HospitalInspections.org

Based on documentation review, staff interview, and policy review the Critical Access Hospital (CAH) failed to maintain proper air exchanges (these settings are used for comfort as well as asepsis (the exclusion of bacteria and other microorganisms, typically during surgery), safety, and control of odors) in the Operating rooms (OR) in 3 of 3 ORs (#1, #2 and #3) and failed to ensure the negative pressure room (includes a ventilation system that generates negative pressure to allow air to flow into the isolation room but not escape from the room, as air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air from escaping the room).functioned properly for one of two rooms (#121). This deficient practice has the potential of microbial growth and increased risk of infections to their patients.


Findings Include:

- Maintenance records reviewed on 9/26/2017 at 10:00AM revealed the CAH failed to ensure documentation of air exchanges in all Operating Rooms. The CAH provided no evidence of any preventative maintenance from an outside company to ensure the air exchanges followed acceptable standards of practice.

Director of Maintenance Staff E interviewed on 9/26/2017 at 10:00 AM indicated the air exchanges had not been monitored. Staff E stated they have no evidence of preventative maintenance on the air exchanges and they did not know it was a requirement.

- American Institute for Architects (AIA) recommend a minimum of 15 exchanges per hour in the OR.

- The CAH failed to provide a policy directing staff to monitor air exchanges in the ORs and to have preventative maintenance to ensure the systems worked properly.

- Observation of the acute inpatient unit on 9/26/2017 at 11:30 AM revealed one of the negative pressure rooms (#121) failed to function properly during the maintenance tour.

Director of Maintenance Staff E interviewed on 9/26/2917 at 11:30 AM acknowledged the negative pressure did not work properly. Staff E placed a paper towel to the vent inside the door of room 121 and there was no suction. Staff E stated they think the belt broke.

- The CAH failed to provide a policy directing staff to ensure the proper maintenance of the negative pressure rooms.

Based on observation, document review, and staff interview the Critical Access Hospital (CAH) failed to provide a store drugs in a safe manner for two of two crash carts in the emergency department (ED) and intensive care unit (ICU). This deficient practice failed allowed drugs to be available for unauthorized use.

Findings include:

- Observation in the ED on 9/25/17 at 11:25am and observation in the ICU on 9/25/17 at 12:00pm revealed a black box placed on the top of each of the crash cart. The CAH had not secured the boxes to the crash carts and the boxes had a red break away plastic lock attached to them. These break away locks are easily opened with a twist of the plastic lock potentially giving access to the contents of the box to anyone.

Staff G, Registered Nurse (RN), ED manager explained the box is equipped with supplies and drugs that they use in an emergency for intubation (placing a tube in a patient's throat to help them breathe). The boxes had a label on top of them listing the contents of the box including the following drugs:

1- Pre-filled syringe of Lidocaine 2% (used to numb the skin).
3- Vials of Ketamine (used to produce anesthesia of the patient).
3- Vials of Diprivan (used to cause relaxation of the patient).
2- Vials of Fentanyl (a narcotic to treat pain).
3- Vials of Etomidate (an anesthesia that caused sedation (sleepiness).
3- Vials of Versed (helps patients feel relaxed).
2- Vials of Zemeron (a paralytic used to relax muscles).
2- Vials of Anectine (a paralytic used to relax muscles).


Administrative staff G, RN interviewed on 9/25/17 at 11:25pm confirmed the emergency boxes only had the red plastic break away lock on it and they had not secured the boxes to the crash cart making it available for unauthorized use.

Staff H, pharmacist interviewed on 9/25/17 at 1:00pm explained they were not aware of the box of drugs on the crash cart and explained the drugs need to be double locked and secured because of the controlled substances in the boxes.

Based on observations, staff interview, and policy review, the Critical Access Hospital's (CAH's) Infection Control Officer failed to ensure the hospital provided proper cleaning for three of four toe nail clippers; failed to ensure the hand washing sink is separated from clean/sterile supplies for one of one procedure room; failed to ensure clean supplies are stored properly for one of one Endoscopic cleaning room; failed to ensure staff performed hand hygiene for three of four hand hygiene observations (Staff F, Staff A, and Staff I); failed to ensure kitchen staff date food and drink for one of two inpatient kitchenettes; failed to ensure patient water bottles are stored properly for one of two surgery inpatient kitchenettes (recovery room); failed to ensure the integrity of sterile supplies for two of four Post Anesthesia Care Unit (PACU) bays (bay 3 and pediatric bay) and failed to ensure all supplies are maintained to meet patients' needs for one of one inpatient nursing medication room and one of one PACU unit. These deficient practices have the potential to expose all patients and healthcare workers to infectious diseases and placed all patients at risk for receiving ineffective supplies.


Findings Include:


- Nurses' Medication room observed on 9/25/2017 at 11:40 AM revealed three rusty toe nail clippers in the drawer next to entrance door.

Registered Nurse (RN), Staff D on 9/25/2017 at 11:40 AM acknowledged the clippers were rusty. Staff D stated I would not have used them, we soak them so maybe that caused them to rust.

- The CAH failed to have a policy regarding cleaning and storage of toe nail clippers.


- Observation of the procedure room on 9/26/2017 at 10:30 AM revealed opened clean/sterile supplies for patient #26 lying on the counter close to the hand washing sink. RN, Nurse Manager Staff E washed her hands and reached over for a paper towel. The paper towel holder was just above the clean/sterile supplies and so the supplies could potentially be contaminated by dripping water.

