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Based on observation, review of hospital construction standards, and staff interview, the Critical Access Hospital (CAH) failed to ensure the nurses call system activated a visible signal in the corridor in 2 of 2 clean workrooms/utility rooms (Swingbed and acute care) and 1 of 2 soiled workrooms/utility rooms (acute care). Failure to ensure call lights activate a visible signal may pose a safety hazard to patients should the need to summon assistance occur.

Findings include:

The 1992-93 Guidelines for Construction and Equipment of Hospital and Medical Facilities has outlined the standards regarding a nurses calling system stated, "In patient areas . . . Calls shall activate a visible signal in the corridor at the patient's door, in the clean workroom, in the soiled workroom, and at that nursing station of the nursing unit. . . . A nurses emergency call system shall . . . be designed so that a signal activated in the patients' calling station will initiate a visible and audible signal distinct from the regular nurse calling system . . ."

On 01/09/13 between 9:15 and 10:30 a.m., a check of the call light system from within the clean utility rooms on the Swingbed unit and acute care nursing unit did not activate a visible signal. A check of the call light system in the dirty utility room on the acute nursing unit showed the call light also did not activate a visible signal.

During interview on the morning of 01/09/13, a maintenance staff member (#1) reported he was not aware of the inactivated visible signals. The staff member stated there were no routine checks/maintenance of the call light system.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure proper maintenance of ice machines on 2 of 2 nursing units (Swingbed and acute care) located in clean utility rooms. Failure to ensure regular cleaning of the ice machines may affect the palatability of the water and has the potential to affect the health of patients consuming ice from the machines.

Findings include:

On 01/09/13 between 9:15 a.m. and 10:30 a.m., observation showed the presence of two ice machines within the facility, one in a clean utility room on the Swingbed unit and one in the clean utility room on the Acute care unit. During an interview, a maintenance staff member (#1) reported maintenance staff does not clean nor maintain the ice machine, and he was unaware of who does.

On 01/09/13 at 11:00 a.m., the maintenance staff member (#1) reported the housekeeping department did not clean nor maintain the ice machines. The staff member (#1) did not provide a policy regarding the cleaning and maintenance of the ice machines.

1. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices observed during patient care on 2 of 3 days of survey (January 7-8, 2013). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

Review of the facility policy titled "Hand Washing and Hygiene" occurred on 01/09/13. This policy, revised September 2012, stated, ". . . E. Indication For Hand Hygiene . . .
1. Before and after each patient contact,
2. Before and after touching wounds/non-intact skin, whether surgical, traumatic, or associated with an invasive device . . .
5. Between patient care procedures involving different body sites of the same patient (i.e., from urinary to respiratory system).
6. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, an inanimate objects [sic] that are likely to be contaminated) . . .
9. After removing gloves. (Gloves are an adjunct to, not a substitute for hand washing).
10. After performing personal hygiene activities. . . ."

Review of the facility's skills checklist titled "Peri-care for the Incontinent Patient" occurred on 01/09/13. This checklist, revised November 2008, stated, ". . .
9. Washes and dries buttocks and peri-anal area.
10. Replaces wet incontinent pad with dry incontinent pad.
11. Removes and disposes of gloves and soiled pad into wastebasket, and washes hands.
12. Repositions client.
13. Replaces top covers . . .
16. Places call light within patient's reach . . .
18. Washes hands. . . ."

- Observation on 01/07/13 at 4:45 p.m. identified a certified nursing assistant (CNA) (#4) assisted Patient #27 with toileting in the patient's bathroom. The patient's brief was wet with urine and she voided in the toilet. After performing perineal cares, the CNA (#4) removed her gloves, transferred the patient from the toilet to her wheelchair using a sit-to-stand mechanical lift, positioned the patient in her wheelchair, offered her a drink of water, placed the call light within reach, and then washed her hands. The CNA (#4) failed to perform hand hygiene after completing perineal cares and prior to completing other tasks.

