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Based on document review and staff interview, the facility failed to ensure the emergency water agreement considered the facility's usual supply on hand, quantities needed for water during an interruption in service, and was reviewed on a regular basis. The administrative staff identified a census of 6 inpatients at the time of the survey, an average daily census of 7 inpatients, and 260 employees.

Failure to ensure emergency water is available to meet the facility's critical functions during an emergency/crisis situation inhibits the facility's ability to ensure patient safety and quality of care while responding to and recovering from a situation that resulted in disruption of water.

Findings include:

1. Review of a document dated 8/4/04, revealed an agreement with Culligan Water Conditioning to provide the facility with water in the event of a natural disaster or state of emergency. The agreement stated in part "... this service will be provided only in a state of extreme emergency when city water and all other sources of local water have been exhausted ..." The agreement lacked details to address the amount of water the company would be willing to and capable of supplying or the timeframe in which they could accommodate the facility's needs.

2. Review of a document dated 3/20/06, provided by administrative staff as one of the facility's emergency water agreements, revealed correspondence with the City of Shenandoah regarding emergency water in the event of a failure in the city and/or hospital's water transmission line. The letter included in part "... In the event ... water service is interrupted there are at least two emergency sources for potable water. One, arranging for water service from Page One Rural Water District which has a distribution line in close proximity to the area ... The second choice would be the City Water Distribution Department which would dispatch a tanker truck with connector apparatus to the hospital ..." The letter included a contact name and number for the options outlined and closed in part with "hope these suggestions are of some benefit in your decision-making process ..." The document failed to define what, if any, agreement was reached with the city for emergency water.

Review of a maintenance policy titled "Interruption in Water Service", approved in 7/2013, revealed in part "... If the water is interrupted for any reason, the hospital shall ... contact local vendors to order bottled water for drinking ... calculated at nine gallons per patient bed per day. Water for drinking and hand washing shall be supplied from local vendors, HyVee Inc, Fareway Inc, Culligan water company, Lion water company in Red Oak, Anderson Erickson Dairy, etc. The City of Shenandoah shall be contacted to provide a tank truck from the fire department to provide water for the boilers, also water to be used for flushing toilets ..."

During an interview on 7/10/13, on the environment of care tour beginning at 10:00 AM, Staff K, Maintenance Director, acknowledged the date on the Culligan water agreement and did not realize it had not been updated recently. Staff K reported the facility would rely on Culligan for potable water and the city for non-potable water and was not aware of any planning or calculations in terms of the amount of water the facility would need, in the event of a disruption in service, or the amount of water that was kept on hand and available for use. Staff K reported the facility had considered using a nearby rural water transmission line as a possible option for emergency water needs several years back, but it was never pursued.

During an interview on 7/10/13 at 3:10 PM, Staff F, Food Service Director, reported she keeps 4 to 6 cases of 24 - 16 ounce bottles per case (approximately 12 to 16 gallons) of bottled water on hand, which would be available for use in the event of a disruption in water service.

I. Based on review of documents and interviews with staff, the facility failed to develop and implement an effective system to detect, track, and monitor surgical site infections for lens implants. An average of 19 surgical implants (cataract lens) procedures were completed at the facility monthly.

Failure to have an effective system to detect, track, and monitor surgical site infections inhibits the ability of the Infection Control Manager to identify any patterns or trends of surgical related infections; investigate to identify the potential sources of the infections; and to modify practices to prevent additional infections as indicated.

Findings include:

1. During an interview on 7/10/13 at 1:15 PM, Staff E, the person responsible for managing the facility's Infection Control activities, verified the facility lacked a system for post-op follow-up of patients for one year after the cataract lens implants. Staff E stated the facility followed the CDC (Centers for Disease Control) guidelines. Staff E lacked documentation of the CDC guidelines to follow surgical site infections.

The surveyor provided documentation of the CDC Definitions of Nosocomial Infections dated 1996, for surgical site infections. The definition states in part ...Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure.

Staff B, Performance Improvement Manager, verified a log is kept in the surgery department with each patient's name, physician, and type of lens implanted. The facility relied on the physician to report any associated surgical site infections regarding the lens implant.


