HospitalInspections.org

Based on observation, staff interview and documentation review, the facility failed to develop and maintain routine proucedures for cleaning and sanitizing the ice machine and failed to follow the manufacturer's recommended cleaning frequency. This had the potential to affect all patients who utilized the ice machine.

Findings are:

A. A tour of the patient care area was conducted on 9/3/14 with the Quality Assurance (QA) coordinator at 4:30 P.M. An ice machine was located in the patient care area across from Room 6. The QA coordinator indicated that the nurses were responsible for cleaning the ice machine, but only on the outside of the unit.

B. On 9/4/14 at 12:30 P.M. an interview conducted with the head of the maintenance department indicated that the ice machine was cleaned on the inside by the maintenance department, on an as needed basis only and that they did not have written instruction on how to clean the interior of the unit, or what sanitizing solutions were safe and effective.

C. A review of the manufacturer's instruction manual, page 18, stated "Sanitizing of the ice storage bin should be scheduled for a minimum of 4 times per year." Additional instructions recommended using a dilute Clorox solution for sanitizing the interior.

Per the Centers for Disease Control and Prevention Morbidity and Mortality Weekly 8/18/2009 Guidelines for Environmental Infection Control in health Care Facilities,
ice machines harbor a host of bacteria, parasites and fungi. They serve as a reservoir source for potential hospital-acquired patient infections.

Based on review of the All Hazards policy and procedure manual and staff interview, the Critical Access Hospital (CAH) failed to develop a disaster plan that included sewer system failure and how the CAH would provide food during emergency/disaster situations. Census on the first day of survey was 1 swing bed patient. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 102 acute inpatients and 53 swing bed patients. The lack of a plan for sewer system failure and provision of food had the potential to affect all patients of the CAH.

Findings are:

A. Review of the All Hazards policy and procedure manual (which included the Disaster Plan and Utility Loss Plan/Policy) revealed no plan for sewer system failure or provision of food during emergency/disaster situations.

B. Interview with the Dietary Team Lead on 9/3/14 from 9:00 AM - 10:00 AM revealed the following:
- Confirmed no plan for providing food during emergencies/disaster situations;
- Felt the CAH had enough canned food to provide for patients; and,
- Did not know whether the emergency generator provided electricity to equipment in the kitchen during electrical outages.

C. Interview with the Maintenance Supervisor and the IC (Infection Control)/Occupational Health Coordinator (duties include disaster preparedness) on 9/3/14 from 2:30 PM to 2:55 PM revealed the following:
- Identified that bedside commodes would probably be used if the CAH could not use their sewer system;
- Indicated that the emergency generator provided electricity to the kitchen;
- Thought dietary kept enough food on hand for emergencies;
- Confirmed the lack of a written plan for sewer system failure and provision of food during emergency/disaster situations.

Based on review of Medical Staff Credentials Policy, review of practitioner credential files and staff interview, the CAH (Critical Access Hospital) failed to follow the Medical Staff Credentials Policy during reappointment for 7 of 11 practitioners reviewed (Practitioners I, J, L, N, O, P and R) reviewed. (The term "practitioner" includes physicians, dentists, optometrists and/or podiatrists.) The Medical Staff Credentials Policy requirements for reappointment included practitioner's competence, compliance with bylaws, rules and regulations and medical record completion. A total of 11 physician credential files were reviewed. The Medical Staff Roster (no date) listed 45 practitioners. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 102 acute inpatients, 53 swing bed patients, 371 emergency room visits, 90 outpatient operating room procedures, and 758 outpatient visits with specialty physicians. This failed practice has the potential to affect all patients treated by practitioners at the hospital.

Findings are:

A. Review of the Medical Staff Credentials Policy approved by the Governing Body on 11/15/12 under Article 5 Reappointment, 5.A.1. Eligibility for Reappointment listed the following requirements:
- "completed all medical records";
- "continued to meet all qualifications and criteria for appointment and the clinical privileges requested"; and,
- "had sufficient patient contacts to enable the Medical Executive/Staff Committee to assess current clinical judgment and competence for the privileges requested. Any individual seeking reappointment who has minimal activity at Hospital must submit such information as may be requested (such as a copy of his/her confidential quality profile from his/her primary hospital, clinical information from the individual's private office practice, and/or a quality profile from a managed care organization), before the application will be considered complete and processed further."

continues under 5.A.2. Factors for Evaluation which lists the following factors for the determination of whether to reappointment the practitioner:
- "current clinical competence, judgment and technical skill in the treatment of patients";
- "compliance with the Bylaws, Rules and Regulations, and Medical Staff and Hospital polices at Hospital";
- "capacity to satisfactorily treat patients as indicated by the results of Hospital's performance improvement and professional and pThe Credentialing Policy eer review activities"; and,
- "appropriate resolution of any verified complaints received from patients and/or staff".

