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Based on observation, policy/procedure, document review, and staff interview, the CAH (Critical Access Hospital) failed to ensure maintenance staff inspected and tested for performance and safety for patient use for 25 of 25 Stryker electric beds used for patients on the medical/surgical and obstetric units.

Failure to ensure maintenance staff inspected and tested the performance and safety for patient use for each of the 25 Stryker electric beds used for patients on the medical/surgical and obstetric units complete required electrical safety inspections on could potentially result in patient harm from electrical malfunction.

Findings include:

1. Review of the CAH policy titled "Utilization of Medical Equipment", reviewed 9/2012 documented in part ..."Policy: Plant Operations is responsible for asset management, equipment safety, maintaining and repair of owned medical equipment. Procedure: Patient care equipment and other equipment used in patient care areas will be inspected by Plant Operations and/or other service provider prior to use and at regular intervals to be determined by Plant Operations Supervisor. An inspection label will be affixed by Plant Operations to each item inspected."

2. Review of the hospital document, CAH purchase orders for 25 Stryker electric beds revealed the following; 15 beds were delivered on 6/23/2013, 7 beds were delivered on 12/13/2013 and 3 beds were delivered 12/31/2013 and all 25 beds were placed in service for patient use.

3. Observation on 2/1/15 at 12:30 PM during an environmental tour of the medical/surgical and obstetric units with Staff C, Chief Nursing Officer (CNO) showed 25 of 25 Stryker electric beds used for patients lacked documentation of a electrical safety inspection.

4. During an interview on 2/2/16 at 1:10 PM, Staff Q, Maintenance Supervisor stated the 25 Stryker electric beds did not have current biomedical electrical safety checks and maintenance staff did not not check the beds for electrical safety and performance since 2013. Staff Q reported the maintenance staff did not add the 25 Stryker electric patient beds to the biomedical safety check log.

I. Based on observations, policy and document review and staff interviews, the Critical Access Hospital (CAH) Foodservice Department failed to use sanitary practices during food handling and patient meal service. The administrative staff identified a census of 9 patients. The Dietary Manager reported dietary staff provided an average of 25 patient meals daily.

Failure to maintain sanitary practices during meal service and food handling could potentially result in contamination leading to foodborne illness or a nosocomial infection.

Findings include:

1. Observation during food preparation and meal service on 2/2/16, from 11:00 AM to 11:50 AM, revealed the following concerns:

a. Staff L, Foodservice Worker, touched multiple surfaces, including but not limited to refrigerator handles, cupboard/drawer handles, package of chopped lettuce and a package of boiled eggs. Staff L donned clean gloves on 4 separate occasions and failed to wash hands prior to donning gloves. Staff L handled the packages of lettuce and boiled eggs, and touched his clothing with gloved hands and handled ready to eat food, including chopped lettuce and a peeled boiled egg with the contaminated gloves, to prepare a salad for service to a patient.

b. Staff M, Foodservice Worker, obtained a package of sliced ham and sliced cheese from the walk-in cooler. Staff M donned gloves but failed to wash her hands prior to donning the gloves. Staff M obtained a package of bread with her gloved hands and removed 2 slices of bread. Staff M then opened the packages of sliced ham and cheese, removed slices of ham and cheese and prepared a sandwich for service to a patient, with the contaminated gloves.

c. Staff N, Cook, donned gloves in preparation to dish hot food for patient meals. Staff N touched a variety of surfaces, with the gloved hands, including but not limited to, steamer handle, counter surfaces, bread package, fryer handle, clothing and face. She changed gloves once but failed to wash her hands prior to donning a clean pair of gloves. Staff N handled ready to eat food, for service to patients, including an order of prepared chicken strips, fish, onion rings and a bread slice, with the contaminated gloves.

d. Staff K, Foodservice Worker, prepared to deliver patient meals trays by donning gloves. Staff K delivered meal trays to 7 patient rooms, 3 of which had a signed posted at the door titled "Contact Precautions". Between each tray delivery, Staff K removed her gloves in the hall and placed the used gloves on top of the meal delivery cart, . Staff K failed to perform any hand hygiene following the removal of gloves and donning new ones.

