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Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure 2 of 3 negative pressure rooms (for airborne isolation- a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room), (room 103 on the medical/surgical wing and the isolation/pediatric room on the operating room wing) were properly maintained and monitored.

Findings include:

On 12/10/24 at 2:38 p.m., a tour of the nursing unit was completed with the maintenance manager (MM). During the tour, patient room 103 and the isolation/pediatric room were observed to have the capabilities of being converted to a negative pressure room. MM confirmed room 103 and the isolation/pediatric room were the CAH's negative pressure rooms. MM had nursing staff demonstrate the negative pressure in room 103 was activated by closing the door and setting negative pressure on a panel on the wall to the left of the door. The panel indicated the pressure fluctuated between 0.1450 and 0.0140. The negative pressure set point of 0.0060 was not reached. The indicator light did not activate red or green to indicate if the negative pressure was working or had been interrupted. MM had nursing staff demonstrate the negative pressure in the isolation/pediatric room on the operating room wing was activated by closing the door and setting the negative pressure panel on the wall to the left of the door. The panel indicated the pressure fluctuated between 0.0080 and 0.1050. The negative pressure set point of 0.0060 was not reached. The indicator light did not activate red or green to indicate if the negative pressure was working or had been interrupted.

During an interview on 12/10/24 at 3:12 p.m., MM confirmed the above findings and indicated the negative pressure rooms had faulted in the past due to the belts on the roof being worn out. MM indicated the belts needed to be replaced.

During an interview on 12/10/24 at 3:14 p.m., the safety officer (SO) identified the negative pressure rooms were to be tested monthly. SO stated he thought they were being tested monthly by the managers responsible for the medical/surgical and operating room wing. SO indicated. "I should probably take the monthly negative pressure room checks off the managers plates as I have to check the ones in the clinic as well." SO stated he did not have any monthly logs documentation showing the negative pressure rooms had been tested.

During an interview on 12/11/24 at 11:56 a.m., director of nursing (DON) indicated she was not aware the negative pressure rooms were not working properly. DON stated she was not aware she was responsible to perform monthly checks on the medical/surgical wing.

During an interview on 12/11/24, 4:30 p.m., chief executive officer (CEO) acknowledged the negative pressure rooms were not working and there were no logs identifying the negative pressure rooms were being tested monthly.

Email received from DON on 12/11/24 at 12:21 p.m., indicated the facility did not have a policy specific to negative pressure rooms.

Review of the facility instructions titled To Set Low Pressure Alarm, undated, indicated the negative pressure set point was to be at 0.0060.

Based on observation, interview and document 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 the Life Safety Code inspection tags: K321, K353, K712 and K901 for additional information.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure Patient Rights and Dietary Services were evaluated through the quality assurance program.

Findings include:

During an interview on 12/11/24 at 10:40 a.m., with health information management (HIM) director stated there was no formal Quality Assurance and Performance Improvement (QAPI) projects related to patient rights.

During an interview on 12/11/24 at 2:48 p.m., the Cief Nursing Officer (CNO) confirmed she had not been able to find anyone in the hospital who was aware of QAPI projects regarding patient rights.






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During a follow-up interview on 12/10/24 at 3:38 p.m., CNO identified she was aware the facility was expected to review and develop a QAPI project for the dietary department however confirmed the facility had no current QAPI projects for the dietary department.

During an interview on 12/11/24 at 4:30 p.m., chief executive officer (CEO), indicated he understood the QAPI requirements.

Review of facility policy titled Organizational Quality Assurance and Performance Improvement, dated pending, the facility will have a comprehensive program and plan that guides all performance improvement activities in accordance with the organization's mission and vision.