HospitalInspections.org

Based on policy review, medical record review and interview the facility failed to ensure staff provided a History and Physical (H&P), within 30 days of two surgical procedures (#1 and #3) of three reviewed. These failures had the potential to affect the quality of care for all patients that presented for surgical procedures. The facility census was two Acute Care patients and 10 Swing Bed patients for a total patient census of 12.

Findings included:

1. Review of the facility's policy titled, "OR-Admission of Patient to the Operating Room," dated 11/2014, showed the direction for staff to ensure that H&Ps were rewritten if older than 30 days before surgical procedures.

2. Review of Patient #1's medical record, surgical procedure dated 04/25/23, showed that Staff A, Gastroenterologist (physician that specializes in disorders and diseases of the digestive system), completed the patient's H&P on 02/28/23, re-signed and failed to complete a new H&P on 04/25/23.

Review of Patient #3's medical record, surgical procedure dated 02/28/23, showed that Staff A, Gastroenterologist, completed the patient's H&P on 12/13/22, re-signed and failed to complete a new H&P on 02/28/23.

3. During an interview on 06/28/23 at 2:00 PM, Staff C, Surgical Nurse Manager and Chief Nursing Officer, stated that the physicians should have updated the H&Ps before the procedures.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to:
- Contain three unclean (contaminated) endoscopes in the clean central sterile processing room.
- Provide a clean and rust (reddish-brown oxidation of metal that can harbor bacteria)-free bilateral Myringotomy tray (sterile ear tube tray).
- Remove unclean tape and spider traps (Sticky substances that can harbor bacteria) from the central sterile processing rooms.
- Provide quality testing of the concentration of disinfectants used for endoscope cleaning.
These failed practices had the potential to expose all patients and staff to cross-contamination and increased the potential to spread infection. The facility census was two Acute Care patients and 10 Swing Bed patients for a total patient census of 12.

Findings included:

1. Review of the facility's policy titled, "Central Sterile - Care and Operation of Steam Sterilizer," dated 11/2014, showed that disinfectants or chemical cleansers inhibit growth of bacteria and kill some types of bacteria, but they may not achieve complete sterility and this process was only accomplished by high-level diinfection.

Observation and concurrent interview on 06/26/23 at 1:00 PM, in the central sterile processing clean suite, showed three unsterilized (contaminated) endoscopes laying on top of a cart. During an interview, Staff E, Operating Room Technician (OR Tech), stated that the endoscopes had been on top of the cart since Tuesday of last week (7 days) waiting on the sterilizer to be serviced.

2. Review of the facility's policy titled, "Central Sterile - Instrument Care and Cleaning," dated 12/2014, showed the direction for staff to ensure the sterilization of instrument sets using a stainless steel pan or tray.

Observation on 06/26/23 at 1:15 PM, in the central sterile processing clean suite, upon opening a sterile Bilateral Myringotomy (ear tubes) tray, showed tape (uncleanable surface that can harbor bacteria) and rust on the exterior and rust on the inside of the stainless steel tray.

3. Review of the facility's policy titled, "Purpose and Scope Infection Prevention," dated 05/2021, showed the direction for staff responsibility to be aware of the source and methods of transmission of infection and follow the policies approved by infection prevention.

Observation on 06/26/23 at 1:30 PM, in the central sterile processing clean suite, showed 13 pieces of unclean tape on the cabinets.

Observation on 06/26/23 at 12:45 PM, in the central sterile processing dirty suite, showed:
- 16 pieces of unclean tape on the cabinets.
- A spider trap (uncleanable surface that can harbor bacteria) in the corner.
- Cidex test strips (used for high-level disinfection to measure the accurate amount of concentration to ensure integrity) with an expiration date of 01/28/23.

During an interview on 06/28/23 at 2:00 PM, Staff C, Surgical Nurse Manager and Chief Nursing Officer (CNO), stated that:
- The OR Technician shouldn't have left the endoscopes out for a week.
- Rust shouldn't have been in the instrument kit.
- The unclean tape should have been removed.
- They were unaware there were spider traps in the sterile processing rooms.

Based on policy review, document review, record review and interview, the facility failed to:
- Perform a discharge assessment for four discharged Observation patients (#24, #25, #26, and #27) reviewed out of 11 total discharged assessments reviewed.
- Initiate a discharge plan for four discharged Observation patients (#24, #25, #26, and #27) reviewed out of 11 total discharge plans reviewed.
- Provide the Medicare Outpatient Observation Notice (MOON, a standardized notice to inform patients they are an outpatient receiving Observation services and are not an Inpatient of the hospital) for four out of four discharged Observation Electronic Medical Health Records (EMHR) (#24, #25, #26 and #27) reviewed for patients that received Observation services from the facility. The failed practice to perform a discharge assessment and initiate a discharge plan for patients had the potential to affect the outcome of all patients discharged from the facility. The failed practice to provide the MOON notice to patients placed in Observation services had the potential to affect the patient's coverage and payment of care after the patient has been discharged from the facility and had the potential to affect all patients admitted to Observation services provided by the facility. The facility census was two Acute Care patients and 10 Swing Bed patients for a total patient census of 12.