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II. Based on observations, policy review and staff interviews, the facility failed to maintain a monitoring system to ensure the dish machine reached the required temperature to effectively sanitize all dishware and food preparation equipment. The administrative staff reported a current census of 6 inpatients and the Food Service Director reported serving an average of 18 patient served daily.

Failure to ensure food contact surfaces are effectively sanitized could potentially result in the contamination of patient food.

Findings include:

During the initial kitchen environment tour on 7/8/13 at 12:50 PM, observation of the Hobart dish machine revealed the data plate on the machine identified a required temperature of 180 degrees Fahrenheit (F) for the rinse cycle. During an interview at the time, Staff F, Food Service Director, reported staff visually monitor the temperature gauge, for the rinse cycle, on a routine basis to ensure the water reaches the required temperature, but the information is not documented. She said staff place a Taylor Temp Rite temperature strip (a color-change band verifies the water reached proper sanitizing temperature) in the machine three times weekly to verify the correct temperature is reached, then temperature strips are dated, initialed by the staff member, and saved.

Observation of the dish machine during operation, on 7/8/13 at 1:15 PM, revealed the rinse temperature gauge registered only 118 degrees F. Staff F reported the temperature gauge sometimes took a little while to rise and operated another cycle with a temperature strip. The rinse temperature gauge registered 118 degrees F. once again, but the temperature strip did verify the water reached a minimum temperature of 180 degrees F. Staff F said she would call maintenance and notify them of the problem.

Observation of the dish machine during operation, on 7/8/13 at 3:30 PM, revealed the rinse temperature gauge registered only 118 degrees F. During an interview at the time, Staff G, Food Service Worker and Staff H, Cook, reported they were not sure when the rinse temperature gauge quit working and had not placed a temperature strip in the dish machine to verify it reached the required temperature that afternoon. Staff G said it was working last Thursday, her last scheduled day of work. Staff H said the Ecolab maintenance technician was here 2 to 2 1/2 weeks ago, for the monthly dish machine maintenance visit, and thought he noticed the gauge was not working properly.

Observation of the dish machine during operation, on 7/9/13 at 7:32 AM, revealed the rinse temperature gauge registered only 118 degrees F. During an interview at the time, Staff J, cook, said she was not sure when the rinse temperature gauge quit working and was not sure if a temperature strip had been checked this morning. Staff I, Room Service Assistant, reported she had operated the dish machine this morning, but had not put a temperature strip in the machine yet.

During an interview on 7/9/13 at 1:30 PM, Staff F reported she was aware the dish machine rinse cycle temperature gauge was not working properly early in June and said it would only go up to 140-145 degrees F. She said when the temperature strips were placed in the machine, they verified the water reached the required minimum temperature of 180 degrees F. Staff F reported the Ecolab maintenance technician came on 6/26, for the monthly routine maintenance visit, and confirmed the rinse temperature gauge needed to be replaced. Staff F said he provided a bid for replacement, but the facility required 3 bids prior to approval to purchase, and she had not pursued the other two bids. Staff F said that dietary staff actually used a temperature test strip daily, but only saved one about every other day. Staff F provided evidence that staff routinely checked a temperature test strip 3 times weekly, which indicated the minimum required temperature was reached, but lacked documentation to support the dish machine reached the required temperature on other days.

Review of a Maintenance policy titled "Hospital Dishwasher Maintenance", approved in 7/2013, revealed in part "It is important to ensure that the water temperature within the dishwashing machine is maintained at a high enough temperature for infection control and proper cleaning ..."

Review of a Food Service policy titled "Dish Machine Usage", approved in 7/2013, revealed in part "... Run a temperature strip through on a plate ... at the beginning of each shift change ..."


III. Based on observation, policy review and staff interviews, the facility failed to use proper hand hygiene with food handling, to protect patient food from contamination. The administrative staff reported a current census of 6 inpatients and the Food Service Director reported serving an average of 18 patient meals daily.

Failure to use proper hand hygiene with food handling could potentially result in the contamination of patient food.