B. Review of the credential files for Practitioner I (last reappointment dated 2/20/14), Practitioner J (last reappointment dated 4/3/13), Practitioner L (last reappointment dated 11/21/13, Practitioner R (last reappointment dated 10/2/13), Practitioner O (last reappointment dated 5/15/14), Practitioner P (last reappointment dated 4/17/14), Practitioner R (last reappointment dated 11/21/13) revealed no information concerning these 7 practitioners' performance at the CAH including: completion of medical records; patient contact at the hospital; information on professional and peer review activities; and, information on whether there were any verified complaints.

C. Interview with the CEO (Chief Executive Officer) on 9/8/14 from 1:45 PM to 1:55 PM when asked how the medical staff and the governing body would know about a physician's practice at the hospital i.e. number of patients seen, medical record completion, peer review activity, verified complaints, CEO commented:
- "Not sure it is happening";
- "An area we can improve";
- "We used to do something like that; not sure what happened".
During a second interview on 9/8/14 at 3:40 PM the CEO confirmed that at the time of reappointment the medical staff and governing body would have no information on a practitioner's activity at this CAH.

Based on review of medical records and staff interviews, the facility failed to ensure the medical records were complete and accurate for 5 of 41 sampled patients. Of the 5 records,
1 patient record (Patient 3) lacked a signed consent for treatment (the consent signed upon admission to the hospital to grant the hospital permission to provide treatment.); 2 patient records (Patients 19 & 33) lacked documentation that the ordered Occupational Therapy (OT) evaluations were completed and 1 Patient (Patient 19) record lacked documentation that the ordered Speech Therapy (ST) evaluation and swallowing study were completed; and 2 Patients (Patients 9 and 36) record lacked documentation that a Dietary consultation was completed following a Nutritional Screening that identifed the patients at nutritional risk. The facility census was 1 swing bed patient. This had the potential to effect the 53 patients admitted to swing bed or the 102 patients admitted to inpatient acute care for the fiscal year 7/1/13 to 6/30/14.

Findings are:

A. A review of Patient 3's medical record for the 5/9/14-5/13/14 inpatient acute care stay lacked a signed Consent for Treatment (the consent signed upon admission to the hospital to grant the hospital permission to provide treatment).

B. An interview with the Vice President of Patient Services (VP of Pt Services) on 9/8/14 at 11:00 AM regarding the follow up on questions related to Patient 3's medical record revealed, "I could not find a consent. Nursing did not get a consent form signed, it was an after-hours admission on a Friday and no one was in the office."

C. A review of Patient 19's medical record for the 7/18/14-7/20/14 inpatient acute care stay revealed the following Physician admission orders dated 7/18/14:
- "Diet-thickened liquids (fluids that are thickened due to swallowing difficulties) until swallowing study (completed).
- Swallowing study (a procedure performed by the ST to evaluate the ability for the patient to safely swallow food and fluids).
- PT (Physical Therapy) & OT to eval (evaluation) and treat.
- ST (Speech Therapy) to eval & treat."

D. A review of Patient 19's medical record for a 7/18/14-7/20/14 admission lacked documentation that swallowing study, ST evaluation and treatment plan, OT evaluation and treatment plan had been completed for Patient 19; and that the thickened liquids had been provided as ordered.

E. An interview with the VP of Pt Services on 9/8/14 at 11:00 AM regarding a follow up on questions related to Patient 19's medical record revealed:
- "The OT order was after hours on Friday. The OT staff had called in to see if any patients were admitted. OT had planned to see the patient on Monday, but the patient was already gone."
- "Regarding the ST order and the swallowing study, the nurse documented a call to ST on Friday at 5:10 PM and "left a message". There was no documentation from the ST. I called the ST and was told that if the order was received after hours on Friday they would not see the message till Monday morning. I will follow up with the ST office to see how we would contact them if we needed a swallow evaluation on the weekend. Their (ST) contract reads "hours available are Monday-Friday with weekend coverage as deemed medically necessary. I would say that a swallow evaluation on a patient is deemed medically necessary."
- "Regarding the order for the thickened liquids until after the swallow study, I saw that the chart identified the patient as NPO (nothing by mouth) on all days except for swabs (swabs used to clean and moisten the mouth). When talking with the nurse that weekend [gender] felt the patient would not have tolerated anything oral but did not talk to the provider of change the order."

F. A review of Patient 33's medical record (for a 7/7/14-7/11/14 swing bed care stay) lacked documentation of an OT to evaluate and treatment plan as ordered on 7/7/14.