Findings included:

1. Review of the facility's policy titled, "Discharge Planning," dated 11/16/2020, showed staff directives:
- ICMC staff members will identify patient discharge needs as early as possible during hospitalization to ensure planning for continuity of care and safety as the patient moves from one level of care to another.
- The process begins at admission and will continue through discharge.
- Discharge planning will be initiated on all inpatients; outpatients receiving observation services; outpatients undergoing surgery or other same day procedures for which anesthesia or moderate sedation are used; emergency department patients identified by the emergency department practitioner responsible for the care as needing a discharge plan.
- The discharge plan shall reflect both the patient's and the support person(s) internal, external, social, emotional, medical, and psychosocial needs and assets. The plan must address the patient's goals of care and treatment preferences.
- The discharge planning process must ensure that the discharge goals, preferences, and needs of each patient are identified and result, in the development of a discharge plan for each patient. Discharge planning must be initiated within 24 hours after admission or registration.

2. Review of the facility's document titled, "Medicare Outpatient Observation Notice," showed:
- You're a hospital outpatient receiving observation services.
- You are not an inpatient because:
- Being an outpatient may affect what you pay in a hospital.
- When you're a hospital outpatient, your observation stay is covered under Medicare Part B.
- For Part B services, you generally pay:
- A copayment for each outpatient hospital service you get.
- Part B copayments may vary by type of service.
- 20% of the Medicare-approved amount for most doctor services, after the Part B deductible.
- Observation services may affect coverage and payment of your care after you leave the hospital:
- If you need skilled nursing facility (SNF) care after you leave the hospital, Medicare Part A will
only cover SNF care if you've had a 3-day minimum, medically necessary, inpatient hospital stay
for a related illness or injury. An Inpatient hospital stay begins the day the hospital admits you as
an Inpatient based on a doctor's order and doesn't include the day you're discharged.
- If you have Medicaid, a Medicare Advantage plan or other health plan, Medicaid or the plan may
have different rules for SNF coverage after you leave the hospital. Check with Medicaid or your
plan.
NOTE: Medicare Part A generally doesn't cover outpatient hospital services, like an observation stay. However, Part A will generally cover medically necessary Inpatient services if the hospital admits you as an Inpatient based on a doctor's order. In most cases, you'll pay a one-time deductible for all your Inpatient hospital services for the first 60 days you're in a hospital.

3. Review of patients' EMHR showed:
- Patient #24 was discharged from Observation services on 01/29/23, the patient was admitted with complaints of possible overdose;
- Patient #25 was discharged from Observation services on 03/22/23, the patient was admitted with complaints of altered mental status;
- Patient #26 was discharged from Observation services on 03/24/23, the patient was admitted with complaints of hypertension; and
- Patient #27 was discharged from Observation services on 05/17/23, the patient was admitted with complaints of dizziness.

Review of Observation Patient #24's, #25's, #26's and #27's EMHR showed staff failed to perform discharge assessments and initiate discharge plans.

Review of Observation Patient #24's, #25's, #26's and #27's EMHR showed staff failed to provide the patients with the MOON notice.

Staffs' failure to provide Observation patients with the MOON notice had the potential to deny the Observation patients' knowledge of how receiving Observation services could affect out of pocket cost for receiving Observation services at the facility and possible required Skilled Nursing Services after discharge, which could impact the discharge planning process and needs of the patient.

4. During an interview on 06/28/23 at 8:25 AM, Staff O, Social Service Worker, Swing Bed Coordinator, stated discharge planning assessments needed to be completed within 48 hours of the patient's admission to the facility.

During an interview on 06/28/23 at 9:34 AM, Staff D, Registered Nurse, Director of Infection Control, Employee Health Quality, acknowledged that discharged Observation Patient #24's, #25's, #26's, and #27's EMHR did not contain the MOON notice required to be given to patients admitted to Observation services.

Based on record review and interview the facility failed to:
- Complete a comprehensive quality of life activities assessment, which identified specific individualized activity interest for four out of four current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#7, #19, #20 and #21) reviewed for a comprehensive quality of life activities assessment.
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for four out of four current Swing Bed patients (#7, #19, #20 and #21) reviewed for specific individualized activity interests of the patient.
- Develop a comprehensive activity care plan, which included activity interests and interventions for four out of four current Swing Bed patients (#7, #19, #20 and #21) reviewed for a comprehensive activity care plan.
These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests.
The facility census was two Acute Care patients and 10 Swing Bed patients for a total patient census of 12.

Findings included:

1. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #7 was admitted to the facility's Swing Bed program on 06/11/23, with complaints of status post hip fracture, status post gastrointestinal bleeding and weakness;
- Patient #19 was admitted to the facility's Swing Bed program on 06/16/23, with complaints of falls, activity intolerance and pain;
- Patient #20 was admitted to the facility's Swing Bed program on 06/24/23, with complaints of a fall and status post left hip fracture; and,
- Patient #21 was admitted to the facility's Swing Bed program on 05/10/23 with complaints of falls and status post left hip fracture.

Patient #7's, #19's, #20's and #21's EMHR showed staff failed to conduct a comprehensive quality of life activity assessment of the patients to assist in identifying the patients' activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility's Swing Bed program.

2. During an interview on 06/28/23 at 8:25 AM, Staff O, Social Service Worker, Swing Bed Coordinator, stated the facility's Swing Bed program currently does not perform an activity assessment of patients admitted to the Swing Bed program and the facility does not include the activity component in Swing Bed patients' care plan. Staff O stated the facility received notification from the hospital association informing Critical Access Hospitals that the hospital's Swing Bed program no longer was required to hire a certified activity director, so Staff O retired the activity component from the Swing Bed policies, procedures and electronic system. Staff O stated staff have not been performing the activity assessment or including activities on Swing Bed patients' care plans since the facility received the notice from the hospital association.