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Based on observation and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards. The failed practices had the likelihood to affect all patients relying on electrical equipment connected to the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, and the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
C. Observation on 06/14/21 at 02:45 PM of Operating Room (OR) 2 showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into the wall receptacle and resting on a stool across the room from the equipment the power cord served. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.
D. Observation on 06/14/21 at 03:00 PM of Operating Room (OR) 1 showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into the wall receptacle and resting on the floor across the room from the equipment the power cord served. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.
E. Observation on 06/15/21 at 10:25 AM of the GI Procedure Room showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into a wall receptacle near the sink and resting on the counter across the room from the equipment the power cord served. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.

Based on observation and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to provide all master alarm panels for the medical gas system in accordance with NFPA 99 standards. The failed practices had the likelihood to affect all patients relying on electrical equipment connected to the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 5.1.9.1 showed all master alarm systems shall include visual indicators for each condition monitored, visual indicators that remain in alarm until the situation that caused the alarm has been resolved, means to visually indicate a lamp or LED failure, and visible indication that communication with an alarm-initiating device has been disconnected.
B. Observation on 06/15/21 at 03:00 PM of the Environmental Services (EVS) Office showed the master alarm panel for the medical gas system did not illuminate any of the visual indicators when tested or when in regular use. This finding was confirmed with the Director of Maintenance at the time of observation.

Based on review of Arkansas Rules and Regulations for Hospitals and Related Institutions, review of Physician Credentialing files and interview, it was determined the facility failed to follow Arkansas State Regulations in that they failed to provide complete credentialing files that included Physician privileges in nine of nine (#1-#9) files and did not include three peer references in seven (#1-#6 and #8) of nine (#1-#9) files. By not maintaining completed credentialing files the facility could not assure that physicians were competent and practiced within the boundaries of professionally accepted norms, which improves the quality and safety of the health care provided. The failed practice had the likelihood to affect all patients that were treated at the hospital. Findings follow:

A. Review of the Rules and Regulations for Critical Access Hospitals in Arkansas, Section 6. MEDICAL STAFF, A.2, 7, showed, an individual file shall be maintained for each physician practicing in the hospital and shall include specific delineation of privileges requested and granted and verification of three references.
B. Review of Physician Credentialing files showed Physicians #1 - #9 did not have delineation of privileges requested and granted.
C. Review of Physician Credentialing files showed Physicians #1-#6 and #8 did not have verification of three references.
D. The above findings in A, B and C were verified with the Quality Assurance Facilitator on 06/16/21 at 12:45 PM.

Based on observation and record review, it was determined the facility failed to ensure all patient care equipment was maintained in safe operating condition in that one of one electro-surgical unit in the Gastrointestinal (GI) Procedure Room was not maintained by an annual Preventative Maintenance (PM) program. The failed practice had the potential to impact all patients receiving GI procedures. Findings follow:

A. Observation on 06/15/21 at 10:20 of the GI Procedure Room showed an electro-surgical unit was present with a maintenance sticker that indicated annual preventative maintenance was due 3 months ago.
B. Review of the facility's PM log provided by Crothall Healthcare on 06/15/21 at 11:00 AM showed the electro-surgical unit was not included in the PM inventory and had not had preventative maintenance performed in the last 12 months. This finding was verified 06/16/21 at 11:00 AM with the Director of Maintenance.

Based on observation and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, the facility failed to maintain two of two (Health Information Management, Central Supply) smoke door assemblies as required by NFPA 101 2012 Edition in that the smoke doors were not closed when released. The failed practice had the likelihood for the smoke doors not to close in the event of a fire, allowing smoke to rapidly transfer into the adjacent spaces. The failed practice had the likelihood to affect all patients, staff, and visitors. Findings were as follows:

