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Based on findings from observations and interview, the Critical Access Hospital failed to maintain the required ventilation of a room used for clean storage. Table 7-1 of the guidelines for Design and Construction of Health Care Facilities (2010) requires positive air pressure in rooms used for clean storage.

Observed on 9/16/2014 at 11:45 AM: Clean and sterile items are being stored in a caged area with an open ceiling. This storage area is not completely separated from adjacent office spaces. Therefore proper air pressure relationships to adjacent areas cannot be maintained. The lack of a contiguous ceiling exposes stored items to overhead heating and cooling supply lines, which poses additional potential for contamination.

The findings were verified at the time of observation with the Director of Engineering Services and the Infection Control Nurse, who accompanied the survey team.

Based on medical record review and interview it was determined the facility did not provide documentation of an ongoing program of activities designed to meet, the interest and the physical, mental, and psychosocial well-being of patients in swing bed status evidenced by 4 of 4 swing bed patients records reviewed.

Findings include:

Review of medical records for 2 swing bed patients on 9/15/14 and 2 closed swing bed patients records on 9/17/14 revealed no documentation of an initial activities assessment , ongoing assessment or if activities were provided to the patients on swing bed status. There was no evidence of a formal activities calendar or patient attendance records.

Interview with the nurse manager and staff nurse on 9/15/14 confirmed there was not a formal process in place.