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Based on observation and policy review, the facility failed to adhere to their policy on the use of universal precautions for controlling infections. Infection control policies were not followed during a medication pass observation with Staff A and 2 of 2 sampled patients, #1 and #2.

Findings:

At approximately 8:30am on 8/21/14 an observation was conducted of staff member "A" while she was performing medication administration with two separate patients. The nurse was observed to collect the medications for patient #1 from her medication cart which was stationed in the hallway. The cart contained drawers that held individually packaged medications, but there were two medications that she was not able to locate on the cart for patient #1. The nurse locked the cart and returned to the pharmacy, which was located on another hall of the hospital, to obtain the missing medications. She returned to the cart and continued to assemble the patient's medications per the medication administration record. Once she had all of the patient's medications accounted for, she knocked on the door and entered the patient's room with permission. She introduced herself and explained her purpose to the patient and then began to remove the medications from their packaging and place them in a soufflé cup for the patient. The nurse did not wash or sanitize her hands prior to entering the patient's room or prior to administering the patient his medications. Some of the medication packaging allowed the nurse to peel away a protective covering from the medication package and she was able to efficiently get those medications into the soufflé cup without touching them. The nurse was also observed using her fingernails to puncture the protective covering on some of the medications that were not easy to peel which meant that the nurses fingernail would come into contact with the medication. The nurse was observed to wash her hands prior to leaving the room of patient #1 before she returned to her cart to gather medications for patient #2.

The nurse repeated the same medication gathering for patient #2 as she pulled the individually wrapped medications from the cart and compared them to the medication administration record. The nurse then knocked and with permission entered the room of patient #2. Again the nurse was not observed to wash or sanitize her hands prior to entering the patient's room or prior to administering the patient's medications. The nurse was again observed to utilize her fingernail to puncture the protective covering of some of patient #2 medications which allowed the nurse's fingernail to come in contact with the patient's medications.

Review of the facility infection control policy (pg.35) that was approved and adopted by the hospital and governing board on May 22, 2013 showed that routine universal precautions used for all patients must include: hands will always be washed before and after contact with patients.

Based on observations, staff interviews, record reviews and equipment inventory list review, the facility failed to ensure medical devices and equipment received a regular periodical maintenance and testing to ensure an acceptable level of safety and quality (C0222). The most recent preventative maintenance was performed on 8/5/13 through 8/12/13, slightly over a year ago. According to the facility's equipment inventory list, all listed equipment was to either be inspected semi-annually or have an electrical safety check semi-annually.

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment. Please see findings at C0222.

The findings:

Please refer to C0222: Based on observations, staff interviews and record reviews, the facility failed to ensure medical devices and equipment received a regular periodical maintenance and testing to ensure an acceptable level of safety and quality.

Based on observations, staff interviews and record reviews, the facility failed to ensure medical devices and equipment received a regular periodical maintenance and testing to ensure an acceptable level of safety and quality.

Findings:

On 8/18/14 at approximately 1:00pm, during entrance conference with the facility's administrator, it was revealed that on 8/14/14 the facility renewed a maintenance agreement with Clinical Engineering Technology (CE Tech) for the period of 7/1/14 through 6/30/17 to provide preventative maintenance checks.

On 8/18/14 at approximately 1:50pm, a tour of the nursing unit was conducted. Observed a crash cart in hallway of the nursing unit with a 'Zoll M Series' defibrillator with a CE Tech inspection sticker dated 8/2013. Two Welch-Allyn blood pressure machines were also observed to have the same inspection sticker date. An intravenous infusion pump observed in use for Patient #1 was also noted to have a CE Tech inspection sticker, dated 8/2013.

In interview with the Director of Nursing on 8/18/14 at approximately 2:00pm, she stated she thought the equipment was inspected every 6 months; and confirmed the sticker on the equipment did not indicate this had been done.

On 8/18/14 at approximately 3:00pm, a tour of the Radiology Department was conducted in the presence of the Radiology Director. The Director stated the x-ray machine preventative maintenance is conducted annually and provided a certificate of inspection from 'RTI Medical Systems, Inc'. documenting the preventative maintenance inspection (PMI) was performed on May 28, 2013 and the next inspection date due was on May 27, 2014. Interview with the Director revealed the inspection scheduled for May 27, 2014 was not completed as company was running behind and knew they had to look for a part as the machine had been having a "banging sound." The Director stated the x-ray part was replaced, but PMI not performed at that time, but scheduled to return on 8/20/14 to conduct the PMI. Observed a CE Tech sticker dated August 2013 located on the stationary x-ray machine and on the portable x-ray machine.

Observed an ultrasound machine with a CE Tech sticker dated 3/6/13. The Director stated preventative maintenance (PM) was conducted annually on the machine by the manufacturer, Phillips; and provided documentation to support that Phillips provided PM on 9/26/13. Observed a CE Tech sticker dated 3/6/13.

