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Based on interview and record review it was determined that the hospital did not ensure proper temperature and humidity control. Specifically, the hospital did not track or maintain temperature or humidity in the operating room.

Findings include:

A tour of the operating room (OR) was conducted on 5/22/19; no temperature or humidity log was noted.

On 5/22/19 at 1:18 PM an interview was conducted with the director of nursing (DON). The DON was asked how they track and maintain the temperature and humidity in the OR. The DON responded that the OR manager checks whenever she comes in for surgery, but doesn't document it anywhere. She was then asked how often that was. She stated that is wasn't very often. The main surgeries are caesarean sections and cataracts and they are rare.

The hospital could not provide any evidence that they ensure proper temperature and humidity control in the OR to inhibit microbial growth, and reduce risk of infection. They also could not provide any evidence that a system was in place for when readings were out of range.

Based on interview and record review, it was determined that the hospital did not ensure that their infection control officer was qualified through education, experience, inservices or training. Furthermore, based on interview and record review, it was determined that the hospital did not ensure that there were specific measures for prevention, early detection, control, education, and investigation of infections specific to Legionella.

Findings include:

A.

1. On 5/23/19, an interview was completed with the administrator with regard to who at the hospital was in charge of their infection control program. The administrator stated that they had a new person who was promoted in January 2019 to be the infection control officer (ICO). When the administrator was asked what training and education the new ICO had, to be qualified in this new position, she stated that she doesn't have experience, education or training yet but they do have plans to get her education and training.

2. On 5/22/19 and 5/23/19 the state surveyor requested to have an interview with the ICO. The ICO wasn't available for an interview either day and wasn't available to surveyors before the end of survey.

3. There was no documented evidence that could be provided that the infection control officer had any type of training.


B.

1. On 5/21/19, an interview was conducted with the facilities manager (FM). The FM stated they did not complete any testing for Legionella, or have a program.

2. There was no evidence found of a facility risk assessment to identify Legionella, that a water management program was developed or implemented, that policies and procedures were created to reduce the risk of growth and spread of Legionella, or that testing protocols and acceptable ranges for control measures were documented.

Based on interview and record review it was determined that the hospital did not ensure a nursing care plan was developed and kept current for each inpatient. Specifically, 8 out of 20 medical records that were reviewed had no care plans completed. (Patient identifiers: 2, 3, 7, 8, 9, 10, 19, 20)

Finding include:

On 5/20/19 through 5/23/19, 20 medical records were reviewed. 8 out of 20 had no documented evidence of any plan of care (POC) being created or followed.

On 5/22/19 at 3:13 PM an interview was conducted with the director of nursing (DON). The DON was asked about the missing care plans. She responded that the POC are not populating as a tasks for the nurses anymore, so they are getting missed.

Based on interview and record review it was determined that the hospital did not ensure that physical therapy services were provided by qualified staff. Specifically, the hospital did not have any evidence that the hospitals contracted physical therapist was qualified.

Findings include:

On 5/21/19 the administrator was asked to provide personnel files on contracted staff. None could be provided.

An interview was conducted on 5/21/19 at 9:21 AM with the administrator. She was asked how she ensures contracted staff, such as their physical therapist was qualified. She responded that they just assumed they were qualified because they were employed somewhere else.

No evidence could be provided that the contracted physical therapist had the necessary education, experience, training, or documented competencies to provide services.

Based on interview and record review it was determined that the Critical Access Hospital (CAH) did not ensure that their certified registered nurse anesthetist (CRNA) was under the supervision of an operating practitioner.

Findings include:

On 5/21/19, an interview was conducted with the facility administrator regarding CRNA oversight. The administrator stated the facility "contracts our CRNA to administer anesthesia and we do not have CRNA oversight. Our CRNA tells us he does not need oversight to practice."

The facility did not have a policy or protocol in place that addressed the supervision of CRNAs by the operating practitioner.

Based on interview and record review, it was determined that the hospital did not ensure that patients were assessed for dental needs or receive routine dental care.


Findings include:

On 5/23/19 during record review, the Health Information Management (HIM) office manager assisting surveyors was interviewed regarding where dental assessments would be documented. She stated "I don't see anywhere where dental assessments were charted."

On 5/23/19 the facilities dental contract was requested. A dental contract was given to surveyors from 2010. The administrator told surveyors she was in the process of getting an updated dental contract signed. She was unable to provide an updated dental contract before the end of survey.

On 5/23/19, an interview was conducted with the charge nurse currently working and overseeing long term care residents. She was asked what system they had in place for assessing the dental needs of residents, where they chart their dental assessments and if she's ever taken a resident to the dentist. She stated "there's not an actual system in place, it's on the family. If they don't have family, we can take them in the van." She also stated "there's no actual dental assessment in Cerner" (the facilities electronic medical record) and "I haven't taken a patient to the dentist."

On 5/23/19, four residents residing in the long term care department were interviewed to see if they had received dental assessments or if they or any other residents that they know of attend routine dental check-ups. All four stated they hadn't been assessed for dental needs or been to a dentist since living here. One of the residents interviewed named one particular resident that she said does see a dentist regularly. When surveyors interviewed this particular resident that allegedly sees a dentist regularly, she stated she hadn't been assessed for dental needs here at this facility but that she does see a dentist regularly "only because my cousin takes me."