HospitalInspections.org

Based on observation, interview, and policy manual review, the provider failed to ensure:
*Appropriate policy and procedures were developed, reviewed, and revised for three of three services (oxygen administration, nebulizer treatments, and intravenous (IV) solutions) provided to one of one observed patient (32) in the emergency department.
*Appropriate policy and procedures were developed, reviewed, and revised for the use of one of one emergency tracheostomy set located in the emergency department.
*Appropriate policy and procedures were developed, reviewed, and revised in accordance with services provided in the surgical department.
Findings include:

1. Observation in the emergency department (ED) on 1/3/17 from 2:25 p.m. through 3:40 p.m. revealed:
*Patient 32 had been brought into the ED bay by ambulance. She had been complaining of chest pain, left shoulder pain, and had a history of shingles.
*Nasal oxygen was administered to the patient.
*An IV solution had been started in her right forearm area by registered nurse (RN) A.
*Cardiac monitoring was started on the patient.

Interview and observation on 1/4/17 at 9:00 a.m. in the ED with registered nurse (RN) F regarding the services provided in the ED revealed:
*Oxygen was administered per nasal cannula and per mask.
*Nebulizer treatments were administered.
*There was a tracheostomy kit available.
*Intravenous medications were administered in the ED.
*Cardiac monitoring was done.

Review of the ED policy and procedure manual revealed there were no policies or procedures for the following services delivered in the ED:
*Oxygen.
*IVs.
*Cardiac monitoring.
*Nebulizer treatments.
*Emergency tracheostomy.

Interview on 1/4/16 at 10:30 a.m. with outpatient/surgical coordinator G and the director of nursing (DON) services regarding policies and procedures for the ED revealed:
*The provider had been working for the past year reviewing and revising policies and procedures for all the departments of the hospital.
*The staff could reference a Lippincott Manual for questions regarding procedures in the ED.
*She agreed there was no reviews or revisions documented with regards to the ED manual, and ED policies and procedures should have been developed for the services provided in the ED.



32332

2. Review of the provider's OR (operating room)/Anesthesia Policy Manual revealed it had been signed by the surgical services coordinator and the medical staff designee on 4/8/15 indicating the policies had been reviewed and approved.

Interview on 1/4/17 at 2:10 p.m. with the director of quality control and infection control and the DON regarding those policies revealed they:
*Stated the current policies and procedures were not organized and had needed to be updated.
*Confirmed the surgical policies and procedures had been last reviewed on 4/8/15.
*Were aware the policies had not been reviewed in the last year.
*Were in the process of rewriting the policies.
*Planned to rewrite those policies using the Lippincott Nursing Policies and Procedures manual as a guideline.
*Had received access to another hospital's policies and procedures but wanted to create their own.

Based on observation, interview, and policy review, the provider failed to ensure hand hygiene was performed by four of four hospital staff [registered nurse (RN) B, certified nurse practitioner (CNP) E, laboratory (lab) technician (tech) C, and lab tech D] during one of one sampled emergency department (ED) patient's (32) emergency department visit. Findings include:

1. Observation on 1/3/17 from 2:25 p.m. through 3:40 p.m. in the ED revealed:
*RNs A and B were on the right side of the gurney attempting to start an IV on patient 32.
*Both RNs had gloves on.
*RN A with her gloved hands left the patient's right side and went to the cupboards:
-Opened the cupboards.
-Took supplies out of the cupboard.
-Then returned to start the intravenous (IV) with those same gloved hands.
*RN B removed her gloves without washing or sanitizing her hands. Returned supplies to the cupboard. Touched the patient with her bare hands.
*CNP E came into the ED to examine the patient. She did not wash or sanitize her hands. She then touched the patient's edematous lower leg with her bare hands. She took her stethoscope and listened to the patient's lungs. She then put on gloves without washing or sanitizing her hands first.
*Lab tech C entered the room and put on gloves without washing or sanitizing her hands first. She then took a piece of paper with those same gloves on to review some information. She then drew the patient's blood using those same gloves.
*Lab tech D entered the ED to perform an EKG; she put on gloves without washing or sanitizing her hands first.

Interview on 1/4/17 at 10:50 a.m. with the director of nursing (DON) services and outpatient/surgical coordinator G regarding the above observations revealed:
*They both agreed there were issues with improper hand hygiene with all staff.
*The staff in the ED should have washed or sanitized their hands before and after direct patient contact.
*The DON had not performed audits to ensure staff compliance for proper hand hygiene.

Review of the provider's 9/11/13 Hand Hygiene policy revealed the purpose of the policy and procedure was to:
*Prevent the spread of infection and disease to other patients, personnel, and visitors.
*Keep hands free from potentially infectious material.
*Use an alcohol-based hand rub before and after direct patient contact.

Review of the provider's 5/20/99 Gloves policy revealed:
*The purpose was to prevent the spread of infection and disease to other patients, personnel, and visitors.
*When gloves were indicated disposable single-use gloves should have been worn.
*Non-sterile gloves were used primarily to prevent the contamination of the employees hands when providing care/services to the patent.
*Gloves did not have to be worn if "no touch" techniques could have been used.

Based on the 2015 Critical Access Hospital (CAH) 2015 program evaluation review and interview, the provider failed to ensure their health care polices and procedures were reviewed as part of the annual program evaluation. Findings revealed:

1. Review of the provider's 2/22/16 CAH program evaluation revealed there was no documentation the provider's health care policies had been reviewed or revised.

Interview on 1/5/17 at 9:40 a.m. with the administrator, director of nursing, and the director of quality and infection control revealed:
*The provider was not sure when all health care policies and procedures had been reviewed last.
*The provider had not discussed their policies and procedures at the annual program evaluation.
*They were not aware policies and procedures should have been reviewed at the annual program evaluation to determine if policies needed to be revised or deleted.