G. An interview with the VP of Pt Services on 9/8/14 at 11:00 AM regarding a follow up on questions related to Patient 33's medical record stated, "The order was noted by the admitting nurse. I checked the OT's log of patients and nothing was noted that the OT staff was notified of the order. The missed order was not noted on the 24 hour chart check or by nursing doing concurrent chart reviews. It appears it was missed and can't see that OT received the order."

H. A review of Patient 9's medical record (for a 6/12/14-6/15/14 inpatient acute care stay)revealed a score of 8 on The Adult Nutrition Screening which indicated the patient was at 'moderate nutritional risk'. The medical record lacked documentation of the Clinical Dietician being notified of the patient being at a moderate nutritional risk The Clinical Dietician is to be notified of the results of the Adult Nutrition Screening tool when the patient score (5-9) indicates the patient at moderate nutritional risk or when the patient score (>10) indicates the patients at high nutritional risk.

I. An interview with the VP of Pt Services on 9/8/14 at 11:00 AM regarding a follow up on questions related to Patient 9's medical record stated, "Our Dietary Supervisor was on PTO (personal time off) on Friday the 13th and did not see the patient."

J. A review of Patient 36's medical record (for a 3/6/14-3/14/14 swing bed care stay) revealed a score of 7 on The Adult Nutrition Screening which indicated the patient was at 'moderate nutritional risk'. The medical record lacked documentation that the Clinical Dietician being notified of Patient 36 being at a moderate nutritional risk. The Clinical Dietician is to be notified of the results of the Adult Nutrition Screening tool when the patient score (5-9) indicates the patient at moderate nutritional risk or when the patient score (>10) indicates the patients at high nutritional risk.

K. An interview with the VP of Pt Services on 9/8/14 at 11:00 AM regarding a follow up on questions related to Patient 36's medical record stated, "This patient had been an acute inpatient before going into the swing bed. When the patient was assessed for the acute inpatient Nutritional Screen the score was a 4. Upon being assessed during the swing bed admission the score was a 7. Nursing never changed the patients status to swing bed; therefore, [the dietary manager] did not know to re-evaluate the patient. [The dietary manager said that routinely if [gender] knows a patient has gone to swing bed [gender] will copy the acute care notes and continue on charting with the swing bed stay, contacting the dietician when appropriate."

Based on observation of the electronic system used for Cardiac and Pulmonary Rehabilitation, review of DVD (Digital Versatile Disc - round disc used for storing video, audio and/or still images that can be placed in a computer and viewed) for Cardiopulmonary Rehabilitation System, review of paper medical records and staff interview, the CAH (Critical Access Hospital) failed to ensure the confidentiality and potential unauthorized use of medical record information for 1 of 1 Cardiac Rehabilitation records reviewed (Medical Record 40). The CAH currently had 5 Cardiac and Pulmonary Rehabilitation outpatients. From 7/1/13 to 6/30/14 the CAH had a total of 8 Cardiac and Pulmonary Rehabilitation outpatients.

Cardiac and Pulmonary Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart or lung problems.

Findings are:

A. Interview with the Outreach Coordinator on 9/3/14 from 1:15 PM to 1:30 PM revealed the following information about the Cardiac/Pulmonary Rehabilitation services:
- They use a computer program that electronically monitors the patient during their exercise session;
- At the end of the session the individual conducting the session prints the data from the computer and signs the Session Report;
- The session reports become part of the paper medical record for the patient;
- The 2 people that can access the patient information in the Cardiac/Pulmonary Rehabilitation computer system include the Outreach Coordinator and RT (Respiratory Therapist) G; and,
- Both the Outreach Coordinator and RT - G use the same user login and password to access patient information.

B. Observation on 9/3/15 at 1:30 PM the Outreach Coordinator demonstrated how to access the Cardiac/Pulmonary Rehabilitation program on the computer by putting in a user name and password. During this same observation RT-G accessed the electronic portion of Medical Record 40 and explained how to change information in the stored information.

C. Review of Medical Record 40 revealed this patient's first session was on 2/26/14. The record included a Session Report for Session 1 that included patient's personal health information such as medications, diagnosis, vital signs, and comments from the person person directing the session. This session report was signed by LPN (Licensed Practical Nurse)-W. (LPN-W no longer works at the CAH.)

