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Based on facility tour/inspection and interviews with hospital staff, the hospital failed to ensure facilities and patient care equipment are maintained for safety and quality care.

Findings:

The hospital is a 25-bed facility.

1. At the time of surveyor tour on the morning of 04/11/2014, not all patient lights over the beds were in operating condition. The surveyors could not identify whether the non-functioning condition was due to electrical or defective bulbs. Patient room lighting was checked and verified with the administrator at the time of the tour.

2. At the time of the tour on 04/11/2014, the facility had only one operational IV infusion pump. Staff N and AA stated the hospital "used" to have six infusion pumps. Staff AA stated she had planned to obtain two infusion pumps from another hospital, but had not obtained the pumps yet.

Based on review of hospital documents and staff interview, the hospital failed to implement an emergency preparedness plan.

Findings:

Staff K was interviewed on the afternoon of 04/11/14, regarding the hospital's emergency preparedness plan.

Staff K was asked for documentation regarding disaster drills for the hospital. None was provided. Staff K stated the hospital had not performed any disaster drills for 2013 year.

The above information was presented to the administrative staff during the exit interview, no additional information was provided.

Based on review of policy and procedures, committee meeting minutes, and interviews with hospital staff the hospital failed to ensure policies and procedures are periodically reviewed and approved through Medical Staff and Governing Body. The policy and procedure manuals provided to surveyors had no evidence of current review and approval of the policies. There was no documentation in any of the hospital's committee meeting minutes of review and approval of the hospital's policies and procedures. Seven of seven hospital departments did not have evidence of current review and approval by the medical staff or governing body of their policies and procedures.

Findings:

1. Pharmacy, housekeeping, physical therapy, radiology, swing bed, infection control and emergency departments did not have evidence of current review and approval of their policies and procedures.

2. Nursing policies had a policy allowing smoking in the patient rooms.

3. Housekeeping policies had 1995 as the last date of review.

4. Infection control had 2009 as the last date of review.

5. Pharmacy and swing bed policies did not have any evidence of any current review.

6. Emergency policies had 2003 as the last date of review.

These findings were verified by hospital staff.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze IP surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

c. Provide initial and on-going education/training for the infection preventionist (IP) in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

Findings:

Plan/Program:

1. The hospital has not conducted a hospital-wide IC risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not conducted a tuberculosis risk assessment. Staff K stated on 04/10/2014 at 1550 that in 2013, the hospital had trouble getting the solution for tuberculin testing and so no one was tested.

3. The hospital does not have a current infection control plan (Plan). The Plan contained in the IC policy and procedure manual had a date of 2001.

4. These findings were reviewed and confirmed with Staff K, the person identified as the infection control preventionist on the morning of 04/11/2014.


IP Training/Education:

1. On the morning of 04/10/2014, administrative staff told the surveyors that Staff K was the infection control preventionist (IP).

2. Review of Staff K's personnel files did not contain documentation of training in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

3. On the morning of 04/11/2014, Staff K confirmed he had not received any training in establishing and maintaining a comprehensive effective infection control program. Staff K stated he had a friend who was the IP at another hospital and had talked with that IP.


Surveillance:

On the afternoon of 04/10/2014, Staff K told the surveyors that, except for monitoring patient infections that occurred, he did no surveillance.

1. The IC program has not monitored to ensure all departments followed infection control policies and current recognized infection control practices.

2. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. No monitoring documentation was provided and the IC manual did not contain a monitoring tool for hand hygiene. The IP stated on 04/10/2014 that hand hygiene surveillance was not performed.

3. Documents provided and meeting minutes did not demonstrate that, other than patient infections, the IC program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

4. Central sterile processing is not monitored, including, but not limited to:
a. Maintenance and monitoring to ensure safe and effective autoclave sterilization;
b. Appropriate cleaning and packaging of instruments occurs;
c. Sterilization practices - correct temperature, correct sterilizing time and correct dry time;
d. High level disinfection practices - correct product at correct temperature for correct amount of time; and
e. Appropriate disinfection occurs - products used according to manufacture's guidelines.

5. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines;
b. Isolation materials/supplies are readily available (Although staff knew the locations,staff had to go from area to area to show the surveyor where they would obtain the needed supplies, including the isolation signs.);
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.

6. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are applied and remain "wet" contact time according to the manufacturers guidelines.
c. Nursing staff interviewed did not know if the hospital's disinfectant was effective against C-difficile and did not know the "wet" contact time in order for the disinfectant to be effective.


Policies and Procedures:

1. The IC policy and procedure manual did not contain specific IC policies and procedures for each department/service (or notification of where to find specific IC policies for each department) for:
a. Central sterile services, including policies and procedures on how to process instruments and the requirements testing of the equipment;
b. Pharmaceutical services;
c. Radiology services;
d. Respiratory therapy services.

2. The IC manual policy and procedure did not contain specific policies for respiratory isolation protection and requirement of specialized masks, N-95 respirator. The IC policies and procedures did not specify:
a. Detail on how this was to be accomplished and by whom; and
b. Based on the current standards of practice and requirements by OSHA (Occupational Safety and Health Administration), how often fit testing would be performed.
c. Some staff interviewed did not know the hospital had N-95 masks or where they were kept.
d. No staff had been Fit tested to ensure the proper mask was identified and available.
e. The hospital only had one brand and one size, medium.

3. The IC manual did not contain a policy and procedures on how patients and staff with potential or confirmed influenza will be medically managed, including:
a. Screening;
b. Any required tests to confirm infection;
c. Any particular requirements according to current CDC guidelines.

4. Although the IC manual's Table of Contents listed reportable diseases, it was not the current list (05/13). The form contained in the IC manual had a issue date of 72012. The one contained in the Nursing manual had an issue date of 5/2002. The policy and procedure for reporting reportable infections and diseases to the proper authorities, with delineation of responsibilities was not current.

5. The IC manual did not contain policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:
a. mixture;
b. wet time contact with surface to be effective; and
c. what organisms each approved disinfectant kill.

7. The IC manual did not contain policies and procedures concerning nail hygiene and artificial nails.


Meeting Minutes:

On 04/10/2014, Staff K told the surveyors that IC meeting minutes were part of the Committee of the Whole. The surveyors reviews meeting minutes for quality, medical staff and governing body where infection control was listed as a topic.

1. The meeting minutes did not contain review, evaluation and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff. Although nosocomial/HAI (hospital acquired infections) were identified in the attached reports, there was not review and analysis to determine if process should be changed to improve patient care and outcomes.

2. The meeting minutes did not demonstrate central sterile services were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

3. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IC policies and procedures and current standards of practice are followed. Staff K stated on the morning of 04/11/2014 that this did not occur.

4. Concerns identified in meeting minutes showed to review and analysis to determine if corrective actions need to be developed or if current policies and procedures were followed. Example: January 2013 quality assurance meeting minutes identified an employee exposure/needle stick. No report was provided whether the employee received appropriate screening and treatment. Subsequent meeting minutes did not document if the policies and procedures for follow-up was performed according to OSHA (Occupational Safety and Health Administration) and current standards of practice.

5. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. Staff K confirmed disinfectants had not been reviewed as part of IC. The surveyors observed Cavi-Wipes available for use in the emergency department, radiology and housekeeping cart and the nursing supply rooms. Staff N did not know the disinfectant was effective against Clostridium difficile (C-diff).

6. The meeting minutes did not reflect employee illnesses and immunizations were part of the program. Review of personnel files, including contract and physician and allied health files did not show complete immunizations as recommended by CDC and its advisory committee (ACIP).

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure all patient care policies are reviewed at least annually.

Findings:

1. Pharmacy, housekeeping, physical therapy, radiology, swing bed, infection control and emergency departments did not have evidence of current review and approval of their policies and procedures.

2. Nursing policies had a policy allowing smoking in the patient rooms.

3. Housekeeping policies had 1995 as the last date of review.

4. Infection control had 2009 as the last date of review.

5. Pharmacy and swing bed policies did not have any evidence of any current review.

6. Emergency policies had 2003 as the last date of review.

These findings were verified by hospital staff.

