HospitalInspections.org

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Based on interview and review of patient rights information, the Critical Access Hospital failed to provide written notice to patients that a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) was not present in the hospital 24 hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference:

42 CFR 489.20(w): "(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay, or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay, or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. Document review of the admission packet (consent to treat, notice of privacy notices, Important Message from Medicare, Medicare Outpatient Observation Notice, and Patient Rights and Responsibilities) did not show evidence that the hospital provided a disclosure notification to patients that a MD or DO is not on-site twenty-four hours per day, seven days per week.

2. On 08/24/22 at 10:45 PM, Surveyor #3 and the Patient Care Coordinator (Staff #302) toured and inspected the hospital's emergency department (ED). Surveyor #3 interviewed the on-duty ED Registered Nurse (Staff #303). During the interview, Staff #303 stated that the ED was staffed with a credentialed provider 24 hours a day, 7 days a week but that it was not always a physician on duty.

3. On 08/24/22, Surveyor #3 and the Patient Care Coordinator (Staff #302) toured the facility entrance; the acute care area, and the emergency department. Surveyor #3 was not able to locate any signage that would indicate an MD or DO is not on site 24 hours/ 7 days per week.

4. 08/25/22 at 2:10 PM, Surveyor #3 and #4 interviewed the Chief Executive Officer (Staff #301) about on-site presence of a physician, 24 hours a day. Staff #301 indicated that a credentialed provider was always on site but it was not always a physician. She was unsure if the facility had signage posted which indicated that an MD or DO is not on site 24 hours a day, 7 days a week.
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Item #1 - Crash Carts

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff-maintained supplies and equipment to meet patient needs during an emergency for 1 of 3 emergency carts inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Crash Cart Procedure," policy number 10241898, last approved 08/21, showed that crash carts will be checked to assure the cart is completely stocked with medications and supplies, and that the cardiac monitor/defibrillator is functioning properly and ready for use. The Code Cart in the Outpatient Services area will be checked each day there is a patient in the department.

2. On 08/23/22 between 10:45 AM and 12:00 PM, Surveyor #3 and a Registered Nurse (RN) (Staff #304) inspected the Outpatient Services emergency cart. The observation showed the following:

a. One package of Lifepak Quik-Combo Redi-Pak (Pacing/Defibration/ECG Electrode PreConnect System) with an expiration date of 06/16/22.

b. One package of Lifepak Quik-Combo RTS with an expiration date of 04/20/22.

c. One package of Lifepak Quik-Combo RTS with an expiration date of 03/19/22.

d. One endotracheal tube 3.0 mm with an expiration date of 07/30/20.

3. At the time of the observation, Surveyor #3 interviewed the Outpatient Services RN (Staff #304) about the checking of the emergency cart. Staff #304 verified that the emergency cart is check daily when outpatient services is open. She confirmed the expired items found by the surveyor and stated she would have them replaced.

Item #2 - Expired patient care supplies

Based on observation, document review, and interview, the Critical Access Hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer expiration date.

Failure to establish a systematic process for ensuring patient care supplies do not exceed their expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Discontinued, Expired or Outdated Supplies," policy number 19065905, last approved 01/21, showed that all items with expiration dates will be removed from stock on or just prior to that date and disposed.

2. On 08/23/22 between 9:00 AM and 10:30 AM, Surveyor #3 and the Operating Room Supervisor Staff (Staff #306) toured the perioperative areas and observed the following:

Neonatal Resuscitation Airway Kit

a. One endotracheal tube size 2.5 with an expiration date of 08/02/21
b. One endotracheal tube size 4.0 with an expiration date of 01/18/22
c. One endotracheal tube size 4.5 with an expiration date of 01/18/22
d. One laryngeal mask anesthesia (LMA) size 2.0 with an expiration date of 07/28/22

Operating Room

a. One endotracheal tube size 3.0 with an expiration date of 01/21/21
b. One endotracheal tube size 4.5 with an expiration date of 08/06/21
c. One endotracheal tube size 5.5 with an expiration date of 08/28/21
d. Two endotracheal tubes size 6.0 with an expiration date of 08/19/22

3. At the time of the observation the surveyor asked Staff #306 about the expired airways. Staff #306 verified the expired items and stated that Respiratory Therapy is responsible for checking expiration dates of respiratory supplies including airways.