D. On 9/3/14 from 4:15 PM To 4:30 PM surveyor and Outreach Coordinator reviewed a DVD that came with the computer program for monitoring of cardiac/pulmonary rehabilitation patients. The DVD included a section under System Basics - Section Username and Password that identified how to set up security for individuals using the computer system by creating a username and password.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to provide each patient with a resident rights notice that contained all of the 13 Swing Bed Resident Rights. The notice that was provided to the patients lacked 4 of the 13 Rights including:
- The right to be informed in writing at the time of admission of the charges covered under Medicaid or Medicare, and those items that the patient may be charged and the amount of the charges;
- The right to work;
- The right to send and receive mail unopened; and,
- The right to share a room with their spouse when married and live in the same facility.
The facility census was 1 swing bed patient. This had the potential to effect all patients admitted to the swing bed unit.

Findings are:

A. A review of the Patient Packet for Swing Bed, revealed a "Patient Handbook revised September 2013" which included a section labeled "Patient Rights & Responsibilities." The Patient Rights & Responsibilities section lacked 4 of the 13 rights. The Patient Packet for Swing Bed also included a half sheet green paper titled "Comfort Items Not Paid by Medicare". This paper listed 10 items (mouthwash, comb, denture cup, kleenex, lotion, toothbrush, toothpaste, toothettes, slippers and shampoo) with no mention of the cost of the items or how the patients could find out the cost.

B. An interview with the Social Services Designee (SSD) on 9/8/14 at 1:00 PM-1:55 PM revealed, "We have a separate admission packet for our swing bed patients. In the admission packet is the handbook with the patient's rights. But no, I don't see that this booklet (Patient Handbook) spells out all of the swing bed rights." When asked about how the patients are aware of what is not covered under Medicare during their stay, the SSD identified that the patients are provided the half sheet green paper titled "Comfort Items Not Paid by Medicare " in their patient packet for swing bed. "I'm not sure how we would provide the prices, I know they just could ask. The prices change sometimes and we would need to keep that updated, we will figure out something."

C. Interview with the Vice President of Patient Services (VP of Pt Services) on 9/8/14 at 1:30 PM verified, "I just called [my consultant nurse] and was told that there is a separate Patient Handbook available for swing bed patients that spells all of the rights out just as they are written in the regulation. But we did not get that book, so we will get it ordered and put into place."

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a policy and procedure in place to ensure the written notice for the facility initiated transfer or discharge of the resident includes all the necessary components. The facility census was 1 swing bed patient. This had the potential to effect the 53 patients admitted to swing bed for the fiscal year July 1, 2013 to June 1, 2014

Findings are:

A. Review of the "CAH Discharge Planning and Social Services Policy -TRANSFER and DISCHARGE RIGHTS" (dated 1/5/01) revealed the lack of required components for a written notice including:
- The reason for transfer or discharge;
- The effective date of transfer or discharge;
- The location to which the resident is transferred or discharged;
- A statement that the resident has the right to appeal the action to the State; and,
- The name, address and telephone number of the State long term care ombudsman.

B. Interview with the Vice President of Patient Services (VP of Pt Services) on 9/8/14 at 3:30 PM stated, "I found the Transfer/Discharge Policy." The VP of Pt Services verified that the policy laced the components that were to be included in the written notice.

Based on staff interview and review of 5 of 5 patient records (Patients 32, 33, 34, 35 and 36), the CAH (Critical Access Hospital) failed to ensure that a qualified professional directed the patient activities program. The total swing bed sample was 5. The swing bed census during survey was 1. This had the potential to effect the 53 patients admitted to the swing bed unit.

Findings are:

A. An interview with the Social Services Designee (SSD) on 9/8/14 at 1:00 PM-1:55 PM revealed, "I do the Activity Assessment, make the activity care plan and provide them with the activity calendar. I also do the social history and the demographics when they are admitted to swing bed." When asked if (the SSD) had completed a training course for activities, the SSD presented a certificate of attendance for the 36-Hour Social Service Director Course. The SSD verified, "This is the course I took, I didn't do a course specific to activities."

B. Record review for Patients 32, 33, 34, 35 and 36 revealed an activity assessment completed by SSD.

Based on review of facility brochure, "Patient Rights and Responsibilities" and staff interview, the Critical Access Hospital failed to inform each patient of their visitation rights. The facility census was 1 swing bed on entrance. This had the potential to effect all patients admitted to the facility.

Findings are:

A. Review of the patient packet for acute care revealed a "Patient Handbook revised September 2013" which included a section labeled "Patient Rights & Responsibilities." The Patient Rights & Responsibilities lacked information about visitation including the domestic partner (same sex partner) verbiage.

B.. Interview with the Vice President of Patient Services (VP of Pt Services) on 9/8/14 at 11:00 AM verified, "I know we talked about that part of the information about the domestic partner. I thought it was included on the consent form we have them sign, but I don't see it. We must not have gotten it included, we will get that taken care of."