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I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure clinic staff removed and disposed of any outdated medical equipment and supplies. Failure to remove and discard of expired medical equipment and supplies based on manufacturer's recommendation could result in a potential risk to patient safety. The CAH administrative staff identified a census of 2 at the time of the survey.

Findings include:

1. During a tour while in the CAH's Pharmacy on 5/22/2023 at approximately 1:00 PM with the Director of Pharmacy revealed the following:

In the storage room revealed:

a. 117 of 126 BD 5 milliliter (mL) Luer-Lok Syringes, expired on 12/31/21.

2. Review of policy, "Expiration Date Monitoring" approved 11/28/2014, revealed in part, "Expired supplies must be removed from inventory before the expiration date and sequestered so as not to re-enter the usable inventory until such time that the supplies can be returned or discarded."

3. During an interview at the time of each tour, Director acknowledged they expected their staff to check the supplies every month and remove any outdated supplies. This failure to remove the expired supplies from their department could result in potential use of the expired supplies for patient care.

II. Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscope procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The hospital's administrative staff identified surgical services staff performed an average of 20 endoscope procedures per month during the fiscal year from July 2022 to May 2023.

Findings include:

1. Observations during a tour of the surgery department on 5/24/2023 at approximately 08:28 AM in Procedure room revealed 1 of 1 bottle Baxter 1000 mL bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions indicated in part... "For single-dose only ...Discard the unused contents of open containers, as Sterile Water for Irrigation contains no antimicrobial preservative." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

3. During an interview at the time of the tour, Surgical Service Manager stated the surgery staff opened the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty. The Surgical Service Manager verified with the Olympus representative that the sterile water for irrigation should be removed after each case. The Surgical Service Manager acknowledged the manufacturer's directions for the Baxter 1000 mL bottles of sterile water for irrigation did not support using the bottles of sterile water for irrigation for more than one patient.

Based on observation, document review, and staff interviews, the Critical Access Hospital ' s (CAH) administrative staff failed to ensure the CAH staff kept patient medical information secure from unauthorized access in the CAH's Laboratory Department. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified a census of 2 at the time of the survey.

Findings include:

1. Review of the CAH policy "Protection of Information Guideline Sets," approved 4/2003, revealed in part, " ...Information must be protected according to its sensitivity, criticality, and value, regardless of the media on which it is stored, the manual or automated systems that process it, or the methods by which it is distributed. All employees are responsible for protecting ...from unauthorized access ...whether accidental or intentional"

2. Observation on 5/22/23 at approximately 11:37 AM, during a tour of the Laboratory Department with the Medical Laboratory Technician (MLT) A, revealed a large television monitor that displayed the patient's names, medical records number and lab test to be drawn or has been drawn.

3. During an interview on 5/22/23, at the time of the tour, MLT A, revealed the television monitor is never turned off and the South Laboratory door is kept unlocked at all times. The West Laboratory door has a vertical window which faces the television monitor. Both doors allow access for unauthorized staff or personnel to see the information displayed on the television monitor. Laboratory Technician was unaware of the situation and acknowledged the Laboratory was fully accessible to any unauthorized personnel.