- Observation on 01/08/13 at 8:30 a.m. showed a nurse (#5) giving Patient #4 a bed bath in the patient's room. The nurse performed perineal cares and changed the patient's brief, wet with urine. While wearing the same gloves, the nurse (#5) cleansed around Patient #4's biliary tube and insertion site using a wet wipe. The nurse (#5) failed to remove her gloves, perform hand hygiene, and don clean gloves prior to cleansing around the patient's non-intact skin.

- Observation on 01/08/13 at 9:50 a.m. showed a nurse (#5) insert an intravenous catheter into Patient #28's right hand. After removing her gloves, the nurse (#5) exited the procedure room without performing hand hygiene and proceeded to the laboratory to obtain a blood product to administer to Patient #28.

- Observation on 01/08/13 at 11:40 a.m. showed two CNAs (#6 and #7) gowned and gloved per contact isolation precautions and transferred Patient #2 from his recliner to the bathroom. The CNA (#6) performed perineal cares and observation showed visible stool on the wet wipe. The CNA (#6) changed her gloves after completing perineal cares, transferred the patient back to his recliner, applied a chair alarm, elevated the patient's legs, gave Patient #2 his call light, and then covered him with a blanket. Using the same gloves, the CNA (#6) emptied the receptacle of urine in the toilet, placed the patient's oxygen tubing, performed oral cares, removed her gown and gloves, bagged the garbage, and then washed her hands. The CNA (#6) failed to perform hand hygiene after performing perineal care, after emptying the urine receptacle, and prior to completing oral cares.

During an interview on 01/09/13 at 11:00 a.m., an administrative nurse (#3) stated she expected staff to perform hand hygiene between patients, after removing gloves, immediately after perineal cares, and prior to cleansing around non-intact skin.

2. Based on review of the infection control reports and meeting minutes and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 12 of 12 months (January through December 2012) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Reviewed on 01/08/13, the infection control program lacked evidence the CAH identified and recognized infections of outpatients. The infection reports and meeting minutes from January through December 2012 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 01/08/13 at 2:00 p.m., the infection control coordinator (#2) stated she did not receive or request infection control information from outpatients. The staff member (#2) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

The failure to document and perform surveillance among all patients of the CAH, limited the CAH's ability to identify, monitor, track, control, and prevent infections.

Based on policy and procedure manual review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel annually review the CAH's health care policies and procedures in 2012 for 8 of 8 policy and procedure manuals (Nursing, Cardiac Rehabilitation, Medical Records, Pharmacy, Infection Control, Quality Assurance, Laboratory, and Radiology) reviewed. Failure to have the required group annually review the policies and procedures limits the CAH's ability to ensure the policies and procedures model the CAH's current practices and were in compliance with federal regulations.

Findings include:

Review of the policy titled "Patient Care Policies and Procedures" occurred on 01/09/13. This policy, revised 11/11, stated,
". . . The committee:
A. Meets a minimum of annually . . .
C. Oversees policy development regarding healthcare services for Critical Access Hospital . . ."
The policy did not require the committee to annually review the CAH's health care policies.

Review of the policy titled "Annual Program Evaluation" occurred on 01/09/13. This policy, revised 11/11, stated,
". . . The annual review will include review of :
3. Evaluation of CAH health care policies. . . ."

Review of the CAH's policy and procedure manuals occurred on all days of the survey. The following manuals lacked evidence of annual review in 2012 by the required members of a group of professional personnel (a physician; a physician assistant, nurse practitioner, or clinical nurse specialist; and a non-staff member): Nursing, Cardiac Rehabilitation, Medical Records, Pharmacy, Infection Control, and Quality Assurance. The following manuals lacked evidence of annual review in 2012 by a physician assistant, nurse practitioner, or clinical nurse specialist and a non-staff member: Laboratory and Radiology.

Reviewed 01/08/13 at 9:35 a.m., the "LAHS (Lisbon Area Health Services) Policy & Procedure Committee Meeting" minutes from 09/13/12 lacked evidence of review of the CAH's health care policies and procedures.

During interview on 01/09/13 at 9:55 a.m., an administrative staff member (#8) confirmed the CAH's Policy and Procedure Committee had not reviewed all the CAH's health care policies and procedures in 2012.