HospitalInspections.org

Based on policy and procedure manual review and staff interview the Critical Access Hospital (CAH) failed to develop policies with the advice of a group of professional personnel that included at least one physician assistants or nurse practitioners, an outside reviewer, and the Governing Body for 9 of 9 policy and procedure manuals reviewed.

Findings include:

- Review of the policy and procedure manuals provided during the survey between 5/9/11 through 5/12/11 lacked evidence that a physician assistant or nurse practitioner, an outside reviewer, and the Governing Body was included as part of the group of professional personnel that developed and/or reviewed the policy and procedure manuals within the last year.

Staff A interviewed on 5/10/11 at 3:45pm acknowledged the CAH lacked evidence the physician assistant or nurse practitioner, outside reviewer, and the Governing Body developed/reviewed the policy and procedure manuals within the last year.

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 precautions for one of one observed cleaning of a patient room and one of one observed glucometer testing.

Findings include:

- The CAH's information sheet for "pH7Q ULTRA" manufacturer's guidelines for disinfection reviewed on 5/10/11 at 2:55pm instructed staff to allow surfaces to remain wet for ten minutes to assure disinfection.

- The CAH's information sheet for "Clorox" bleach solution manufacturer's guidelines for disinfection reviewed on 5/10/11 at 2:55pm instructed staff to allow surfaces to remain wet for ten minutes to assure disinfection.

- The CAH's policy for hand hygiene reviewed on 5/10/11 at 4:30pm directed "...hands are to be washed after touching blood, body fluids, secretions, excretion, or other contaminated items, whether or not gloves have been worn ..."

- Staff L was observed on 5/10/11 at 12:10pm cleaning room 106 on the nursing unit. Observations during the room cleaning process revealed the following breaches in infection control practice: regarding hand hygiene, cleaning from less dirty areas to more dirty and disinfectant wet time per manufacturer's recommendations. For example:

Staff L, wearing a protective gown and gloves, used "pH7Q ULTRA" cleaner on the window ledge, mayo stand, counter top and sink. The surfaces remained wet for six minutes not the required ten minutes for disinfection.

Staff L then wiped down the bathroom toilet with "pH7Q ULTRA". Staff L then squirted bleach disinfectant on the inside and outside surfaces of the toilet and wiped the surface of with a cloth. The surfaces of the toilet remained wet for one minutes not the required ten minutes for disinfection.

Staff L, without changing their gloves, stepped out of the room to their housekeeping cart and picked up a bottle of glass cleaner and a clean cloth then re-entered the room to clean the mirror.

Staff L interviewed on 5/10/11 at 12:30pm acknowledged they failed to change their gloves and perform hand hygiene after cleaning the toilet and the cleaned surfaces in room 106 failed to remain wet for ten minutes required for total disinfection.

- The manufacturer's guidelines for the Contour glucometer(a machine to test blood sugars) reviewed on 5/11/11 at 3:15pm directed "...Healthcare professionals or persons using this system on multiple patients should follow the infection control procedures approved by their facility ....should be handled as if capable of transmitting viral diseases ..."

- Staff J observed on 5/9/11 at 12:15pm obtained a glucometer at the nurses station, entered room 108 and laid the glucometer case on the bedside table without a protective barrier. Staff J removed the patient's meal tray and placed the tray on the tray cart. Staff J performed hand hygiene, picked up the glucometer in the case then left the room. Staff J entered room 107 and laid the glucometer in the case on the counter without a protective barrier, performed hand hygiene, gloved, and removed the glucometer from the case and laid it on the bedside table without a protective barrier. Staff J obtained the blood sugar test, laid the glucometer on the counter, removed their gloves and performed hand hygiene. Staff J picked up the glucometer and case, returned to the nurses station, laid the case on the desk and cleaned the glucometer but failed to clean the glucometer case.

Staff J interviewed on 5/9/11 at 12:20pm acknowledged they laid the cased glucometer on surfaces in two rooms and failed to clean the glucometer case.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 15 of 33 sampled medical records (#'s 1, 5, 8, 9, 17, 19, 20, 22, 24, 27, 28, 29, 30, 31, and 33).

