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Tag No.: C0211
Based on interview, the Critical Access Hospital (CAH) failed to develop a policy which included the criteria for observation bed utilization. This had the potential to affect all patients in the CAH.
Findings include:
CAH staff were requested to provide a policy related to criteria for utilization of an observation bed. The director of nursing (DON) and the performance improvement (PI) coordinator confirmed on 3/30/16, at 2:00 p.m. that no observation criteria policy had been developed and/or approved by the medical staff. The PI coordinator indicated the utilization of observation bed data is reported as part of their annual evaluation. However, it was verified that specific criteria had not been developed for placement in and discharge from observation status, and that a well-defined set of specific, clinically appropriate services which are clearly distinguishable from those used for inpatient admission and discharge was lacking.
Tag No.: C0225
Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the floor, wall, countertops, dishwasher drain and food shelves located in the dietary kitchen were maintained properly so the area could be properly cleaned and well kept. This has the potential to affect any patients who receive dietary services while in the CAH.
Findings include:
On 3/29/16 at 1:30 P.M. a tour of the kitchen was conducted with cook-A. The following observations were noted: The half wall which separated the commercial dishwasher and the kitchen had brown rust like substances around the entire base of the wall. There were 6 missing floor tiles under the dishwasher which exposed a concrete floor. Also in the area of the dishwasher, 9 other floor tiles were cracked with sections missing, making for an uncleanable surface. During the observation of the dishwasher operation on 3/29/16, at 1:50 p.m. it was noted the floor drain was not able to handle the amount of dirty water discharged from the machine which resulted in an overflow of water onto the floor underneath the dishwasher.
In the dietary kitchen there was a portable shelving unit where clean food containers were stored. The laminated covering on this unit was peeling off on the sides and the bottom shelf. Under this peeling laminate, there was a large accumulation of a black and white substance.
Two areas of the counter tops had edges approximately 4-6 inch long where the laminate covering was missing, leaving exposed and splintered wood.
When interviewed on 3/31/16, at 11:00 a.m. the director of maintenance (DOM) stated the areas noted in the dietary area would be addressed and had no further information.
Tag No.: C0226
Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure proper ventilation in the only patient bathroom/shower room on the nursing unit. This had the potential to affect all inpatients in the CAH.
Findings include:
During the environmental tour on 3/28/16, at 2:00 p.m. the ventilation fan in the patient's bathroom/shower room was not functioning. There was no evidence of suction and/or air drawn from the ceiling vent. This bathroom is utilized by all CAH patients due to the lack of availability of individual bathrooms for each patient room. During a follow-up recheck of this ventilation system on 3/29/16, at 7:15 a.m. the unit remained non-functioning.
When interviewed on 3/31/16, at 7:55 a.m. the director of maintenance (DOM) stated the motor for the ventilation system "was shot" and had since been replaced after the environmental tour on 3/28/16. The DOM stated the ventilation units are scheduled for a monthly check but this had not been completed according to the preventative maintenance schedule. Review of the maintenance log on 3/31/16 at 10:15 a.m. identified the most recent check was dated 1/15/16 (2 months prior). According to documentation, the ventilation unit was functional at that time but no further checks had been logged.
The facility policy "System Maintenance", last revised 01/12/15, stipulated "HVAC (heating ventilation air conditioning) units-filters checked and changed monthly".
Tag No.: C0231
Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.
Findings include:
Please refer to Life Safety Code inspection tags: Bld:01-K0011, K0054, K0147, K0154, K0155; Bld:03-K0011, K0054, K0147, K0154, K0155.
Tag No.: C0271
Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure staff properly clean and disinfect the glucometer equipment after patient use according to policy for 1 of 1 patient (P1) who was observed to have a blood sugar test. This has the potential to affect all patients who required blood sugar tests.
Findings include:
During observation on 3/29/16, at 11:20 a.m. registered nurse (RN)-A obtained a glucometer from the docking station located at the nursing station. RN-A entered patient (P)-1's room, checked the blood sugar and immediately returned to the nursing station with the glucometer. RN-A was observed to obtain a moistened wipe from the canister labeled, "Sani-Cloth AF3" and quickly wiped over the surface of the meter without allowing the meter to remain in contact with the sanitizing solution for the manufacture's recommendation of 3 minutes. RN-A confirmed the solution was not in contact with the meter for the recommended time period and if needed would have been utilized the equipment for the next patient without allowing any additional drying/decontamination time.
Review of the manufacturer's written instructions located on the label of the Sani-Cloth canister indicated the treated surface must have three minutes of continuous wet contact with the germicidal disposable wipe for proper disinfection. During observation of the cleaning process the germicidal wipe was only in contact with the glucometer for under 60 seconds.
When RN-A and licensed practical nurse (LPN)-A were interviewed on 3/29/16, at 11:30 a.m. they verified the usual cleaning practice was implemented as observed. Both RN-A and LPN-A confirmed they were not aware of the manufacturer's three minute contact information documented on the label of the canister.
During a subsequent interview with RN-A, on 3/29/16, at 2:45 p.m. it was stated a discussion had been held with the director of nursing (DON) and it was learned that staff were expected to utilize the individual packaged wipe called DISPATCH to clean the meter between use and not the Sani Cloth. DISPATCH wipes were unavailable for use.
The facility policy titled, Maintenance-Cleaning the Meter, Shared Medical Equipment last reviewed 6/13, the meters exterior will be cleaned between each patient. The policy titled, Shared Medical Equipment Cleaning and Disinfection with last revision date 1/2016 indicated- Glucometers: Follow manufacturer's guidelines.
