HospitalInspections.org

Based on observation and staff interview the facility failed to ensure a Kansas State Food Code regulation for a Backflow Prevention Device was in place to prevent potential contamination of the sink where food is prepared. This failure placed all patients and staff at risk for food borne illnesses.


Findings included:


- During a tour of the Critical Access Hospital kitchen 9/12/2016 at 3:54 p.m. it was noted that the sink used to prepare fresh food did not have an air gap to prevent potential contamination of the sink where food items are prepared in the event of a backflow of sewage, gas or other contaminates. A staff member confirmed the sink located on the west wall of the kitchen was used for food preparation. The administrator was notified.


- A second observation on 9/14/16 at 2:30 p.m. was conducted. The dietary manager confirmed the sink was without an air gap 9/14/2016.


According to the Kansas State Food Code 2012 regulation 107 5-203.14 Backflow Prevention Device, states "A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to: ...cafeterias, public or nonprofit organizations routinely serving food ...").

Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) failed to remove outdated sterile medical supplies from patient care areas in the facility in central supply, the Emergency Department (ED), and in the anesthesia cart. This deficient practice had the potential for staff to use outdated or non-sterile medical supplies for direct patient care.

Findings include:

- Observation on 9/13/16 at 10:45 AM in Central Supply revealed 1 of 6 sterile central line insertion kits (a long thin flexible tube inserted into a large vein in the chest to give medicines and fluids) outdated.

Interview with Central Supply Staff O at that time verified all supplies are logged into system upon receipt and rotated when new supplies are received. Monthly random outdate checks are made and supplies are removed from inventory if found to be outdated. The outdated central line insertion kit was removed by Staff O.

- Observation of the ED revealed open sterile Yankauers (suction tip used in medical procedures) attached to suction tubing in two of two ED suites.

Interview at that time with Staff D verified the opened sterile packages and s/he replaced them.

- Observation on 9/13/16 at 8:45 AM of the Anesthesia Cart (medications used in surgery) in the operating room revealed 2 of 2 tracheostomy tubes (a curved tube placed in a hole in the neck to assist in breathing) that were in sterile packages opened in the top drawer. The opened medical supplies were removed and replaced by Staff O.

Review of the Association for the Advancement of Medical Instrumentation and the Guidelines for Disinfection and Sterilization in the Healthcare Facilities revealed "...shelf life and expiration date for commercial sterile patient care items and supplies ...if the item has an expiration date and it contains fluids, antimicrobial agents, special coating, or other materials that are subject to deterioration or degradation over time there by reducing the effectiveness or quality of the product, the item must be discarded safely by the manufacturer's expiration date ..."

Based on observation, staff interview and policy and procedure review the Critical Access Hospital (CAH) failed to secure 1 of 2 large oxygen tanks in the respiratory department. Failure to secure the oxygen tank put staff and patients at risk for fire from the explosive contents.

Findings include:

- Observation on 9/13/16 at 2:15 PM revealed the large oxygen tank in the respiratory treatment room was not secured.

Interview on 9/13/16 at 2:15 PM, Staff C verified the oxygen tank was not secured and that he would get what was needed to secure it. He stated it had been secured in another location with a chain to the wall and then was moved to this new location.

Policy and Procedure Review on 9/14/16 at 8:35 AM states policy "Storage of Portable Oxygen Tanks in Facility" ...All freestanding cylinders shall be stored in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them...
.

Based on observation, interview and policy and procedure review the Critical Access Hospital (CAH) failed to follow the rules for the storage of drugs and biologicals in that the pharmacy failed to have a system in place to ensure outdated or unusable drugs were not available for use for 1 expired medication bag on the inpatient floor, 4 expired medication bags on the Emergency Room Crash Cart, 2 expired medication bags and 3 vials of medication on the Operating Room Crash Cart, 2 expired medications in the pharmacy and 3 multi dose bottles not dated when they were opened, 2 packages of Racepinephrine Inhalation Solution (a medication to open the bronchi (airways in the lungs) to assist with breathing) and medications were being set up/dispensed for a 24 hour period per patient in the pharmacy room. Failure to ensure the accepted professional principles for the dispensation of medications and to discard medications and supplies put the patients at risk for unsafe and ineffective use as intended. Failure to administer medications at the designated time puts the patient at risk for receiving the wrong medication.