A. Review of NFPA 101 2012 Edition: 8.2.2.4 showed all door assemblies required to be smoke leakage-rated shall be installed in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives. Review of NFPA 105 2010 Edition: 5.1.2.1 showed smoke door assemblies shall be kept closed or arranged for automatic closing.
B. Observation on 06/15/21 at 10:00 AM showed the doorway to Health Information Management was constructed of a smoke door assembly consisting of a door leaf which did not fully close when released, leaving approximately a half-inch gap between the door leaf and the door frame. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.
C. Observation on 06/15/21 at 02:25 PM showed the doorway to Central Supply was constructed of a smoke door assembly consisting of a door leaf which did not fully close when released, leaving approximately a one-inch gap between the door leaf and the door frame. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.
D. Review of NFPA 101 2012 Edition:8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 4.2.1 showed all listed items of a fire door assembly shall be identified by a label.
B. Observation on 06/14/21 at 02:15 PM showed the doorway of the Soiled Utility room was constructed of a fire-rated door assembly consisting of a listed door frame which did not have a label. This finding was verified on 06/16/21 at 11:30 AM with the Director of Maintenance.

Based on review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and observation of the Physical Therapy Building and MRI Building, it was determined the facility failed to install two of two alcohol-based hand-rub (ABHR) dispensers in locations to ensure the safety of patients and staff to prevent electrical shock or fire. The failed practice had the potential to affect all patients admitted into the Physical Therapy Building and MRI Building. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6(8) showed alcohol-based hand-rub dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source.
B. Observation on 06/15/21 at 9:45 AM of the Physical Therapy Building showed one ABHR dispenser installed directly above a duplex electrical receptacle on the wall adjacent to the bathroom in the corridor leading to staff offices. This finding was verified with the Quality Assurance Director at the time of observation.
D. Observation on 06/16/21 at 9:05 AM of the MRI Building showed one ABHR dispenser installed directly above a duplex electrical receptacle on the wall adjacent to the entrance. This finding was verified with the Director of Maintenance at the time of observation.

Based on observation, policy review, and interview it was determined the facility failed to implement practices and policies in the surgical area including prevention and surveillance to control transmission of infectious diseases by not wearing proper surgical attire when moving from the restricted to non-restricted area and by not wearing professionally laundered scrubs. The failed practice had the potential to affect all patients having surgery in the facility. Findings Follow: See C1208

Based on review of Association of Perioperative Registered Nurse (AORN) 2020 guidelines and interview it was determined the facility failed to ensure a sanitary environment in that operating room personnel were wearing their own home laundered scrubs from home into the operating room. Failure to ensure personnel wore scrubs that had been laundered at a health care accredited laundry facility did not assure patients would be protected from likely sources of infection. The failed practice was likely to affect all surgical patients. Findings follow:

A. During an interview with the Infection Control Preventionist on 06/14/21 at 11:00 AM she stated the facility followed the AORN guidelines.
B. Review of AORN guidelines 2020 for surgical attire showed all individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a healthcare-accredited laundry facility.
C. During interview with the Director of Nurses (DON) on 06/14/21 at 1:15 PM, she stated that some of the nurses were home laundering their scrubs and some are wearing those cleaned by the laundry service.
D. The above findings in A and B were verified with the DON on 06/14/21 at 1:15 PM.

Based on policy and procedure review, observation, and interview it was determined that the Infection Control Nurse did not have a system for identifying, controlling, and preventing the transmission of infections in that three of three ( Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #2 & RN #3 ) staff members moved to and from the non-restricted area to the restricted area of the Surgical Suite wearing the same scrub attire. The failed practice did not ensure the sterile Surgical Suite was maintained free of contaminants and had the potential to affect all surgical patients in the facility. Findings follow.

A. Review of policy and procedure titled "Surgical Attire "dated 04/20/21 showed: "Clean surgical attire will be worn in semi-restricted and restricted areas. Individuals who enter semi-restricted and restricted areas will wear scrub attire that has been laundered and clean or wear single use scrub attire provided by the facility ...."
B. During observation of endoscope cleaning procedure on 06/16/21at 12:45 PM, LPN #1 left the procedure room where an endoscopy procedure was performed and entered the surgical suite wearing the same scrub attire with no cover.
C. During observation of a surgical procedure in OR #1, RN #2 entered from the pre- and post-operative area into the operating room with the same scrubs.
D. During observation of endoscope cleaning procedure on 06/16/21 at 1:00 PM RN #3 came from the post-operative area into the surgical suite (restricted area) room wearing the same scrubs with no cover.
E. During interview with Director of Quality on 06/21/21 at 9:00 AM the above findings were verified.