Tag No.: C0337
Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure that all patient care services including medical records, dietary, pharmacy and infection control had been evaluated over the past year (2015). This has the potential to affect all patients served by the CAH.
Findings include:
The facilities Quality Assessment and Performance Improvement Plan (QAPI) approved January 2016 indicated the QAPI plan applies to all departments and each department and service will report to the QAPI Committee according to the following schedule: Medical Record Services-quarterly; Pharmacy Services (including P & T [Pharmacy & Therapeutics]functions)-quarterly; Dietary Services-quarterly and Infection Control -quarterly. The QAPI plan identified the QAPI committee responsibilities as: define, measure, analyze, and monitor QAPI indicators, indicator goals, data, and quality reports with each department and service including contracted services; and review and analyze adverse events and medical errors, including , but not limited to, transfusion reactions, drug administration errors, adverse drug reactions and incompatibilities. The Departments/Services role was identified as: report quality data to the QAPI committee according to the reporting schedule and delegate department/service staff to participate in quality improvement teams and initiatives as appropriate.
It was noted during review of the quarterly QAPI meetings dated 12/29/15, 9/25/25, 6/25/15 and 12/19/14 that new and/or revised quarterly data had not been submitted by pharmacy, dietary, infection control and medical record services.
There had been no revisions implemented nor submission of dietary quality data reported to the QAPI committee on a quarterly basis as defined in the facility PI plan. The only data collected in the dietary department had been identified as monitoring of food temperatures; although no problems had been identified related to food temperatures for the past year (2015), no revision nor new goal had been developed to evaluate ongoing dietary services.
On 3/29/16 at 9:00 a.m. the Health Information Manager, (HIM) provided a QAPI project for the time period of fiscal year July 2014 - June 2015. This consisted of a reviewing medical charts for completed history and physicals (H &P) within a 24 hours from patients admission. The data revealed a 100 % completion for the entire time period, yet no revision nor new goal had been developed to evaluate ongoing patient services.
During review of QAPI data related to infection control, it was noted that handwashing audits of all staff had been conducted for the past 3 years. It was also noted the CAH had met the goal at 100% for the past couple of years; yet no revision had been made to evaluate other aspects of infection control/patient care services in the CAH. When interviewed on 3/30/16, at 10:00 a.m. the infection control officer (ICO) indicated the CAH had been expected by the Network Hospital to continue with the staff audits even though they had met the identified goal at 100%. The ICO verified the CAH could evaluate other patient care services related to infection control practices.
When the QAPI documentation was reviewed for 2015, it was noted that no pharmacy related goals and/or data was evident for review. According to the QAPI plan, quarterly data was to be submitted to the committee. Evidence was lacking that ongoing pharmacy services had been evaluated. The PI coordinator confirmed on 3/29/16, at 3:00 p.m. that pharmacy data was not available for review and indicated she had not received any quality indicator reports from pharmacy since 2014.
On 3/30/16, at 10:05 a.m. the PI coordinator again confirmed the QAPI program had not evaluated services related to dietary, clinical record review, infection control and pharmacy for the past year (2015). The PI coordinator confirmed that no new goals were developed, revised nor had data had been submitted to the PI committee for review in the noted areas.
Tag No.: C0338
Based on interview and document review the Critical Access Hospital (CAH) failed to ensure medication therapy had been evaluated in the past year as required by Pharmacy and Therapeutics ( P & T) Committee policy. This has the potential to affect any patients admitted to the CAH.
Findings include:
During review of the Pharmacy and Therapeutics (P & T) committee meeting minutes it was noted that medication therapy had not been evaluated. The P & T meetings dated 3/10/16, 10/13/15, 10/28/14 and 4/24/14 lacked any reference to drug/medication evaluation. Information provided at those meetings involved formulary discussions but there was no documentation related to medication therapy evaluation, medication safety, medication use guidelines and protocols nor any quality assessment and performance improvement (QAPI) data practices or projects.
The pharmacist was interviewed on 3/29/16, at 11:40 a.m. and indicated monitoring of medication therapy was completed by the computer system, "EPIC" which she would review and verify all medications administered. The pharmacist indicated medication incidents were reviewed on a weekly basis by the director of nursing and the administrator and sent to her for review.
During a subsequent interview with the pharmacist on 3/31/16, at 10:40 a.m. it was indicated evaluation of medications and their effectiveness was completed at the P&T meetings and documentation would be in the meeting minutes, "if there was any".
The Performance Improvement coordinator (PI) was interviewed on 3/29/16, at 2:00 p.m. and indicated she was not aware of any medication therapy evaluation conducted within the CAH for the past year (2015).
On 3/30/16, at 1:14 p.m. the director of nursing (DON) was interviewed and indicated the P&T meeting is supposed to meet quarterly, but stated "it rarely does". The DON also confirmed she was unaware of any medication therapy evaluation projects and if it had, it would have occurred during P & T meetings.
Review of the Pharmacy Manager job description the following was identified under Position Summary: responsible for the coordination of clinical services, medication use evaluation, Adverse Drug Reaction (ADR) reporting program and Staff Development program and responsible for participation in the PI (Performance Improvement) process. It was also identified responsibility for submitting quarterly reports to P&T committee. The summary included "other related duties": responsible for the development, implementation and annual review of a pharmacy PI.
The Pharmacy and Therapeutics (P & T) Committee policy and procedure dated 12/15 indicated: the P & T Committee will generally meet quarterly. The minutes of P & T committee meetings shall be the responsibility of the Pharmacy Supervisor.