Findings include:

- Observation on 9/13/16 at 2:00 PM on the Inpatient floor revealed 1 of 2 sterile magnesium sulfate medication bags (an inorganic salt for treating low levels of magnesium in the body) outdated on the obstetric (a branch of medicine for childbirth) delivery cart.

Interview with Director of Nursing (DON) Staff RN B verified the obstetric delivery cart is checked monthly by defined obstetric nursing staff and following all deliveries. The outdated medication was removed by Staff RN B.

- Observation on 9/12/16 at 4:00 PM, Crash Cart in the Emergency Room revealed 2 of 2 bags of Heparin Sodium (a medication to thin the blood) that expired 8/2016, and 2 of 2 bags of Dopamine HCI (a medication that helps the heart have more complete and forceful contractions) that expired 9/1/2016.

Interview on 9/12/16 at 4:00 PM, Staff D verified the expired medications and supplies. Staff D replaced them.

- Observation on 9/12/16 at 4:17 PM of the Crash Cart in the Patient Hallway revealed 1 of 2 bags of Heparin Sodium expired 8/2016 and 3 of 3 vials of Furosemide (a medication to treat fluid retention caused by various medical conditions) expired 9/1/2016.

Interview with Staff D at that time verified the expired medications. Staff D replaced them with medications that were not expired.

- Observation on 9/12/16 at 4:20 PM of the Pharmacy revealed 3 multi-dose bottles opened with no date of when they were opened written on the bottles. The medications were: Betamethasone Sodium Phosphate (a steroid medication), Morphine Sulfate (a narcotic medication to treat severe pain), and Tussionex (a medication to relieve moderate to severe pain). There were two expired medications, Pulmicort 1 ampule (a dosage of a medication to help with breathing) expired 8/2016 and Imodium (a medication for diarrhea) expired 8/2016. Staff D put the expired medications in the appropriate tubs of expired medications.

Interview on 9/12/16 at 4:20 PM, Staff D verified the medications were opened and not dated. This had the medications used past the 28 day period. Staff D put the expired medications in the appropriate tubs of expired medications.

- Observation on 9/13/16 at 2:15 PM of the Respiratory Room revealed 2 of 5 packages of Racepinephrine Inhalation Solution expired 3/2016.

Staff C at that time verified the expired medications and removed the medications from the refrigerator.

- Observation on 9/13/16 at 9:15 AM, Pharmacy revealed medications were being set up for 24 hours for each patient. Each patient's medications were placed in a separate drawer with their room numbers on the front of the drawer. There are many potential problems with this practice, including the possibility of a nurse administering the wrong medicine to the wrong patient at the wrong time.

Interview on 9/13/16 at 9:15 AM, Staff D verified the medications were set up each day for a 24 hour period for each patient.

Interview on 9/13/16 at 10:40 AM, Staff F stated they had set up the medications for the patients for the day as they had understood the regulations to allow for this. Staff F will look in to the regulations and make the appropriate changes for the set-up of patient medications.

- Policy and Procedure review on 9/13/16 at 12:10 PM states policy "Requisition, Distribution, Outdate Monitoring and Processing of Pharmaceuticals" ...The pharmacy nurse shall do monthly outdate checks ...Outdated medications shall be removed from stock and placed in the designated location that is properly labeled "Expired; not for patient use." ...

- Policy and Procedure review on 9/13/2016 at 8:50 AM states policy "Multi dose Vials" ...An open multi dose vial may be kept for 28 days and then any unused portion must be discarded." ...

- Policy and Procedure review on 9/13/16 at 12:10 PM states policy "Unit-Dose Drug Distribution System" ...The Pharmacy nurse will distribute drugs on a 24 hour drug exchange, centralized unit dose system. Plastic bags containing patient medications will be exchanged on a daily basis...


- According to pharmacy regulation 65-1648, distribution and control of prescription medications by a medical care facility pharmacy...
(3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user.

Based on observation, policy review, and staff interview the Critical Access Hospital's (CAH's) infection control officer failed to enforce proper handwashing, failed to ensure soiled linens were processed in a manner to prevent cross contamination, and failed to post signs designating appropriate surgical attire to be worn in the restricted and semi-restricted surgical and sterilization area. This deficient practice had the potential to expose employees and all surgical patients to bacterial contamination and potential infection.

