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Based on observation, interview and document review the critical access hospital (CAH) failed to ensure staff properly disinfect the common use glucometer equipment after patient testing for 2 of 2 patient (P21 and P22) observed who required blood sugar level testing. In addition, the CAH failed to develop and implement a program to reduce the risk of a Legionella (a bacterium) in the facility water system to prevent cases and outbreaks of Legionnaires' disease (a serious type of pneumonia). This had the potential to affect all patients, visitors, and staff.

Findings include:

During an observation on 3/22/18, at 10:55 a.m. with license practical nurse (LPN)- A, she obtained a glucometer from the patient care cabinet outside P21's room and entered P21's room, obtained a blood sample to check P21's blood sugar and left P21's room. LPN-A opened P21's patient care cabinet, obtained a Sani Cloth disinfectant wipe and quickly wiped over the surface of the glucometer (less than 30 seconds). LPN-A stated her usual practice was to let the machine air dry for two minutes as the facility policy directed. LPN-A stated she did not know how long to keep wiping with the Sani Cloth, but felt the wipe was very wet and fluid was dripping off the wipe.

During an observation on 3/22/18, at 11:13 a.m. with registered nurse (RN)- A, she obtained a glucometer from the patient care cabinet outside P22's room, obtained a blood sample to check P22's blood sugar and left P22's room. RN-A opened P22's patient care cabinet and immediately placed the glucometer in the glucometer case and closed the case. RN-A did not use a disinfectant wipe prior to placing the glucometer back in the case. RN-A stated she was done using the glucometer and walked to the nurses station.

Review of the Sani Cloth manufacture's written instructions, located on the container label of the Sani-Cloth container, indicated the treated surface was to remain wet for three minutes and the let air dry.

During an interview on 3/22/18, at 11:40 a.m. RN-C stated the usual facility practice was to wipe off the glucometer and let the surface air dry for two minutes. RN-C reviewed label on the Sani Cloth disinfectant container and confirmed the Sani Cloth container indicated to have treated surfaces remain wet for three minutes for disinfection. RN-C stated she felt staff were not keeping the glucometer surface wet for three minutes after wiping down the surface.

The facility policy Glucometer Cleaning, undated, indicated the case and meter would be cleaned with Sani-cloth when visibly soiled and at nurse's discretion. Wipe the case/glucometer once to remove what is visible, then wipe a second time and allow it to air dry for two minutes.




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Legionella Monitoring:

When interviewed on 3/21/2018 at 8:10 a.m. the maintenance director (M)-A stated he was completely unaware of any program with regards to a water management program for the prevention of Legionella disease.

The Director of Quality verified on 3/21/18 at 8:45 a.m. the CAH had received the information from Centers for Medicare and Medicaid Services Bulletin S&C 17-30. However, they failed to develop an active program for the prevention, control, and investigation of the bacterium of Legionella. She further stated on 3/22/18 at 10:30 a.m. she plans on meeting with (M)-A and together will develop the necessary water monitoring program.

In review of Infection Control Plan, last revised 7/17, the policy identified the Plan's goals as: Prevention; Surveillance and Control. It did not address any of these goals to be applied to a water management program for the prevention of Legionella

Based on interview and document review, the critical access hospital (CAH) failed to ensure ambulance services were currently under agreement or arrangement. This had the potential to affect all current and future patients of the CAH.

Findings inlcude:

On 3/21/18, at 1:00 p.m. the Chief Executive Officer (CEO) indicated there was no current agreement/arrangement or contract with the ambulance service utilized by the hospital. The CEO stated he was unaware an agreement needed to be in place and indicated he felt it was an assumed the county ambulance would provide services for the CAH.


A policy was requested for provision of transportation services in and out of the CAH, none was provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QAPI) projects were current, comprehensive and incorporated into the CAH's QAPI program for the following departments: infection control, medical staff and services provided through agreement/arrangement or contracted services including ambulance services and organ procurement organization(OPO.) This had the potential to affect all patients receiving services from the CAH.

Findings include:

Infection Control:

On 3/21/18, at 9:00 a.m. the Infection Control Preventionist (ICP)-A stated she had one current projects for QAPI regarding hand hygiene. The ICP-A stated she had other informal projects she had been working on such as proper use of personal protective equipment. The ICP-A was unable to provide data collected, analysis of data or an evaluation of any data collected. The ICP confirmed the CAH did not have a formal QAPI for surgical site infections.

Services provided by agreement/arrangement or contract:

On 3/22/18, at 9:40 a.m. the director of quality (QA)-A confirmed the hospital wide QAPI program did not include any current QAPI projects for ambulance services and OPO.

A facility policy titled, Quality and Performance Improvement Plan reviewed 11/2017, revealed each service area needed to identify one or more major monitoring and evaluation activities in their annual Service Area Quality Management Plan. Each service area was responsible for identifying opportunities to improve processes within their own area or between service area and those of other areas. In addition, the CAH identified the Plan Do Check Act methodology for undertaking performance improvement. This methodology identified potential improvements, or indicated the need for more focused review of the issues involved. It also allowed for checking the results of the improvement after implementation to ensure it produced the intended results.

Based on interview and document review the critical access hospital (CAH) failed to ensure notification to the organ procurement organization (OPO) was completed in a timely manner for 3 of 3 patients (P2, P3, and P4) who died at the CAH.

Findings include:

P2 was admitted to the CAH's emergency department on 10/1/17, for a cardiac arrest. Resuscitation efforts were unsuccessful and P2 was pronounced dead at 4:33 p.m.

A progress note dated 10/1/17, at 7:00 p.m. indicated a call was placed to the OPO (2 hours and 27 minutes post death).

P3 was admitted to the CAH on 1/20/18. At 10:58 p.m. P3 was in ventricular tachycardia (type of regular and fast heart rate that arises from improper electrical activity in the ventricles of the heart). Resuscitation efforts were unsuccessful and P3 was pronounced dead at 11:06 p.m.

An assessment history report dated 1/21/18, indicated a call was placed to the OPO at 1:10 a.m. (2 hours and 4 minutes post death).

P4 was admitted to the CAH's emergency department on 2/3/18, for cardiac arrest. Resuscitation efforts were unsuccessful and P4 was pronounced dead at 7:24 a.m.

A resuscitation record dated 2/3/18, indicated a call was placed to the OPO at 9:00 a.m. (1 hour and 46 minutes post death).

During an interview on 3/22/18, at 11:29 a.m. with registered nurse (RN)-C stated the OPO should be called one hour after a death. RN-C stated the staff should be placing that call to OPO within one hour.

During an interview on 3/22/18, at 11:42 a.m. with the quality director (QD) stated the staff are to call the OPO within one hour.

The Organ and Tissue Recovery Memorandum of Understanding dated 11/30/16, indicated a timely referral means the referral of a patient is within one hour of the patient meeting the clinical trigger for imminent death.