4. On 08/23/22 at 1:00 PM, Surveyor #3 interviewed a staff respiratory therapist (Staff #305) about the number of expired airway tubes in the operating room. Staff #305 stated that the Respiratory Therapy is responsible for checking the neonatal resuscitation airway kits and all respiratory supplies exclusively in the operating room. He was unaware of the expired airways in the perioperative areas and stated they would be replaced.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell B3QK21.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff followed the hospital's policy for the patients placed in restraints for 2 of 3 medical records reviewed (Patient #301, #302).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints," policy number 11730425, last revised 04/21, showed that restraints for management of aggressive or self-destructive behavior may only be used in an emergency to prevent immediate or imminent injury to the person at risk or to others. An order from a physician is necessary for behavioral restraint or seclusion. The physician must be contacted within one hour of initiation and provide a telephone order. Written orders for restraints used for behavioral management are limited to four hours for adults. The Registered Nurse will obtain an order from the physician to renew the initial order for restraints every 4 hours for adults.

2. On 08/24/22, Surveyor #3 and the Patient Care Coordinator (Staff #303) reviewed the medical records of three patients who were restrained during their care received at the hospital. The reviewed showed:

a. Patient #301 was a 28-year-old who presented to the Emergency Department on 12/05/21 with symptoms of altered mental status, confusion, hallucinations, and complaints of homicidal ideation. The patient was in soft four-point restraints upon arrival on 12/05/21 at 8:19 AM. The patient was released from restraints on 12/05/21 at 3:50 PM. Surveyor #3 found no evidence that a provider wrote an order for initial restraints nor ordered the continuation of restraints after the initial order had reached its time limit, a period of 7 hours and 3 minutes.

b. Patient #302 was a 39-year-old who was transported by ambulance to the Emergency Department on 08/12/21 after ingesting isopropyl alcohol. The patient was intoxicated and combative and tried to injure the hospital staff during examination. The patient was immediately placed in four-point restraints on 08/12/21 at 11:30 PM and was later released from restraints on 08/13/21 at 2:15 AM. A provider wrote the initial order for restraints at 08/13/21 at 1:59 AM, a period of 2 hours and 29 minutes after the initial application.

3. On 08/24/22 at 2:30 PM, Surveyor #3 interviewed the Patient Staff Coordinator (Staff #303) about the hospital's policy on restraints being placed for violent or self-destructive behavior. Staff #303 confirmed and verified the missing and/or late provider orders written for the application of restraints.
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Based on observation, interview and review of hospital policy and procedures, the Critical Access Hospital failed to ensure staff members implemented procedures for labeling of medications filled in a syringe.

Failure to label syringes filled with medication puts patients at risk of medication errors and receiving medications with compromised sterility integrity or stability.

Reference: American Society of Anesthesiologist "Statement on Labeling of Pharmaceuticals for Use in Anesthesiology," Amended December 13, 2020. The drugs generic name and concentration should be displayed on the label of each syringe. The date and time of preparation, and the preparer's initials or name should be also included.

Findings included:

1. On 08/23/22 at 9:55 AM, Surveyor #3 and the Operating Room (OR) Supervisor (Staff #306) toured the perioperative areas. During an inspection of the locked OR supply room, Surveyor #3 found the following in an anesthesia cart:

a. One 3 ml syringe with a clear liquid labeled phenylephrine 100 mg with no date or time prepared or initials of the person preparing the syringe.

b. One 3 ml syringe with a clear liquid labeled phenylephrine with a date annotated "11/9 , 0800" with no strength and no initials of the person preparing the syringe.