Findings include:

Observations during preparations for breakfast and lunch meal service on 7/9/13 identified the following concerns:

1. At 7:50 AM, Staff J, cook, answered the telephone and proceeded to set up a patient tray, handling the patient napkin and silverware with her contaminated hands. She washed her hands and donned gloves, opened the door to the True refrigerator and obtained a container of cantaloupe and a bag of grapes. Staff J then took off one of the gloves and place it on the counter, obtained 2 serving scoops out of a drawer, put the removed glove back on and used the contaminated gloved hands to take out a handful of grapes, remove the stems and place the grapes in a serving dish for a patient.

2. At 7:55 AM, Staff J donned gloves without washing her hands, opened the walk-in freezer, obtained 2 biscuits, carried them out with the contaminated gloved hands and placed them on a plate for service to a patient.

3. At 8:20 AM, Staff J used her bare hands to obtain orange slices from the cutting board and placed two slices on each of two plates for service to patients.

4. At 11:32 AM, Staff J opened the door to the cafeteria, donned one glove without washing her hands, opened a package of bread and obtained a slice of bread with the contaminated gloved hand and placed it on a plate for service to a patient.

During an interview on 7/10/13 at 11:40 AM, Staff F reported she thought that Staff J probably got nervous, leading to the lapses in normal procedures for proper hand hygiene. Staff F said dietary staff know not to touch ready-to-eat food and confirmed that opening refrigerators and touching equipment or surfaces contaminate hands/gloves.

The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2009 editions, requires that food employees wash their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, before donning gloves for working with food and after engaging in other activities that contaminate the hands. In addition, food employees may not touch ready-to-eat food with their bare hands.
Review of a Food Service policy, titled "Infection Control Food Handlers", approved in 7/2013, revealed in part "... Ready to eat foods should not be touched or handled if a utensil can be used ... change gloves after touching refrigerator doors or food boxes ... "

Based on policy/procedure review, medical record review and staff interview, the facility failed to ensure the CRNA (Certified Registered Nurse Anesthetist) documented the time and/or date the post anesthesia recovery evaluation after surgery for 5 of 8 patients requiring anesthesia for the surgical procedure (Patients #6, 7, 8, 9 and 10). The facility staff reported completing an average of 96 surgical procedures requiring anesthesia a month at the facility.

Failure to time and/or date the post anesthesia for surgical patients does not demonstrate the completion of post anesthesia evaluation was in compliance with the facility's policy.

Finding include:

1. Review of an undated facility policy titled "Pre and Post Anesthesia Evaluation", stated in part... "All patients receiving anesthesia or sedation and anesthesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services."

2. Review of the Shenandoah Medical Center Medical Staff Rules and Regulations, reviewed and revised 9/21/07 stated in part... "B. Medical Records, 10. All clinical entries in the patient's medical record shall be accurately dated and authenticated. C. General Rules Regarding Surgical Care, 5. The anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition."

3. The following medical records revealed the documentation of the post anesthesia evaluation of recovery from anesthesia by the CRNA.

a. Review of Patient #6's medical record revealed the CRNA for the patient's procedure failed to time of the post anesthesia evaluation following the surgical procedure on 12/10/12.

b. Review of Patient #7's medical record revealed the CRNA for the patient's procedure failed to date and time of the post anesthesia evaluation following the surgical procedure on 4/9/13.

c. Review of Patient #8's medical record revealed the CRNA for the patient's procedure failed to time of the post anesthesia evaluation following the surgical procedure on 4/28/13.

d. Review of Patient #9's medical record revealed the CRNA for the patient's procedure failed to date and time of the post anesthesia evaluation following the surgical procedure on 6/27/13.

e. Review of Patient #10's medical record revealed the CRNA for the patient's procedure failed to date and time of the post anesthesia evaluation following the surgical procedure on 12/10/12.

4. During an interview on 7/10/13 at 5:05 PM, Staff L, CRNA (Certified Registered Nurse Anesthetist) stated he agreed the post anesthesia evaluations were not consistently dated and/or timed after all surgical procedures requiring anesthesia. Staff revised the anesthesia form 6 weeks ago and the CRNA's were instructed all entries on the anesthesia form needed a date and time of entry.