Findings include:

- Observation on 9/13/2016 at 1015 in the CAH microbiology department of the laboratory revealed Medical Technologist Staff M failed to follow handwashing guidelines when processing lab specimens. Medical Technologist Staff M handled lab specimens under the flow hood wearing gloves then typed information on the computer keyboard without removing gloves. S/he opened the refrigerator door while wearing the gloves, removed quality control products from the refrigerator, closed the door and returned to the specimens. S/he removed the specimens from the hood and placed them on the counter with the quality control products, while wearing the gloves.

Interview with Staff M at the time revealed that s/he was aware s/he should have removed the gloves and washed his/her hands without accessing the computer or refrigerator. S/he stated "Yes, I know I should have removed my gloves and washed my hands but I was nervous and just didn't get it done."

Review of Policy titled "Hand Hygiene" reveals "...Indications for Hand washing ...decontaminate hands after contact with body fluids or excretions, ...decontaminate hands after removing gloves ...wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and compromised or non-intact skin could occur ... "

- During a tour of the laundry processing area on 9/14/16 at 8:15 a.m. it was observed the laundry area was shared by dietary, housekeeping and maintenance. Observation of the area revealed soiled linens were collected and placed on the east wall of the laundry area.

Interview with environmental staff revealed the soiled linen was sorted and then placed in the single washer. After the wash, the linen was then placed in a dryer on the opposite side of the room. After the linen was dry, it was then removed from the dryer and folded on a table next to the dryer and across from the soiled linen area.

The clean area and dirty area in the laundry area was defined by a red line painted on the floor. There was no physical separation of the soiled from clean linen areas.

According to 2016 Edition of the Accreditation Standards for processing reusable textiles for use in healthcare facilities:
2.1.2.1. The essential laundry facility design must have a functional separation of areas that receive, store, or process soiled textiles from areas that process, handle, or store clean textiles by one the following methods:
2.1.2.1.1. Physical barrier (e.g., walls or structural partitioning with a means of entry to and from the soiled textiles area), which includes negative air pressure in the soiled textiles area with venting directly to the outside (positive air flow from the clean textiles area through the soiled textiles area); or
2.1.2.1.2. Functional barrier by negative air pressure in the soiled textiles area and positive air flow from the clean textiles area through the soiled textiles area with venting directly to the outside. (JCHLGL Guidelines for Healthcare Linen Service, 1994; 6.B.3, 8.A.1-3; CDC HICPAC GL EIC, 2003:II.G.II.A; ANSI/AAMI ST65:2013; Std.3.2.3.1, 3.3.4; ANSI/AAMI ST79:2010; Std. 3.2.3, 3.3.7.1; FGI GL 2014: 2.1-5.2.1
- Observation on 9/13/2016 with Sterilization Staff RN J, Surgical Director Staff RN D, and Environmental Director Staff G revealed a blanket warmer located inside the sterilization suite.

Interview at that time with Staff J revealed the warmer is accessed by floor staff and "I have given them permission to enter the sterilization suite without designated surgical suite attire by myself."

- Further observation revealed the absence of signage designating restricted and semi-restricted areas requiring appropriate surgical attire and limiting access to restricted and semi-restricted areas.

Review of CAH policy titled, "Operating Room Attire" revealed "...all persons who enter the operating room will wear surgical attire intended for use within the surgical suite..."

Interview with Staff D revealed the surgical policies are based on Association of peri Operative Nurses (AORN) guidelines for safe surgical practice.

According to Tittle 77: Public Health, Chapter I: Department of Public Health, Subchapter b: Hospitals and Ambulatory Care Facilities, Part 250 hospital Licensing Requirements, Section 240.1300 Operating Room reveals "...The surgical area is composed of restricted, semi-restricted, monitored unrestricted, and transition areas.

1) Restricted area: Traffic shall be restricted to authorized personnel and patients. No street clothing shall be worn in the restricted area. Health care workers shall wear hospital laundered scrub attire. Head and facial hair shall be contained within protective covering. Cloth head coverings shall be laundered by the hospital. Additional garments shall be completely contained or covered within the scrub attire. Masks shall be worn in restricted areas where open sterile supplies and equipment are present or scrubbed persons are located. Patients shall wear attire appropriate for their surgical procedure and shall wear hair covering.

2) Semi-restricted area: Traffic shall be restricted to authorized personnel and patients. No street clothing shall be worn in the semi-restricted area. Health care workers shall wear hospital laundered scrub attire. Head and facial hair shall be contained within protective covering. Cloth head coverings shall be laundered by the hospital. Additional garments shall be completely contained or covered within the scrub attire. Masks are not required in this area. Patients shall wear attire appropriate for their surgical procedure and shall wear hair covering.

