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Based on observations, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to create and implement an effective system to ensure staff detected when hot water temperatures exceeded the CAH's acceptable range for hot water (between 110 - 120 degrees Fahrenheit) at 1 of 2 offsite clinics (Ellsworth Family Medicine [EFM]). The facility's administrative staff reported approximately 270 patient visits per week at the Ellsworth Medicine Clinic. Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury related directly to the temperature and duration of exposure to the hot water. Exposure to hot water at 133 degrees Fahrenheit can cause a third degree burn (destruction of the outer layer of skin and the entire layer beneath) to occur is 15 seconds, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit.

Findings include:

1. Observations on 5/21/19 from 10:32 AM to 11:30 AM, during the environmental tour of the EFM Clinic with the Chief Nursing Officer (CNO), revealed the following hot water temperatures at the hand washing sinks in 3 of 3 patient exam rooms:

a. Exam Room -Procedure Room -sink #1 123.8 degrees Fahrenheit; sink #2 125.8 degrees Fahrenheit
b. Exam Room 3 - 129.2 degrees Fahrenheit
c. Exam Room 4 - 127.4 degrees Fahrenheit


2. Review of the documents "Preventative Maintenance Task 38 Monthly Water Temperature" revealed:

a. for the month of April 2019, the maintenance staff checked the water temperatures at the clinic and documented the hot water temperatures at the clinic between 119 - 120 degrees Fahrenheit.

b. for the month of March 2019, the maintenance staff checked the hot water temperatures at the clinic and documented the hot water temperatures at the clinic between 119 - 120 degrees Fahrenheit.

c. for the month of February 2019, the maintenance staff checked the hot water temperatures at the clinic and documented the hot water temperatures at the clinic between 118 -120 degrees Fahrenheit.

The maintenance staff failed to detect the hot water temperatures in the clinic exceeded the CAH's acceptable range for hot water temperatures.



3. During an interview on 5/21/2019 at 1:00 PM, the Maintenance Supervisor acknowledged the water temperatures exceeded the CAH's acceptable limit for hot water temperatures (120 degrees Fahrenheit) and the maintenance staff failed to previously identify the elevated hot water temperatures.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged patients that received anesthesia to the company of a responsible adult for 5 of 5 surgical patients reviewed (Patients #1, Patient #2, Patient #3, Patient #4, and Patient #5). The facility staff reported an average of 61 surgical patients that received anesthesia per month. Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed.

Findings included:

1. Review the policy "[Ambulatory Surgery Unit] Patient Discharge Protocol," effective 12/4/2018, revealed in part, "... Patient Discharge: All patients are discharged in the company of a responsible adult except those exempted by surgeon (example: local anesthesia)."

2. Review of patient medical records revealed the following:

a. Patient #1 received anesthesia for a surgical procedure on 4/22/19. The surgical services staff discharged Patient #1 on 4/22/19 at 8:30 AM. Patient #1's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

b. Patient #2 received anesthesia for a surgical procedure on 4/13/19 at 11:07 PM. The surgical services staff discharged Patient #2 on 4/14/19 at 1:07 AM. Patient #2's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

c. Patient #3 received anesthesia for a surgical procedure on 4/15/19. The surgical services staff discharged Patient #3 on 4/15/19 at 8:19 AM. Patient #3's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

d. Patient #4 received anesthesia for a surgical procedure on 4/8/19. The surgical services staff discharged Patient #4 on 4/8/19 at 9:35 AM. Patient #4's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

e. Patient #5 received anesthesia for a surgical procedure on 4/10/19. The surgical services staff discharged Patient #5 on 4/10/19 at 10:18 AM. Patient #5's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

3. During an interview on 5/22/19 at 1:00 PM, the Chief Nursing Officer (CNO) confirmed Patient #1's, Patient #2's, Patient #3's, Patient #4's and Patient#5's medical records lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.