HospitalInspections.org

Based on observation the CAH (Critical Access Hospital) failed to ensure the dedicated Emergency Room had a notice posted conspicuously in a place(s) likely to be noticed by all individuals entering the dedicated Emergency Department, indicating that the CAH does not have a MD (Doctor of Medicine) or a DO (Doctor of Osteopathy) present in the CAH 24 hours per day, 7 days per week.

Findings:
An observation on 06/17/24 at 3:00 p.m., with Staff C, revealed the posted notice indicating the dedicated Emergency Department did not have a MD (Doctor of Medicine) or a DO (Doctor of Osteopathy) present in the CAH 24 hours per day, 7 days per week was not posted in a conspicuous place likely to be noticed by all individuals entering the dedicated Emergency Department, as evidenced by the posted notice being posted on the top right corner of a "busy" bulletin board with at least 16 other posted notices of the same size. The bulletin board was located in a hallway outside of the Emergency Department's patient rooms.

In an interview on 06/17/24 at 3:00 p.m. Staff C indicated she did not think there was another notice posted anywhere else in the Emergency Department.

Based on record review and interview the CAH failed to ensure all radiological services provided by the facility, (according to CMS 485.635(b)(3) and the CAH policy) was provided by personnel qualified under state law in accordance with acceptable standards of practice which include maintaining compliance with appropriate federal and state laws, regulations, and guidelines governing radiological services, including certification requirements by nationally recognized professional radiological organizations, as evidenced by no documented evidence that the radiology technician/supervisor (Staff E) was a graduate of an accredited radiological technology program or currently enrolled in an accredited radiological technology program or that the radiology technician was ARRT (American Registered Radiologic Technologist).


Findings:
A review of the hospital policy titled, "Radiology Services and Staff", as provided by administration as a current policy, revealed in part: Personnel Qualifications- Graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program, or ARRT registered and in compliance with continuing education credits.

A review of the hospital policy titled, "Radiology Supervisor", as provided by administration as a current policy, revealed in part: Minimum Qualifications- Education and /or Experience: Associates of Applied Science in Radiology, ARRT or State License or equivalent is required. Licensure/Certification: Current Oklahoma Registry, ARRT or State License or equivalent is required.

A review of the employee file for Staff E, with Staff C and Staff D, revealed no documented evidence that Staff E was ARRT registered or was a graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program,


In an interview on 6/20/24 at 11:45 a.m. Staff E indicated she was the Radiology Supervisor and her duties involved performing diagnostic radiologic x-rays on patients, to include routine x-rays and CT (computed tomography) scans. Staff E indicated she was not a graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program. She further indicated she was not ARRT registered and her experience was based on "on the job" training.

Based on record review and interview the CAH failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient's nursing care needs and not solely those needs related to the admitting diagnosis for 4 of 4 (Patient #14, #15, #16, #17) inpatient medical records reviewed for nursing care plans.

Findings:
A review of Patient #14 medical record revealed in part: Patient #14 was admitted to the hospital as an inpatient on 01/13/24 with a diagnosis of acute respiratory failure. A review of the patient's medical history revealed the patient also had a present history of atrial fibrillation, hypertension, neuropathy, and gastric reflux. A review of the care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs developed for atrial fibrillation, hypertension, neuropathy, and gastric reflux.

A review of Patient #15 medical record revealed in part: Patient #15 was admitted to the hospital on 02/11/24 with a diagnosis of shortness of breath. A review of the patient's medical history revealed the patient also had a present history of delusions, dementia, anxiety, and vitamin B deficiency. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs developed for delusions, dementia, anxiety, and vitamin B deficiency.

A review of Patient #16 medical record revealed in part: Patient #16 was admitted to the hospital on 01/24/24 with a diagnosis of a closed ankle fracture. A review of the patient's medical history revealed the patient also had a present history of atrial fibrillation, depression, hypertension, and diabetes. A review of the care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs developed for atrial fibrillation, depression, hypertension, and diabetes.

A review of Patient #17 medical record revealed in part: Patient #17 was admitted to the hospital on 03/16/24 with a diagnosis of altered mental status. A review of the patient's medical history revealed the patient also had a present history of gout, hyponatremia, and hypertension. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs developed for gout, hyponatremia, and hypertension.

A review of the hospital policy titled, "Nursing Care Plans", provided by administration as a current policy, revealed in part: The nursing care plan is based on assessing the patient's nursing needs to include; treatment goals, nursing interventions, on-going assessments and revisions, and discharge planning (and not solely those needs related to the admitting diagnosis).


In an interview on 06/20/24 at 3:30 p.m. Staff I indicated the nurses routinely developed the patient's care plans based only on the admitting diagnoses and care plans were not developed for all the patients' current diagnoses upon admit.

Based on observation, record review, and interview the CAH failed to ensure a functional and sanitary environment according to acceptable professional standards of practice relating to infection control as evidenced by observation of infection control breaches:

1) failing to ensure staff sanitized their hands after removing their gloves,
2) failing to ensure the dietary staff did not use patient serving trays as cutting/chopping boards for raw meats and other cutting tasks, and
3) failing to ensure expired sutures were not available for patient use.


Findings:
1) failing to ensure staff sanitized their hands after removing their gloves,

In observations on 06/20/24 from 9:30 a.m. to 10:30 a.m., in the presence of Staff C, Staff J and Staff K did not sanitize their hands after removing their gloves after performing patient care tasks and before moving to other patient care tasks.

A review of the CDC Guideline for Hand Hygiene in Health-Care Settings, revealed in part: Gloves do not provide complete protection against hand contamination. Pathogens presumably gain access to the caregiver's hands via small defects in gloves. One study found that health care workers who wore gloves during patient contact contaminated their hands more often than those who did not wear gloves. In published studies, the barrier integrity of gloves varies on the basis of type and quality of glove material, intensity of use, length of time used, manufacturer, whether gloves were tested before or after use, and method used to detect glove leaks.


HICPAC (Healthcare Infection Control Practices Advisory Committee) Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
" Immediately before touching a patient
" Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
" Before moving from work on a soiled body site to a clean body site on the same patient
" After touching a patient or the patient's immediate environment
" After contact with blood, body fluids, or contaminated surfaces
" Immediately after glove removal


In an interview on 06/20/24 at 10:45 a.m. Staff C confirmed Staff J and K did not sanitize their hands after removing their gloves after performing patient care tasks and before moving to other patient care tasks.



2) failing to ensure the dietary staff did not use patient serving trays as cutting/chopping boards for raw meats and other cutting tasks,

An observation on 06/17/24 at 3:00 p.m. of some of the patient serving trays in the Dietary Department revealed they were scratched and had small cracks in the trays preventing effective disinfection.

In an interview on 06/17/24 at 3:00 p.m. Staff H indicated the Dietary Department did not have cutting/chopping boards and the dietary personnel were using patient serving trays as cutting/chopping boards to cut and chop meats and other food items. Staff H indicated serving trays was probably not intended for cutting and chopping foods and could harbor bacteria.



3) failing to ensure expired sutures were not available for patient use.

An observation on 06/17/24 at 3:30 p.m. in the Emergency Department supply room revealed a box of sutures that had expired on 05/31/21.

In an interview on 06/17/24 at 3:30 p.m. Staff C indicated supplies are checked periodically by staff for outdated supplies and the expired box of sutures should have been discarded.