Interview with the Director of Environmental Care, on 8/18/14 at approximately 4:25pm, revealed the x-ray machine, the portable x-ray machine and the ultrasound machine are inspected by CE Tech for electrical safety even though the equipment is maintained through another contracted company.

On 8/19/14 at approximately 2:40pm, a tour of the Emergency Department (ED) was conducted in the presence of the ED Registered Nurse. The patient care equipment was observed to have a CE Tech inspection sticker, dated 8/2013. The equipment included the infusion pumps, suction pumps, blood pressure monitoring equipment, electrocardiograph equipment and defibrillator equipment.

Review of facility contracts with CE Tech revealed a contract agreement for preventative maintenance of biomedical equipment expired December 2013; and a renewal maintenance agreement was contracted for 7/1/14 through 6/30/17. The renewal was accepted by the facility's Governing Board Chairman on 8/14/14.

Review of facility's equipment inventory list documented the most recent preventative maintenance being performed on 8/5/13 through 8/12/13, with some equipment documenting a date of 2011 and 2012. The inventory list consisted of 3 pages documenting the location of the equipment, a control number, an asset number, manufacturer description, model number, model description, serial number, service code, risk priority and date last seen.

A telephone interview was conducted with a CE Tech service representative on 8/21/14 at approximately 3:00pm to determine the frequency of preventative maintenance service for the equipment. The representative stated that equipment indicated by the number 0708 indicates a semi-annual inspection, equipment indicated by the number 0707 indicates an annual inspection; and equipment indicated by the number 0719 indicates a semi-annual inspection for electrical safety check only.

Further review of the facility's inventory list after being provided interpretation of the number coding system revealed none of the equipment to be indicated by the number 0707 (indicating an annual inspection). The inventory list indicated semi-annual inspections of the equipment or semi-annual inspection for electrical safety check only. This finding was confirmed by the facility's administrator and the facility's director of plant operations during the survey visit.

Based on observation, interview, record review, policy review, and review of Medical Staff and Governing Board by-laws, the facility failed to ensure that organizational structure requirements were met in the areas of credentialing clinicians, infection control procedures, dietary equipment maintenance, and medical records. The facility's Governing Board failed to ensure medical staff were credentialed with designated privileges to practice within the hospital (C241); failed to ensure infection control standards were maintained (C278); failed to ensure dietary services were provided in a safe and sanitary environment (C279); and failed to ensure medical records were maintained in accordance with established by-laws (C304). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.
The findings:
Refer to C241: Based on interviews, review of medical staff credentialing files and review of medical staff by-laws, the facility failed to ensure the medical staff maintained current credentials and privileges in accordance with their established Medical Staff By-Laws and Governing Board By-Laws for 5 of 7 practitioners. (#1, #3, #4, #5 & #6)

Refer to C278: Based on observation and policy review, the facility failed to adhere to their policy on the use of universal precautions for controlling infections. Infection control policies were not followed during a medication pass observation with Staff A and 2 of 2 sampled patients, #1 and #2.

Refer to C279: Based on observation and interview, the facility failed to provide inpatient dietary services in accordance with recognized dietary practices. Food was not stored in a sanitary environment. Food items were exposed to water dripping from the fan-unit in the walk-in freezer.
Refer to C304: Based on record review and interview, the facility failed to maintain a record for 3 of 7 patients reviewed (#11, #12, & #14) that included a pertinent medical history, health status, and brief summary of the episode within the twenty four hour timeframe specified by the facility bylaws.

Based on interviews, review of medical staff credentialing files and review of medical staff by-laws, the facility failed to ensure the medical staff maintained current credentials and privileges in accordance with their established Medical Staff By-Laws and Governing Board By-Laws for 5 of 7 practitioners. (#1, #3, #4, #5 & #6)

Findings:

On 8/18/14 at about 1:00pm, during the entrance conference with administrative staff, a request was made for a list of the hospital's medical staff who provide services as an employed practitioner or as a contracted practitioner. Administrator stated there are two physicians who provide in-patient services , a radiologist and a pathologist who provide contracted services, and three mid-level practitioners who provide Emergency Department coverage. Request was made to view each of the practitioners credentialing files.

On 8/19/14, a review of the facility's medical staff credentialing files was conducted in the presence of the facility's Administrative Assistant and the Licensed Healthcare Risk Manager (LHCRM). Both confirmed initial appointments to the medical staff are for a one year period; and reappointments are for a two year period.

Review of file for Physician #1 documented an initial appointment January 1996 with most recent appointment on 3/6/2012 for a two year period. There is documentation that privileges were requested on 5/5/14 and awaiting approval from Medical Staff and Governing Body.