3) Transition area: Traffic shall be permitted to allow movement of personnel from unrestricted to semi-restricted areas or restricted areas. Personnel may enter in street clothing and shall exit into the semi-restricted or restricted area in surgical attire.

4) Monitored unrestricted area: Permitted traffic includes authorized personnel, patients, and their families. Health care workers in scrub attire may use this area as a transition area for the purpose of patient management and hospital business.

c) Signage shall clearly define the traffic flow and surgical attire requirements...
.

Based on record review and documentation review the hospital failed to ensure all swing-bed patients were fully informed of patient rights and services. This deficient practice placed all swing-bed patients at risk of making uninformed decisions about their healthcare and their services.

Findings included:

- Review of the "Cheyenne County Hospital" Swing Bed Patient Rights and Responsibilities document indicated patients would be fully informed at the time of admission and during their stay of rights and of all rules and regulations governing patient conduct and responsibilities.

- Although the Critical Access Hospital swing-bed policies and procedures addressed all required areas of swing-bed patient rights, the Swing-bed Patient Rights and Responsibilities document that was given to swing-bed patients did not include information regarding the provision of activities, social services, specialized therapies, nutritional support, advance directive options, grievance process or dental services.

During the exit meeting on 9/14/2016. Staff A was not aware the information given to the swing-bed patients was inconsistent with the facility policies and procedures.

Based on staff interview and record review the Critical Access Hospital failed to ensure 2 of 14 employees (Staff V and Staff X), who provided care to swing-bed patients, had background checks completed checking for actions by a court of law concerning abuse, neglect, mistreatment of residents or misappropriation of property. This failure placed swing-bed patients at risk for receiving care and services from unqualified staff with a positive background review.

Findings include:

- Review of the Critical Access Hospital documentation revealed it frequently had swing-bed patients. The facility currently had two swing bed patients at the time of survey

Review of employee records (Staff V and Staff X) revealed the Critical Access Hospital did not conduct background checks on these employees.

On 9/15/2016 Staff H at 10:00 a.m. stated she had been hired in July 2015 and conducted background checks on all employees hired since July 2015. She was unable to locate a background check verification on one permanent employed nurse hired prior to July 2015 and one agency nurse.

Based on observation, policy review and staff interview the Critical Access Hospital (CAH) failed to inform each patient or support person of visitation rights. Failure to provide visitation rights to the patient or support person could potentially cause misunderstanding of the visitation rules for patients and their families and friends..

Findings include:

- Observation upon entrance of the CAH on 9/12/2016 at 2:00 PM revealed no visitation regulations posted for the public to view.

- Observation of the sign outside the main entrance door on 9/13/2016 at 3:45 PM read: "Doors locked between 8:00 PM and 7:00 AM, Please Push Button for Service."

Review of Policy titled Visitation Rights - Inpatient & Outpatient on 9/14/2016 at 9:00 AM directed ...Visiting hours are from 7 AM to 10 PM daily ..., ...A written notice of "Visitation Rights" shall be provided to the patient, or their designated support person, at the time of admission and in advance of patient care ..., ...Documentation of the receipt of Visitation Rights shall be included in the "Treatment Authorization and Privacy Notice"...

Review of document titled "Treatment Authorization and Privacy Acknowledgement" on 9/14/2016 at 9:15 AM did not reveal any mention of "Visitation Rights" .

Staff RN Q interviewed on 9/13/2016 at 3:35 PM s/he reported the visitation policy is, that all doors were to be locked at 8:00 PM and visitors had to ring the bell to come in after 8:00 PM.

Staff LL interviewed on 9/15/2016 at 8:25 AM s/he report that the front desk rarely does the admission paper work and that it is done by the nurses. She did not know where the written notice of "Visitation Rights" is located. She suggested to check with the nurses. The front office desk had the notice of Patient Rights and Responsibilities and the Treatment Authorization and Privacy Acknowledgement form for patients to sign. S/he confirmed the Treatment Authorization and Privacy Notice was synonymous (the same as) to the Treatment Authorization and Privacy Acknowledgement form.

Certified Nurse aid/ward clerk staff MM interviewed on 9/15/2016 at 8:45. S/he located the Patient Rights and Responsibilities. "Visitation Rights" were not found at the nurse's station.

Administrative staff E interviewed on 9/15/2016 at 8:50 AM s/he was not able to locate patient "Visitation Rights"
.