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Based on observation, interview and document review, the critical access hospital (CAH) failed to complete manual weekly checks of the Zoll R series defibrillator monitors (a device used to create an electrical charge to stop an abnormal heart rhythm) for 3 of 3 defibrillator monitors reviewed for equipment and supplies.

Findings include

On 8/27/24 at 8:58 a..m., during a tour of the surgical services area registered nurse (RN)-D stated the surgery department Zoll monitor did a self-check during the night shift and gave a green check mark to indicate the Zoll monitor was working. RN-D stated the staff signed off on a clip board daily that the Zoll monitor did the self-check daily. RN-D confirmed they would only performed a manual test if there was a red "X" and the staff did not perform a manual test weekly.

On 8/27/24 at 12:45 p.m., during a tour of the emergency department registered nurse (RN)-A stated the emergency department Zoll monitor did a self-check during the night shift and gave a green check mark to indicate the Zoll monitor was working. RN-A stated they signed off on a clip board daily that the Zoll monitor did the self-check daily. RN-A stated they would only performed a manual test if there was a red "X" and the staff had not performed a manual test weekly.

On 8/27/24 at 2:43 p.m., during a tour of the medical surgical unit, registered nurse (RN)-A stated once a day at midnight they checked the Zoll monitor for a green check mark indicating the machine performed its self-checks successfully. If the machine showed a red "X" then they would need to run a manual check, but otherwise didn't need to run a manual check. They recorded their initials on a paper calendar indicating they confirmed a green check mark.

On 8/28/24 at 3:20 p.m., RN-C stated they did a nightly check of the Zoll monitor, if there was a green check mark it was good and meant it did its checks, and if the machine had a red "X" they would do a manual check of the machine.

On 8/29/24 at 9:30 a.m., RN-B confirmed the facility had three Zoll defibrillators and they were checked every night by looking for the green check mark on the machine and recording that. RN-B confirmed he was not aware of the need for a weekly manual check of the system. RN-B stated checking the manufacturer instructions was important in case of an adverse event and for warranty purposes.

On 8/29/24 at 10:18 a.m., the chief nursing officer (CNO) stated the Zoll machines were checked at midnight and the green check was affirmative for the things the machine self-checks, but if there was a red "X", a manual test would need to be run. The CNO stated they didn't routinely run manual checks and he was not aware of the need for that. After review of the Zoll Operator's Guide, the CNO stated it was important to follow the manufacturer's instructions to assure the equipment is working properly.

The Zoll R Series Operator's Guide dated 01/2018, chapter 12 maintenance frequency identified the following:
Visual inspection - once per day, inspect Code Readiness indicator
Code Readiness test (automatic) - once per day, unless configured Off, in which case, perform manual defibrillator testing daily
Manual Defibrillator Testing - Once per week; daily if Code Readiness Test is configured Off

Ely Bloomenson Community Hospital policy, Crash Carts dated 7/18/24, did not address maintenance of defibrillators.

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: K0324, K0353, K0363 K0372, K0511, K0712, K0914, K0920, and K0923.

Based on interview and document review the facility failed to ensure dietary policies were reviewed and updated. This had the potential to affect patients who received food served by the kitchen.

Findings include:

During an interview on 8/27/24 at 1:30 p.m., food service director (FSD)-B verified the dietary policies had not been reviewed in the past year.

Safe food handling procedures dated 2/2007
Identification system for patient trays dated 10/20/11
Procedures for accommodating non-routine occurrences such as admissions, changes in diets dated 10/20/11
Menu planning dated 1/1/11
Meeting the nutritional needs of patients 10/20/11

During an interview on 8/27/24 at 2:30 p.m., staff educator (SE)-C verified the dietary policies were not part of the policy review process for the hospital.

Based on observation and interview the facility failed to ensure proper cleaning for a shared glucometer. This failure had the potential to affect any patient who required glucometer checks. Additionally, based on observation, interview, and record review, the critical access hospital (CAH) failed to implement infection prevention measures to ensure medical equipment indented for patient care was stored in a manner that prevented exposure to cross-contamination of equipment stored in the dirty utility room. This deficient practice had the potential to impact all patients who required the use of a commode.