2. At the time of the observation, Surveyor #3 interviewed the certified nurse anesthetist (Staff #307) on duty about the observation. Staff #307 stated the medications were not prepared by her and should be disposed of. She stated that she ensures syringes are labeled with the drug name, strength, and date and time prepared.

3. Surveyor #3 requested the hospital policy on labeling of syringes from the OR Supervisor (Staff #306). Staff #306 was unable to locate a policy for labeling of syringes with medications.
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Item 1 - Hand Hygiene

Based on observation, document review, and interview, the hospital failed to ensure staff performed hand hygiene according to hospital policy and accepted standards of practice.

Failure to perform hand hygiene according to hospital policy to prevent transmission of infectious microorganisms puts patients and staff at increased risk of communicable illnesses.

Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), October 25, 2002 / Vol. 51 / No. RR-16, Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.

Findings included:

1. Document review of the hospital's policy titled, "Hand Hygiene," PolicyStat ID 10806353, approved 12/21, showed that hand hygiene using alcohol-based products should be performed after removing gloves.

2. On 08/23/22 between 8:30 AM and 9:00 AM, Surveyor #4 observed a discharge clean of exam room 3 in the emergency department by housekeeping (Staff #404). Staff #404 changed gloves 3 times during the clean without performing hand hygiene between glove exchanges.

3. On 08/23/22 at 9:10 AM, Surveyor #4 observed a daily clean of room 220 by housekeeping (Staff #405). Staff #405 changed gloves one time and did not perform hand hygiene between the glove exchange.

4. On 08/23/22 at 12:15 PM, Surveyor #4 observed a terminal clean of Operating Room 1 by housekeeping (Staff #406). Staff #406 did not perform hand hygiene between 3 glove exchanges.

5. On 08/24/22 at 2:00 PM, Surveyor #4 interviewed the infection preventionist (Staff #402) about the cleaning process and expectation of hand hygiene during glove exchanges during cleaning. Staff #402 stated that all staff are required to perform hand hygiene when exchanging gloves. Staff #402 provided a copy of the hospital's Instructions for Hand Hygiene Monitoring form used by the facility to monitor compliance with hand hygiene that includes monitoring for sanitizing after glove removal.

Item 2 - Hydrocollator cleaning frequency

Based on observation, interview and document review, the facility failed to maintain its hydrocollators according to the manufacturer's scheduled cleaning frequency.

Failure to keep the hydrocollator clean and maintained, puts patients at risk of infection.

Findings included:

1. Document review of the manufacturer's instructions for use for the Chattanooga SS-2 hydrocollator showed that it is essential that water be added daily and that the tank should also be drained and cleaned systematically, at minimum intervals of every two weeks.

Document review of the hospital's policy titled, "Hot Pack Unit Care of Equipment," Policy # PT6, reviewed 03/27/13, showed the unit should be cleaned once a month depending on usage.

Document review of the Physical Therapy Aide Duties logbook showed that the hydrocollator is cleaned once per month, and water/temperature checks done weekly.

2. On 08/24/22 at 9:00 AM, Surveyor #4 observed the facility's hydrocollators. The surveyor interviewed the Physical Therapy Office Manager (Staff #408) regarding the maintenance of the hydrocollator. Staff #408 stated the hydrocollator is drained and cleaned monthly, and the water level and temperature are checked weekly. Staff #408 showed the logbooks the department aide used to document weekly and monthly checks.

3. On 08/24/22 at 12:40 PM, Surveyor #4 returned to Physical Therapy to interview the Director (Staff #407). Staff #407 confirmed that the hydrocollators were cleaned monthly.


Item 3- Water Management Plan, Ice Machine

Based on observation, interview and document review, the Critical Access Hospital failed to fully develop and implement their water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

b. Implement a water management program that considers the ASHRAE industry standard and/or the CDC toolkit, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and/or environmental testing for pathogens.

c. Specify testing protocols and acceptable ranges for control measures and document the results of testing and provide corrective actions taken when control limits are outside of acceptable ranges.