Findings include:

- The CAH's Medical Staff By-Laws reviewed on 5/12/11 at 9:45am directed "...All entries shall be dated and signed by the appropriate professional..." The Medical Staff By-Laws failed to include the requirement to time all entries into the medical record.

- Patient #17's medical record reviewed on 5/10/11 at 9:00am revealed an admission date of 2/18/11 with a diagnosis of febrile illness (elevated temperature) and discharged on 2/25/11. Record review revealed six written/verbal/telephone orders lacked the date and time when the practitioner authenticated (signed) the order.

- Patient #19's medical record reviewed on 5/10/11 at 9:45am revealed an admission date of 2/14/11 for a surgical procedure and discharged on 2/16/11. Record review revealed 12 written/verbal/telephone orders lacked the date and time when the practitioner authenticated (signed) the order.

- Patient #20's medical record reviewed on 5/10/11 at 10:15am revealed an admission date of 3/9/11 for a surgical procedure and discharged on 3/11/11. Record review revealed seven written/verbal/telephone orders and progress notes lacked the date and time when the practitioner authenticated (signed) the entry into the medical record.

- Patient #22's medical record reviewed on 5/10/11 at 10:45am revealed an admission date of 4/8/11 with a diagnosis of Sepsis (a severe infection) and discharged on 4/11/11. Record review revealed 10 written/verbal/telephone orders, progress notes, a history and physical, and a discharge summary lacked the date and time when the practitioner authenticated (signed) the entry into the medical record.

Staff K interviewed on 5/11/11 at 8:10am acknowledged the providers failed to date and time all entries into the medical record.

This deficient practice also affected patient #'s 1, 5, 8, 9, 24, 27, 28, 29, 30, 31, and 33.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to safeguard confidential patient information from possible unauthorized use in 2 of 2 unlocked, unattended radiology storage rooms.

Findings include:

- The CAH's Patient Rights reviewed on 5/11/11 at 2:30pm directed "...Each patient has the right to...confidential treatment if all communications and records pertaining to his/her care..."

- Observation on 5/9/11 at 11:30am and 5/11/11 at 3:00pm in the radiology storage room revealed an unlocked, unattended room with four file shelves each containing approximately 75 to 100 x-ray film records.

- Observation on 5/9/11 at 11:45am and 5/11/11 at 3:00pm in the radiology workroom revealed an unlocked, unattended room with ten file shelves each containing approximately 75 to 100 x-ray film records.

Staff K interviewed on 5/9/11 at 11:30am acknowledged the unlocked, unattended radiology films and the CAH failed to safeguard confidential patient information from possible unauthorized use.

Based on interview the Critical Access Hospital (CAH) failed to perform a periodic evaluation of its total program at least once a year, failed to evaluate all CAH services, failed to perform and document a periodic evaluation of the health care policies, failed to perform a periodic evaluation to determine utilization of services is appropriate, current policies and procedures are followed, and the need to revise practices based on the periodic evaluation to assure quality patient care.

Findings include:

- On 5/11/11 at 10:15am the CAH failed to provide documentation of a periodic evaluation of the total program

Staff B interviewed on 5/11/11 at 10:15am revealed the facility failed to perform a periodic evaluation for their total program

- The CAH failed to carry out or arrange for a periodic evaluation of its total program, at least once a year. See further evidence at CFR485.641(a), C-0331.

- The CAH failed to perform a periodic evaluation that included a review of their health care policies. See further evidence at CFR485.641(a)(1)(iii), C-0334.

- The CAH failed to perform a periodic evaluation to determine utilization of services is appropriate, current policies and procedures are followed, and the need to revises practices based on the periodic evaluation. See further evidence at CFR485.641(a)(2), C-0335.

The CAH failed to perform a periodic evaluation of services, policies and procedures to assure quality medical care to the patients of the CAH.

Based on staff interview and document reveiw the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program at least once a year.

Findings include:

- On 5/11/11 at 10:15am the CAH failed to provide documentation of a periodic evaluation of the total program

Staff B interviewed on 5/11/11 at 10:15am revealed the facility failed to perform a periodic evaluation for their total program

The CAH failed to carry out or arrange for a periodic evaluation of its total program, at least once a year.

