinfection.

Staff O interviewed on 10/2/14 at 11:07 acknowledged they moved from dirty to a less dirty area when they cleaned the bathroom first, failed to perform hand hygiene when changing gloves, and surfaces failed to remain wet the required ten minutes for total disinfection.

- Registered Nurse staff P observed on 10/6/14 at 9:35 wearing gloves redressed an intravenous (IV) site on patient #16. Staff P placed their scissors and a roll of tape on patient #16's table, changed the dressing, When completing the dressing change picked up the scissors wiped the blades with an alcohol wipe and placed the contaminated scissors and tape in to their uniform pocket.


- Laboratory staff Q observed on 10/6/14 at 11:10am placed a laboratory supply tray on the chair without a barrier in a outpatient's room. Nursing staff P wearing gloves removed a blood sample from the patient's PICC (peripheral insertion central line catheter). Staff P handed the drawn blood to staff Q. After labeling and packaging the specimen Staff Q picked up the laboratory supply tray set the tray on the counter outside the room, washed their hands, and took the tray into the laboratory and set the tray on the counter. Staff Q failed to disinfect the laboratory supply tray when leaving the outpatient's room.

- The CAH's policy "Negative Pressure Wound Therapy" reviewed on 10/8/14 at 9:00am directed, "...dressing removal utilize standard infection control precautions...discard old dressing according to facility guidelines...remove gloves and wash hands...

- Physical Therapy staff R and S observed on 10/6/14 between 2:35pm and 3:20pm provided a "Wound Vac" (a machine used for negative pressure wound therapy) dressing change to patient #28. Staff R and S wearing gloves placed a towel across patient #28's legs and removed the soiled dressing. Staff R without changing gloves went to the table with clean dressing supplies and cut the foam used inside the open wound. Staff S removed the soiled foam from the open wound and laid the soiled instruments on the towel. Staff R returned to the patient and cleaned patient #28's wound wearing the contaminated gloves. Staff R and S removed their gloves and reapplied gloves without performing hand hygiene. Staff R measured the wound and placed the swabs and tape measure used inside the wound on the towel across patient #28's legs. Staff R cut the white foam with instruments used to clean the retention sutures and lays the scissors on the contaminated towel. Staff R and S apply the clean dressing to patient #28's abdomen. Staff S with soiled gloves obtained the wound vac machine from a cloth bag, laid the wound vac machine against their clothes, removed the full canister, inserted a new canister and placed the machine in the cloth bag. Staff R removed the soiled towel left on patient #28's lap during the dressing change, placed the soiled instruments in a glove, removed their gloves, and then placed the gloved instruments and a camera use to take pictures of the wound on the counter near the sink where they performed hand hygiene. Staff R picked up the soiled instruments and contaminated camera with un-gloved hands and left patient #28's room.

Staff R interviewed on 10/6/14 at 3:20pm indicated they were unaware of the need to perform hand hygiene between glove changes. Staff R acknowledge breeches in infection control practices.

- Patient room #'s 101, 104, 105, 106, and 107 observed on 10/7/14 between 12:50pm to 1:30pm revealed recliners with cracked vinyl exposing foam/mesh in each room.

Environmental Services Director staff T interviewed on 10/7/14 between 12:50pm to 1:30pm acknowledged the torn/cracked vinyl recliners in rooms 101, 104, 105, 106, and 107. Staff T acknowledged the torn/cracked areas allow microorganisms to penetrate the chairs and are non-cleanable surfaces.

- Housekeeping staff U observed cleaning the operating room (OR) on 10/8/14 between 1:25pm to 2:10pm revealed the following breaches in infection control practices regarding manufacturers guidelines, hand hygiene and cleaning of equipment. For example:

Staff U dusted upper areas of the OR. Staff U using "Re-Juv-nal" cleaned the prep table, back table, light, pillow, patient table the surfaces remained wet time for two to eight minutes not the required ten minutes for total disinfection. Staff U using "Re-Juv-Nal" cleaned only the top flat surface of the scope tower, anesthesia machine, and medication cart. Staff U failed to clean all areas of the scope tower, anesthesia machine and medication cart.

Staff U interviewed on 10/8/14 at 2:10pm indicated housekeeping clean the top of machine and thought the surgery staff cleaned the sides, shelves and all other areas of the machine.

Surgery staff V interviewed on 10/8/14 at 2:10pm indicated surgery staff clean the machines and housekeeping staff should do the disinfection of the room. Staff V thought housekeeping cleaned and disinfected all equipment in the operating room.

- The infection control officer failed to develop an active infection control system and implement a surveillance program for staff infection control practices to protect patients, visitors and staff from potentially infectious microorganisms.