Findings included:

1. Document review of the hospital's policy titled, "Water Management/Legionnaires Prevention Plan," PolicyStat ID 11858052, last approved 06/22, showed that the facility's ice machines are identified as a high-risk area and are to be cleaned every six months. The policy does not address cleaning the drain line.

2. On 08/23/22 at 10:20 AM, Surveyor #4 inspected the hospital's 2nd floor clean utility room with the Housekeeping Supervisor (Staff #403). During the inspection, the surveyor observed the ice machine with algae build up on the interior of the ice machine drain line above the air gap. The build of up black growth extended up the inside of the line for approximately 3 feet.

3. Staff #403 confirmed there was a large amount of growth on the inside of the drain line.

4. On 08/25/22 at 10:00 AM, Surveyor #4 reviewed the Water Management Plan with the Director of Facilities (Staff #409). The surveyor and Staff #409 revisited the 2nd floor ice machine in the clean utility room. Staff #409 confirmed there was growth inside the drain line and this had not been addressed in the preventative maintenance on the unit.

Item 4 - Laundry

Based on observation, interview and document review, the Hospital staff failed to ensure that linen is processed within industry standards regarding water pH and temperature during on-site laundering of patient care items.

Failure to ensure linen and laundry meets industry standards for cleanliness and sanitary conditions puts patients and staff at increased risk to harmful pathogens.

References: Guidelines for Design and construction of Health Care Facilities, 2.1-6.4; Guidelines for Environmental Infection Control in Health-Care Facilities; Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) page 114 recommends pH levels between 12 and 5.

Reference: Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Environmental Infection Control in Health-Care Facilities 2003 Updated: July 2019; Recommendations - Laundry and Bedding IV. Laundry Process A. If hot-water laundry cycles are used, wash with detergent in water >160 degrees Fahrenheit (>71 degrees Celsius) for >25 minutes. D. Choose chemicals for low-temperature washing at proper use concentration if low-temperature (<160 degrees Fahrenheit [<70 degrees Celsius]) laundry cycles are used.

Findings Included:

1. Document review of the hospital's policy titled, "Linen Handling, Clean/Soiled", PolicyStat ID 8309343, approved 07/20, showed that physical therapy shorts and pads can be washed by housekeeping staff, the policy did not include nationally recognized standards or procedures for processing laundry.

2. On 08/23/22 at 10:00 AM, Surveyor #4 observed the laundry facilities with the Housekeeping Supervisor (Staff #403). The surveyor interviewed Staff #403 regarding testing water pH and temperature monitoring during the on-site laundering process. Staff #403 stated the facility launders physical therapy shorts on-site and does not currently test for pH or monitor temperature during laundering.

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Based on interview, document review, and review of the hospital's quality and performance improvement program, the Critical Access Hospital failed to ensure that performance measures for all patient care services were developed, evaluated, and reported to the quality committee.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospital's quality improvement plan titled, "Performance Improvement Plan 2020/2021," adopted 10/24/19, showed the following:

a. The Performance Improvement Committee is responsible for review of committee and departmental findings and assuring corrective measures are implemented to improve quality outcomes.

b. The Performance Improvement Committee is responsible for ensuring the quality, safety and appropriateness of patient care and services provided is monitored and evaluated to ensure appropriate action is taken when indicated.

c. Department Managers are responsible for implementing a performance improvement process and integrating activities with the facility wide performance improvement program.

2. On 08/25/222, Surveyor #3 reviewed the hospital's Performance Improvement Committee minutes for 07/12/22, 04/15/22, 11/16/21, 10/19/21 and 09/22/21 and found no evidence that quality indicators for sleep lab, dietary services, or physical therapy services were discussed or reviewed.

3. On 08/25/22 at 2:10 PM, Surveyors #3 and #4 interviewed the hospital's Chief Executive Officer (Staff #301) regarding the hospital's quality and performance improvement program. Staff #301 confirmed and verified the current hospital's performance improvement program did not include and assess performance metrics for all hospital services and departments which included the sleep lab, dietary services, and physical therapy services.