Findings include:

During an observation on 8/29/24 at 7:50 a.m., registered nurse (RN)-E performed a blood sugar check for P6. RN-E used a glucometer that was shared with other patients. RN-E brought supplies into the room- washed hands with soap and water at the sink- put on gloves- scanned self- scanned the strip bottle- scanned P6- cleansed P6's finger with an alcohol wipe-placed the strip in the glucometer meter-poked P6's finger with a device-wiped away the first drop of blood- touched blood to the strip - received a reading- disposed of sharp in sharps container- wiped machine all over with one bleach wipe walked back to the desk and placed the glucometer machine in the glucometer docking station. RN-E was asked about the dry time and RN-E responded "one minute" then looked at the container Sani-Cloth Bleach and stated the glucometer should remain wet for four minutes. RN-E then removed the glucometer from the docking station and wrapped it in a Sani-Cloth Bleach wipe.

During an interview on 8/29/24 at 10:22 a.m., the chief nursing officer (CNO) verified glucometers were shared between patients. The CNO stated he would expect staff to clean glucometers based on the type of isolation, if any, the patient was in. The CNO stated he would expect staff to follow the directions for cleaning/disinfecting and dwell/dry time based on the product used. The CNO further stated the glucometer should not be placed in the docking station until it had finished the dry time.

The Nova Statstip Glucose Meter no date, directed staff to clean and disinfect the machine after each patient use. The instructions directed staff to use a new, fresh, germicidal bleach wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of three times horizontally followed by three times vertically avoiding the bar code scanner and electrical connector. To observe surface contact time to ensure the machine stayed wet for one minute and to allow machine to air dry for an additional minute.

The Sani-Cloth Bleach wipe general guidelines for use dated 2024, directed staff to allow a surface to remain visibly wet for four minutes and to use additional wipes to keep the surface wet for continuous four minutes. Then to allow the surface to air dry.

COMMODE STORAGE
During an observation and interview on 8/27/24 at 9:31 a.m., two commodes, with a strip of white paper around the toilet seat indicating they were clean, were stacked in the dirty utility room of the medical-surgical unit. Registered nurse (RN)-A and RN-B confirmed these were clean commodes and should not be stored in the dirty utility room and should be stored in a clean area.

During an interview on 8/29/24 at 9:27 a.m., RN-B stated it was important not to store clean equipment in the dirty utility room to prevent cross-contamination.

During an interview on 8/29/24 at 10:18 a.m., the chief nursing officer (CNO) stated it would be his expectation to not have clean equipment stored in a dirty utility room because of the risk for transfer of germs and infection control.

Policy summary.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure the Emergency Preparedness Plan (EPP) was reviewed every two years. This had the potential to affect all patients, visitors, and staff at the CAH.

Findings include:

During a review of the facility EPP on 8/29/24 at 8:20 a.m., indicated the last review date of 2016.

During a review of the facility Emergency Operations Plan on 8/29/24 at 8:30 a.m., indicated the review date of 6/20.

During an interview on 8/29/24 at 8:27 a.m., the chief nursing officer (CNO) stated there had not been a full review of the EPP.

Based interview and document review, the Critical Access Hospital (CAH) Emergency Preparedness Plan (EPP) failed to address the patient population including, but not limited to, patients most at-risk, the type of services the facility has the ability to provide in an emergency and continuity of operations that could be provided to those patients most at-risk. This had the potential to affect all patients residing in the CAH.

Findings include:

During an interview on on 8/29/24 at 8:45 a.m., the chief nursing officer (CNO) stated the EPP did not identify the patient population the CAH served.

Review of the Emergency Operation Plan (EOP) undated and EPP dated 2016, lacked evidence of addressing the patient population at-risk.

Based on interview and document review, the Critical Access Hospital (CAH) failed to develop emergency preparedness policies and procedures which included provision of subsistence needs for patients and staff during an emergency. This had the potential to affect all patients and staff.

Findings include:

The CAH's Emergency Operations Plan (EOP) 6/20, lacked evidence of policy and procedures for non-potable water and waste management.

An interview on 8/29/24 at 8:40 a.m., the chief nursing officer (CNO) stated there was nothing in the EOP about non-potable water and waste management.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure their emergency operations plan (EOP) addressed the use of volunteers in an emergency. This had the potential to affect all patients and staff.

Findings include:

On 8/29/24 at 8:48 a.m., a review of the EOP with the chief nursing officer (CNO), lacked evidence of the use of volunteers in an emergency or other emergency staffing strategy that utilized volunteers to address surge needs in an emergency.

During an interview on 8/29/24 at 8:48 a.m., with the CNO verified the EOP lacked a policy or procedure that addressed the training of and use of volunteers during an emergency.