2. Review of an undated Foodservice Department policy titled, "Tray Assemble and Delivery-Room Service" revealed in part " ... If the patient is in isolation, be sure to follow hospital procedures ... "

3. Review of the sign posted for contact precautions revealed it identified the need to wear gloves when entering the room, removal of gloves before leaving the patient room and the need to wash hands with an anti-microbial agent immediately after glove removal.

4. During an interview on 2/2/16, at 11:50 AM, Staff K reported she wears gloves with patient tray delivery and changes between each room. She acknowledged she preferred to use gloves rather than hand sanitizer. Staff K reported when a patient room has a precaution sign on the door, she checks with nursing to find out for sure what she needed to do and had been told to wear gloves.

5. During an interview on 2/3/16, at 4:00 PM, Staff J, Foodservice Director, confirmed Staff K failed to follow the expected practice with patient meal tray pass. Staff J reported staff are to don gloves for all meal trays delivered, but are to discard the gloves in the patient room and use hand sanitizer prior to donning new gloves, to prevent the potential spread of contaminants from room to room. Staff J acknowledged the concern for cross-contamination with the meal service observation in the kitchen. He reported foodservice staff are to wash their hands prior to donning gloves and if other surfaces are touched, the gloves would be considered contaminated and the employee would need to remove them, wash hands and don a new pair.

6. During a follow-up interview on 2/4/16, at 8:05 AM, Staff J acknowledged the department does not have a specific policy to address proper glove use with food preparation and patient meal tray pass. He reported he plans to have a staff in-service meeting this month on the proper use of gloves.

7. During an interview on 2/3/16, at 7:45 AM, Staff F, Infection Preventionist/Employee Health, reported the infection control policy for precautions does not include specific language for foodservice employees to address patient meal tray pass . Staff F acknowledged concern with the described procedure Staff K used while performing patient meal tray pass for patients in contact isolation and reported gloves must be used and removed while in the patient room, under contact precautions, and hand sanitizer used, prior to proceeding to the next room.

8. The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires gloves to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation and hands must be washed before donning gloves when working with food.


II. Based on review of policies, documents, and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH volunteer personnel heath examinations were completed every 4 years.

Failure to ensure 3 of 3 CAH volunteer personnel reviewed, current health examinations could potentially result in causing harm to patients in the event of an unknown staffs' exposure and transmission of communicable diseases to the patients. (Staff G, H and I) The CAH identified 60 volunteers.




Findings include:

Review of an undated volunteer policy titled, "Infection Control Guidelines in Volunteer-Contract Services", revealed in part "... establish guidelines for volunteers/contract workers to follow for the prevention or spread of infection among patients, hospital staff, visitors and volunteers ... A volunteer/contract worker must be free from communicable disease and skin infections ..." The policy failed to define the specific health requirements required for volunteers providing services within the CAH.

Review of a packet of information provided to new volunteers revealed an undated document titled "Infection Control for Volunteers", which included in part " ... A health assessment will be completed prior to starting volunteer service and every four years. Temperature, pulse, etc will need to be completed by a nurse or ER tech ... "

Review of the selected volunteer files, on 2/3/16, at 12:50 PM, revealed they lacked documentation of a health assessment completed in the past 4 years for Staff G, H and I, Volunteers.

During an interview on 2/3/16, at 1:10 PM, Staff E, Foundation and Marketing Director, reported she coordinates the CAH volunteers, whom are required to have a tuberculosis (TB) test and health assessment when they start, and repeat the health assessment every 4 years. Staff E confirmed the health assessment, required to be completed by a medical professional, had not been completed in the past 4 years for Staff G, H and I. Staff E acknowledged the health assessment forms are supposed to be completed by an Registered Nurse (RN) in the clinic but she failed to review the forms, when returned to her, to ensure medical professional section had been completed.