Based on staff interview and document review the Critical Access Hospital (CAH) failed to perform a periodic evaluation that included a review of their health care policies.

Findings include:

- On 5/11/11 at 10:15am the CAH failed to provide documentation of a periodic evaluation of the total program that included a review of their health care policies.

Staff B interviewed on 5/11/11 at 10:15am revealed the facility failed to perform a periodic evaluation for their total program that included a review of their health care policies.

The CAH failed to perform and document an annual evaluation of their health care policies.

Based on staff interview and document review the Critical Access Hospital (CAH) failed to perform a periodic evaluation to determine the utilization of services are appropriate, current policies and procedures were followed and/or needed revised based on the periodic evaluation.

Findings include:

- On 3/18/08 at 2:35 the CAH failed to provide documentation of a periodic evaluation of the total program to evaluation utilization of services, current policies and procedures, and determine if changes needed to be made.

Staff B interviewed on 5/11/11 at 10:15am revealed the facility failed to perform a periodic evaluation for their total program to evaluate services and current policies and procedures.

The CAH failed to perform and document a periodic program evaluation to assure the CAH reviewed the appropriateness of the utilization of services and that policies and procedures were followed and or needed revised based on the program evaluation.

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to provide evidence of activities for 5 of 5 sampled swing bed residents (#'s 14, 15, 16, 17, and 18).

Findings include:

- The CAH's policy "Social Services and Activity" reviewed on 5/10/11 at 4:15pm directed "...Social Services and Activities will be offered to all Skilled and Intermediate Care Patients within the first 48 hours of admission ..."

- Patient #14's medical record reviewed on 5/9/11 at 12:30pm revealed an admission on 5/3/11 with a diagnosis of Urinary Tract Infection. The medical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

- Patient #15's medical record reviewed on 5/9/11 at 1:00pm revealed an admission on 5/3/11 with a diagnosis of Pneumonia. The medical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

- Patient #16's medical record reviewed on 5/9/11 at 1:30pm revealed an admission on 5/4/11 with a diagnosis of Congestive Heart Failure (the heart can't pump enough blood to meet your body's needs). The medical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

Staff F interviewed on 5/10/11 at 8:30am acknowledged they were responsible for activities for swing bed residents and failed to assess and provide activities to the swing bed residents.

This deficient practice also affected patient's #17 and #18.

Based on medical record review, document review and staff interview the Critical Access Hospital (CAH) failed to provide social service per the CAH's policy and failed to document appropriate interventions in the plan of care for 5 of 5 swing bed sampled patients (#'s 14, 15, 16, 17, and 18).

Findings include:

- The CAH's policy "Social Services and Activity" reviewed on 5/10/11 at 4:15pm directed "...Social Services and Activities will be offered to all Skilled and Intermediate Care Patients within the first 48 hours of admission ..."

- Patient #14's medical record reviewed on 5/9/11 at 12:30pm revealed an admission on 5/3/11 with a diagnosis of Urinary Tract Infection. The medical record lacked evidence of a social service assessment focused on the psychosocial needs of the patient. The patient's care plan failed to document social service interventions.

- Patient #15's medical record reviewed on 5/9/11 at 1:00pm revealed an admission on 5/3/11 with a diagnosis of Right Middle Lobe Pneumonia. The medical record lacked evidence of a social service assessment focused on the psychosocial needs of the patient. The patient's care plan failed to document social service interventions.

- Patient #16's medical record reviewed on 5/9/11 at 1:30pm revealed an admission on 5/4/11 with a diagnosis of Congestive Heart Failure (the heart can't pump enough blood to meet your body's needs). The medical record lacked evidence of a social service assessment focused on the psychosocial needs of the patient. The patient's care plan failed to document social service interventions.

Staff F interviewed on 5/10/11 at 8:30am acknowledged they were responsible for social services for swing bed residents and failed to assess and care plan social service interventions for the swing bed residents.

This deficient practice also affected patient's #17 and #18.