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A. Based on document review, observation, and interview, it was determined the CAH failed to ensure crash carts were checked on a daily basis to assure safe functioning, per policy. This has the potential to affect all inpatients and outpatients who receive care by the CAH.

Findings include:


1. A tour of the Medical unit was conducted on 7/11/23 at approximately 11:30 AM with Acute Care Manager (E#5). The following crash cart logs were observed and lacked the documentation of the required daily checks:
a) February 2023- 5 of 28 days
b) March 2023- 4 of 30 days
c) April 2023- 12 of 30 days
d) June 2023- 3 of 30 days
e) July 2023- 1 of 31 days

2. An interview was conducted with E#5 during the tour. E#5 verbally confirmed the lack of the crash cart checks.

3. A tour was conducted of the Recovery Room on 7/13/23 with the Operating Room Supervisor (E #11). The crash cart daily check logs for June and July 2023 lacked documentation of the required daily checks.

4. An interview was conducted during the tour with E #11. E#11 verbally confirmed the lack of documentation the crash cart was checked in June and July 2023.

5. The policy titled "Emergency Crash Cart/ Defibrillator Daily Check (revised 9/23/2010)" was reviewed on 7/13/23. The policy noted, "Crash carts will be checked daily...Document initials on crash cart log..."


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B. Based on observation, and staff interview, it was determined the Facility failed to ensure expired emergency supplies were not available for patient use. This failure has the potential to affect all patients, staff, and visitors serviced by the facility.

Findings include:

1. On 07/11/23 between 11:00 AM and 12:30 PM, observational tours were conducted on the Medical Unit and the Emergency Department. During the tour it was noted there were expired supplies available for immediate patient use to include the following:

a. Medical Unit - Cetacaine spray expired on 6/23.

b. Emergency Department: Room 1 - Two (2) emergency cricothyrotomy kits expired 10/22. Supply room - Four (4) 5% Dextrose 50 ml IV solution expired 3/23.

2. On 07/11/23 during the observational tours, an interview was conducted with the Acute Care Manager (E #5). E #5 verbally agreed the items were expired, and should not have been available for patient use.

3. The policy titled, "Unusable and Outdated Drugs (revised 5/8/19)" was reviewed. The policy stated, "All drug storage areas of the hospital will be inspected, including Med-Surg, Surgery, Emergency, Outpatient Clinics, Cardiac Rehabilitation, and Radiology, for outdated drugs... The Pharmacy staff member conducting the inspection will remove all of these types of drugs from the area..."

4. The policy titled, "Managing Inventory Outdates (revised 10/18/21)" was reviewed. The policy stated, "... Monitoring - Periodic review of at least monthly, will be done to ensure there are no expired or nearly expired products on the shelf. Disposal - Expired products will be disposed of using the appropriate protocol for each product."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on July 18, 2023, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH) failed to ensure all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients serviced by the CAH.

Findings include:

1. An observational tour of the Speciality Clinic and Wound Clinic was conducted on 7/13/23 at 10:00 AM with the Director of Clinical Operations (E#4). Located in the patient exam room #5 A was an exam light with a preventative maintenance sticker date that noted next due date was 3/23.

2. An interview was conducted with E #4. E #4 verbally confirmed the expired preventative maintenance sticker.

3. The policy titled " Preventative Maintenance (revision date 02/06/2023)" was reviewed on 7/13/23. The policy noted "Policy Statement.. a comprehensive preventative maintenance program....all equipment in the program at established intervals of at least once yearly."

Based on observation, document review and interview, it was determined for 1 of 1 operating room, the Hospital failed to ensure the temperature and humidity was monitored daily in a patient care area. This has the potential to affect all staff and patients who work or have services provided in the operating room.

Findings include:

1. An observational tour of the surgery department was conducted on 07/13/23 between 10:30 AM and 11:30 AM. The operating room "Daily Q.A. (quality assurance) Checks" were reviewed. The log lacked documentation of temperature and humidity for June 12th and June 28th.

2. The policy titled "Operating Rooms - Temperature, Humidity and Ventilation (reviewed 3/25/20)" was reviewed. The policy noted, "The temperature, humidity and airflow in all operating rooms shall be maintained with acceptable standards in order to inhibit bacterial growth and prevent infection, as well as promote patient comfort and safety.... Operating room temperatures shall be logged on a daily basis."

3. During an interview on 7/13/23, the Surgery Supervisor (E #11) verbally agreed the temperature and humidity logs were incomplete and should be completed daily.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on July 18, 2023, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated July 18, 2023.

Based on document review, observation, and interview, it was determined for 2 of 2 (E #8 and E #9) X-ray technicians, the Hospital failed to ensure x-ray technicians were wearing a dosimetry badge used to monitor radiation exposure. This has the potential to affect all staff who have exposure to radiation.

Findings include:

1. The policy titled "Radiation Exposure Monitoring of Staff (revised 1/19)" was reviewed. The policy stated, "... Personal Dosimeters: All imaging technologists are required to wear a dosimetry badge while on duty..."

2. During a tour of the X-ray department on 07/12/23 at approximately 11:30 AM, with Director of Quality Improvement, Risk Management and Safety (E #3), two X-ray technicians (E #8 and E #9) were observed without a dosimetry badge on. An interview was conducted at that time with E #8. E #8 stated "The dosimetry badges are back here on the counter. I'll admit, I am bad about wearing mine."

3. During an interview on 7/12/23 at approximately 11:40 AM, Radiology Department Manager (E #10) verbally agree all radiology personnel should be wearing the badges to be able to appropriately monitor radiation exposure.

Based on observation and staff interview it was determined the CAH failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. This has the potential to effect all patients receiving outpatient therapy services.

Findings include:

1. A tour was conducted on 7/11/23 at 11:00 AM of the Out patient Therapy services with the Director of Clinical Operations (E #4). During the tour, it was observed the seat of the nustep exercise machine had tears in the vinyl.

2. A tour was conducted on 7/12/23 at 10:15 AM of the Cardiopulmonary Rehabilitation services with E #4. During the tour, it was observed the seat of the nustep exercise machine had tears in the vinyl.

3. An interview was conducted with E #4, during the tours. E #4 observed the tears in the seats and confirmed the need for repair.