During an interview on 2/4/15, at 7:45 AM, Staff F, Infection Preventionist/Employee Health, reported she reviews the health assessments completed on employees but the volunteer health requirements are monitored by Staff E. She confirmed she does not have an infection control policy specific to volunteer requirements nor does she review their health information upon completion of the health assessment form. Staff F reported she believed the volunteers were required to follow the same policy as employees, which required a health assessment every 4 years.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to secure and protect patient information from unauthorized users. The problem was identified for the shred bins/cabinets located throughout the hospital for open and locked containers.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

Review of an undated CAH policy titled "HIPAA [Health Insurance Portability and Accountability Ac] Privacy Minimum Necessary Policy" revealed in part " ... WCHC [Washington County Hospital and Clinics] will take reasonable steps to limit the use or disclosure of, and requests for protected health information ... WCHC will identify those persons or classes of persons, as appropriate, in its workforce who need access to PHI [personal health information] to carry out their duties ..." Review of the document titled "Minimum Necessary Personnel Grid - Access to PHI" (referred to in this policy) revealed the views of PHI identified for a housekeeper included name, bed, room number, special cleaning instructions and the views identified for maintenance included incidental only.

Review of an undated CAH policy titled "Information Security" revealed in part " ... The scope of information security is to protect information whether it is written, spoken, ... from accidental or intentional modification, destruction or disclosure. Information will be protected throughout its life cycle (origination, entry, processing, distribution, storage and disposal).

During an interview on 2/2/16, at 9:00 AM, Staff O, Housekeeping Supervisor, reported the procedure for collection of shred material included an assigned housekeeping staff member emptied the shred containers into a large, yellow unlocked barrel, which would then be emptied into a large locked gray bin. She reported Patient Registration and the Health Information Management (HIM) department each have a small locked cabinet, the Business Office has a large grey locked bin and there are 7 large grey locked bins stored in the garage, for shred material but the majority of areas, throughout the CAH, have open containers to discard shred material. Staff O acknowledged the key to the locked shred bins is stored in the locked housekeeping supply room, which is accessible to all housekeeping an maintenance staff.

During an interview on 2/2/16, at 1:55 PM, Staff R, Medical Records Tech, reported housekeeping staff empty their shred containers while the area is staffed. She confirmed the material in the shred containers would include personal patient information such as name, address, medical information, etc. Staff R reported the contents of the shred containers are emptied into an unlocked barrel and the staff person would have the opportunity to view the information after leaving the area.

During an interview on 2/2/16, at 3:20 PM, Staff A, Medical Office Coordinator, reported she used an open cardboard box for shred information and the box was emptied daily, while she is in her office, by housekeeping staff.

During a follow-up interview on 2/3/16 at 9:30 AM, Staff O acknowledged the potential concern regarding the access to personal health information contained in the CAH's shred containers. Staff O confirmed Environmental Services staff do not have access to patient's electronic health records but acknowledged access to the shred materials would allow for potential unsupervised access to the same type of information. She confirmed the key to the locked shred bins are accessible to 13 Environmental Services employees and 4 maintenance employees.

During an interview on 2/3/16, at 10:15 AM, Staff P, Housekeeping, confirmed one of his regular duties included emptying shred containers, throughout the CAH, into a large yellow, unlocked barrel, which is then emptied into locked containers, stored in the garage. Staff P confirmed the key to the locked bins is located in the housekeeping supply room.

During an interview on 2/3/16, at 1:50 PM, Staff D, Compliance/Privacy Officer, reported housekeeping and maintenance employees would not need to access personal health information to perform their jobs and do not have access to the electronic health record. Staff D reported she would not have a concern with the transport of locked shred bins by housekeeping staff, but acknowledged she lacked knowledge of the current process for the transport of unsecured shred materials to the locked bins, and the key storage allowed housekeeping and maintenance staff access. Staff D confirmed when housekeeping staff are transporting unlocked containers, and have access to the shred bin key, they would have the ability to view the information in an unsupervised setting, and should not be able to do so.