Based on review of the radiology department documents, review of personnel files and interviews with hospital staff, the hospital failed to develop policy and procedures to protect patients and staff from radiation hazards.

Findings:

On the morning of April 10, 2014, the surveyors requested the radiology department policy and procedure manual. None was provided.

During the tour of the radiology department on April 11, 2014, Staff C stated there was no policy and procedure manual for the radiology department and no job descriptions for the radiology staff.

Review of the personnel files for radiology Staff C, D and E did not contain a current license.

The above findings were presented to the administrative staff during the exit interview, no additional information was provided.

Based on review of medical records and personnel files and staff interview, the hospital failed to ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs. This occurred for seven of seven nursing personnel (Staff F, I, J, K, L, M, and N) whose personnel files were reviewed.

Findings:

Competency/Training

In an interview with Staff on April 10, 2014, Staff K stated he was responsible for the sterilization of instruments, infection control, employee health and the drug room.

Review of Staff K personnel file did not contain evidence of training and competency verification for his duties in the drug room by the hospital's contract pharmacist. The personnel file also did not have documentation of training and competency verification for his duties in central sterile, employee health and infection control.

Staff K told the surveyors that licensed nursing staff administered respiratory treatments that included nebulizer treatments. The personnel files for Staff, L, M, and N did not contain documentation of training by the respiratory therapist.

Medical records # 5, 7 and 10 had documentation of hand held nebulizer respiratory treatment, the records did not contain assessment and evaluations of the patient's conditions before and after the treatments, including vital signs, oxygen saturation, lung sounds and presence of a cough, with a description of any productive sputum or if the patient felt or had improved breathing after the treatment. This was confirmed by Staff N on the afternoon of 04/11/14 during medical record review.


Evaluation
Staff A and K were both asked if the hospital had any patient complaint/grievance for the current year, both stated no.

In an interview with Staff N, she stated during a one to two week span a few months ago, she had received several patient complaints of verbal abuse by Staff J.

Staff N was asked if the hospital investigated the complaints and if Staff J received any counseling, Staff N stated not to her knowledge.

Review of the personnel file for Staff J did not contain documentation of an current evaluation or any counseling or corrective action taken related to allegations of patient abuse.

Based on a review of personnel files and interviews with hospital staff, the hospital failed:

a. to ensure that the State nurse aide registry was checked for findings for staff that might have patient contact, this occurred in five of six (Staff C, D, E, F, G and J) personnel files that were reviewed ;

b. to investigate all allegations of patient abuse and;

c. to develop and implement written policies and procedures to prevent patient abuse.

Findings:

Staff C, D, E, F, G and J are staff members who provide direct patient care. Review of the personnel files for did not contain documentation the State nurse aide registry was checked for findings of abuse.

Staff A and K were both asked if the hospital had any patient complaint/grievance for the current year, both stated no.

In an interview with Staff N, she stated during a one to two week span a few months ago, she had received several patient complaints of verbal abuse by Staff J.

Staff N was asked if the hospital investigated the complaints and if Staff J received any counseling, Staff N stated not to her knowledge.

Review of the personnel file for Staff J did not contain documentation of an current evaluation or any counseling or corrective action taken related to allegations of patient abuse.

The hospital's abuse policy was reviewed on 04/10/14. The policy did not indicate what steps the hospital would take to protect the patient during an abuse allegation and investigation.

The above information was presented to the administrative staff during the exit interview, no additional information was provided.

Based on review of the hospital's swing bed policies and procedures and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program with activities based on the individual needs and interests of the patients. This occurred for two of two swingbed patients (Records #7 and 18) whose medical records were reviewed.

Findings:

Review of the medical records for Patients # 7 and 18 did not contain an activity assessment with the required elements and ongoing activities based on their assessment.

This was confirmed by Staff N on the afternoon of 04/11/14 during chart review.

The above information was presented to the administrative staff during the exit interview, no further information was provided.