RN, Nurse Manager Staff E interviewed on 9/26/2017 at 3:00PM regarding the proximity of the clean/sterile supplies to the handwashing sink. Staff E stated they did not think it was a problem.


- Observation of the Endoscopic cleaning room on 9/26/2017 at 10:15 AM revealed RN, Nurse Manager Staff E placing the clean Endoscope into a biohazard container (a dirty container) which was sitting on a cart containing clean supplies (clean supplies should not be mixed with dirty supplies because of the risk of contamination). Also, the CAH staff used a hopper (a large flushable basin used to empty body fluids) located next to the clean supplies cart and the hopper had no shield on it to prevent splashing and potential contamination of the clean supplies.

RN, Staff D on 9/26/2017 at 10:15 AM acknowledged the unclean container was on the clean supply cart and maybe the container should be on the dirty side. Staff D stated the hopper is used by the Post Anesthesia Care Unit (PACU) staff to empty urine or any type of contaminate.

- The CAH failed to have a policy directing staff to keep clean and dirty supplies separate and not in close proximity to a source of potential contamination.


- Observation of Physician Staff F on 9/26/2017 at 12:00 PM revealed Staff F entered room 119 and did not perform hand hygiene.

RN, Staff D who was making rounds with Physician Staff F acknowledged they did not perform hand hygiene when they entered the patient's room.

- Observation of the Pre-operative area on 9/26/2017 at 8:12 AM revealed RN, Staff A did not perform hand hygiene when entering patient #26's room. Staff A then left the room to get the Blood Pressure machine and failed to perform hand hygiene. Staff A reentered Patient #26's room with the Blood Pressure Machine and again failed to perform hand hygiene.

RN, Staff A on 9/26/2017 at 8:20 AM acknowledged they did not perform hand hygiene when entering and exiting patient #26's room.


- Observation on 9/26/17 at 4:00pm revealed RN, Staff I applying a "wound-vac" (an apparatus that is secured over a wound to suction secretions away from the wound and help in healing the wound) to patient #25's right foot. During the process of cleaning the wound and applying the "wound-vac", Staff I removed and reapplied gloves three times and failed to perform hand hygiene in between glove changes.

Policy titled "Hand Hygiene" reviewed on 9/27/2017 at 4:00 PM directed staff "...Hand hygiene is indicated when: before and after having direct contact with patients..." "...After contact with patient's intact skin..."


- Observation of the acute inpatient kitchenette on 9/25/2017 at 12:30 PM revealed 2 peanut butter jars (80-ounces and 64-ounces) opened, used, with no open or expiration date. Also observed on the counter, an undated pitcher of tea.

RN, Staff I on 9/25/2017 at 12:30 PM acknowledged the peanut butter jars and tea did not have a date on them. Staff I stated the peanut butter is for the patients.

- The CAH failed to have a policy directing staff how to label food and drink items when opened and used for patients.

- Observation of the Patient Kitchenette in the surgery unit (recovery room) on 9/26/2017 at 8:45 AM revealed twenty-two 10 ounces water bottles stored under the kitchen sink.

RN, Staff A on 9/26/2017 at 8:45 AM acknowledged there should be nothing under the sink, not sure why the water bottles were there. Staff A stated that those water bottles are used for the patients.

- The CAH failed to have a policy directing staff on how to store drinks for patients.


- Observation of the PACU on 9/26/2017 at 11:04 AM revealed two open sterile Yankauers (suction tip for oral suctioning) packages attached to the suction tubing in PACU bay 3 and in the pediatric bay.

RN, Staff B on 9/26/2017 at 11:10 AM acknowledged the Yankauer packages should not have been opened and attached to the suction tubing.

- Policy titled "Sterility of Supplies" reviewed on 9/28/2017 directed the staff "...Every sterilized piece of equipment or instrument will remain in its original package until the item is ready to be used. At that time it will be opened per sterile technique and used as indicated. If an item is opened and not used at once, sterility is not upheld and it will be discarded ..."


- Inpatient nursing medication room observed on 9/25/2017 at 11:40 AM revealed 9 disks filters (used with intravenous tubing to prevent loss of fluid) with expiration dates of 6/2017 and 7/2017.

RN, Staff D on 9/25/2017 at 11:45 AM acknowledged the disks filters were expired and should have been disposed.


- PACU observed on 9/26/2017 at 11:10 AM revealed one 4x3 telfa dressing (gauze) expired on 3/2017.

RN, Staff B on 9/26/2017 at 11:20 AM acknowledged the dressing was expired and should have been disposed.

- The CAH failed to have a policy directing their staff to dispose of expired supplies.

Based on documentation review, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure the medical record was closed within 30 days of patients discharged for one of 26 medical records reviewed (Patient # 4). Failure to complete medical records in a timely manner may lead to incomplete patient health information being available for other health care providers.

Findings include:

- Patient #4's medical record review on 9/27/2017 revealed an inpatient admission date of 5/11/2017 for Gastrointestinal (stomach and the intestines) bleeding and dismissed on 5/12/2017. The CAH failed to ensure Physician Staff F completed and signed their discharge summary within thirty days after the patient was discharged from hospital. Staff F dictated and signed the patient discharged summary on 6/16/2017 - 35 days after Patient #4 was discharged from the hospital.

Staff C on 9/27/2017 4:00 AM acknowledged the medical record was not completed in the 30 days after the Patient discharged per their policy.

- Policy titled "The Medical Record" reviewed on 9/28/2017 directed staff, "These orders shall be time, dated and authenticated by the prescribing or covering practitioner within 72 hours of the patient's discharge or 30 days after the order is written, whichever occurs first ..."