Based on review of the facility documents, review of medical records, and interview with staff, the administrative staff failed to ensure 5 of 5 patients, admitted to and discharged from swing bed services for post-acute skilled level of care, received a complete list of the required Patient Rights for swing bed patients (Patients # 1, 2, 3, 4 and 5). The administrative staff reported a daily average of 3 swing bed patients receiving skilled level services. There were no swing bed patients in the facility at the time of the survey.

Failure to present all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of the "Swing Bed - Patient Bill of Rights", date effective 4/2/12, lacked the following patient rights:
a. (1) The resident has the right to exercise his or her rights as a resident of the facility & as a citizen or resident of the United States.
b. (3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.
c. (4) In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.
d. (ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility.

2. Review of the following medical records of Swing Bed patients revealed the patient rights documents provide to them at the time they were admitted to a swing bed for skilled level of care, lacked the patient rights listed above.

a. Patient #1 signed the incomplete patient rights document on 5/28/13 when admitted to swing bed as a skilled patient.

b. Patient #2 signed the incomplete patient rights document on 4/30/13 when admitted to swing bed as a skilled patient.

c. Patient #3 signed the incomplete patient rights document on 5/2/13 when admitted to swing bed as a skilled patient.

d. Patient #4 signed the incomplete patient rights document on 6/24/12 when admitted to swing bed as a skilled patient.

e. Patient #5 signed the incomplete patient rights document on 4/1/13 when admitted to swing bed as a skilled patient.

3. During an interview on 7/9/13 at 4:20 PM, Staff A, Chief Nursing Officer (CNO), stated the missing patient rights must have not been added when they updated the Patient Bill of Rights document.

4. During an interview on 7/10/13 at 11:00 AM, Staff B Performance Improvement Registered Nurse confirmed the Swing Bed Patient Bill of Rights document lacked a complete list of all of the required patient rights. Patients receiving the incomplete Patient Bill of Rights did not receive a complete copy of the patient rights.

Based on review of policies and procedures and staff interview, the facility failed to provide activities for patients during the time they received swing bed services for post-acute skilled level of care. A review medical records for 5 of 5 discharged swing bed showed Patient #3's medical record lacked an initial activity assessment and lacked any follow-up documentation of activities and Patients #1, 2, 4, and 5's medical records lacked any follow-up documentation of activities. The administrative staff reported a daily average of 3 skilled patients in swing beds. There were no swing bed patients in the facility at the time of the survey.

Failure to provide activities for skilled patients in swing beds could potentially result in the inability of the patients to engage in activities of their choice while receiving skilled care in swing beds.

Findings include:

1. During an interview on 7/8/13 at 11:35 AM, Staff C, Medical/Surgical Nursing Manager, verified that an initial activity assessment is completed by Staff D, Occupational Therapist within 24-48 hours after admission to swing bed status.

2. During an interview on 7/9/13 at 2:30 PM, Staff D verified completing the initial activity assessments which included plans for activities for the swing bed patients. Staff D acknowledged the process lacked evidence of any follow up planning of activities with the patients and lacked evidence of supervision of the activities program for the swing bed patients.

3. During an interview on 7/9/13 at 2:45 PM, Staff C, Medical/Surgical Nursing Manager, verified that the facility lacked supervision for the activity program for the swing bed patients. The nurses documented the activities that the patients engaged in but the nurses did not provide activities for the patients. The facility lacked an ongoing program of planned daily activities for the swing bed patients on a calendar, schedule, or other format. The administrative staff failed to develop and implement a policy and procedure for activities for the swing bed patients.

4. A review of closed skilled patient medical records, for Patients #1, 2, 3, 4, and 5 revealed the following:

a. Patient #3 received skilled care in a swing bed from 5/2/13 to 5/15/13. Patient #3's medical record lacked an Initial Activity Assessment and documentation of any additional activity.

b. The medical records of Patients #1, 2, 4, and 5 contained a completed Initial Activity Assessment by Staff D but lacked any evidence or documentation of any additional or ongoing activities.

Patient #1 received skilled care in a swing bed from 6/6/13 to 6/9/13.

Patient #2 received skilled care in a swing bed from 4/30/13 to 5/3/13.

Patient #4 received skilled care in a swing bed from 6/22/13 to 6/29/13.

Patient #5 received skilled care in a swing bed from 4/1/13 to 4/3/13.