HospitalInspections.org

Based on observation and confirmed by staff interview, the CAH failed to ensure patient equipment in the Emergency Department (ED) and floors and ceiling in the Surgical Operating Rooms (OR) and ante-rooms were properly maintained. Findings include:

1. A tour of the ED on 10/29/24 at 10:30 AM was conducted to examine the condition of stretcher mattresses utilized by patients during the provision of care and services. Although multiple stretcher mattresses had been replaced, a stretcher in room #14 noted to have torn edges on the foot rest and on sides of the stretcher mattress; in room #15 the stretcher mattress had tears on the upper edge. Per the Association for the Health Care Environment states in a report dated 2/29/2017 states: "Cleaning and disinfecting all patient care areas is essential to preventing healthcare-acquired infections.....Damaged covers cannot be properly cleaned and may allow bodily fluids and pathogens to penetrate the mattress core " The Director of Quality, Risk & Compliance confirmed at the time of observation, the damaged noted to the mattresses.

2. During a tour of the Surgical suites accompanied by the nurse manager for Surgical Services on 10/29/24 at 2:25 PM observations in OR #2 noted a horizontal crack in the flooring sidewall/baseboard near the entrance to the OR. The crack extended approximately 6-8 feet in length. The special non-porous flooring extends and adheres to the wall for approximately 4-5 inches. Although floors in operating rooms must be seamless in order to prevent probability of contamination, having a broken surface/crevices decreases the integrity of the environmental surface permitting dirt and particles in the crack.

3. Within one of the OR ante-rooms above a scrub sink (presently not in use) 2 holes were observed covered in red duct tape, one on the ceiling and the second on the wall above the sink. The nurse manager stated the 2 holes were the result of an outside vendor installing equipment to correct a problem "....with the air handlers and humidity". S/he further stated the company who installed the equipment had removed their equipment when their repair was not effective, thus leaving the 2 holes. The ceiling hole creates the potential for exposure to the Surgical Services environment to possible dust and moisture intrusion.

Contact made on the morning of 10/31/24 the Director of Quality, Risk and Compliance confirmed the noted environmental concerns had been identified during Environmental Rounding in May, 2024, however no Work Orders were created to make the repairs.

Based on record review and confirmed by staff interview, there is a failure by the CAH (Critical Access Hospital ) to ensure policies are reviewed and updated at least biennially. Findings include:

During the course of reviewing CAH policies on 10/29/24 it was identified there are departments within the hospital that have not updated and/or reviewed their specific policies for greater than 2 years to include: Annual Program Review last approved 1/14/2015 (the management plans for the environment of care); Fire Doors last approved 7/14/2020; Housekeeping policies: Cleaning of Discharge Unit last approved 12/4/2017; Cleaning services and schedule of services last approved 9/8/2020; Sequence for cleaning of patient rooms last approved 7/20/21 and Elevator Safety last approved 4/26/2019.

Per interview on the afternoon of 10/30/24 the Director of Quality, Risk & Compliance confirmed although efforts have been made in multiple departments to update policies & procedures, there are many departments who require reinforcement and guidance by the CAH professional health care staff and advisory to assist these departments in reviewing and updating policies & procedures.