Review of file for Physician #3 documented an initial appointment on 10/9/2007 with the most recent reappointment on 2/17/2012 for a period of two years in accordance with by-laws. There is documentation of request for privileges for emergency medicine and internal medicine dated 7/9/14 with no indications of of approval from Medical Staff and/or Governing Body.

Review of file for Physician #4 documented an initial appointment in 2003 with the most recent reappointment on 3/6/2012 for a period of two years. There is documentation that privileges were requested on 5/6/14 awaiting approval from Medical Staff and Governing Body.

Review of file for Advanced Registered Nurse Practitioner (ARNP) #5 documented an initial provisional appointment granted for a one year period commencing on 9/20/12. There has been no further credentialing for this practitioner. There is documentation of privileges requested on 7/18/14 pending approval from Medical Staff and Governing Body. The LHCRM and Administrative Secretory confirmed this practitioner to be out of compliance with the facility's reappointment process since 9/20/13.

Review of file for ARNP #6 documented an initial provisional appointment granted for a one year period commencing on 1/30/08 with the most recent reappointment on 3/6/12 for a period of two years. The most recent privileges request is dated 7/9/14 awaiting approval from Medical Staff and Governing Body.

Section 3(a) of Medical Staff By-Laws with most recent review date of November 2012, titled "Conditions and Duration of Appointment" documents initial appointments and reappointments to the Medical Staff shall be made by the Governing Body.

Section 3(b) documents reappointments shall be made for a period of 2 years as appropriate. Section 3c documents appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body in accordance with these By-laws. Section 2 titled "Appointment Process" documents the initial reappointment for provisional clinical privileges shall be for the term of one (1) year.

Review of facility's Governing Board By-Laws with most recent review date of October 1993, Article IV, titled "Duties of the Administrator" Section 1l. documents "subject to the direction and control of the Board, the management of the hospital shall be vested in the administrator appointed by the Board." Section 2. documents "when acting within the scope of the executive authority, the administrator shall directly represent the Board in all matters pertaining to the administration of the hospital and shall be responsible to the Board alone for the proper performance of his official responsibilities." Section 4. documents "it shall be the duty of the administrator to enforce all rules and regulations for the proper conduct of the hospital, made by or under the authority of the Board ... "

On 8/19/14 at approximately 11:30am, an Interview was conducted with Administrative Assistant who identified herself as being responsible for the medical staff credentialing/ privileging process as of April 2014. She further stated the facility's previous Administrative Assistant was responsible prior to April 2014, but is no longer employed here.
She stated that the facility is contracted with Panhandle Area Health Network (PAHN) Credentials Verification Organization under contract agreement. She stated the facility informs PAHN of medical staff who need initial credentialing and/or recredentialing, then PAHN sends out the packet to the practitioner who then provides her with the completed packet, which in turn is sent back to PAHN by her for completion of the process. She further stated she was not aware of practitioners needing recredentialing until she began getting packets back from various practitioners in June of this year. She stated that within the last week she received the remainder of the documents from the contracted credentialing company to enable the recredentialing/ privileging process to proceed.

Interview conducted with the Administrator on 8/19/14 at approximately 2:00pm confirmed the findings, and acknowledged he was aware that 5 of the 7 practitioners providing care within the facility did not have current credentials and privileges. Administrator stated that it would be addressed at the Governing Body meeting scheduled that evening.

Based on observation and interview, the facility failed to provide inpatient dietary services in accordance with recognized dietary practices. Food was not stored in a sanitary environment. Food items were exposed to water dripping from the fan-unit in the walk-in freezer.
The Findings:

On 8/19/14 at 8:47am an initial inspection of the kitchen was conducted. During this inspection, observations were made of all food storage areas. Observation of the kitchen's walk-in freezer showed a fan unit at the rear of the freezer with two fans that were both operational but the unit had a significant amount of ice build-up on the underside that extended about two feet downward onto a top shelf (See photographic evidence). There was food under the ice build-up and around the ice build-up and several packages of food that had been covered by the ice. During observation of the freezer, the kitchen manager stated that the removal of the ice build-up was a function of the maintenance man.

On 8/19/14 at 9:37am an interview was conducted with the registered dietician who stated that she had made rounds last week and noticed the build-up of the ice and had instructed the kitchen manager to submit a maintenance request form for removal of the ice build-up. She stated that there had been a lot going on with the new computer system in the hospital and that the maintenance director was also responsible for handling the technology issues so he had been extremely busy. She stated that they normally submitted a maintenance request when they needed the ice removed and she had no knowledge of scheduled maintenance for the issue.

On 8/20/14 at 2:10pm an interview was conducted with the maintenance director who stated that where the water is dripping from in the walk-in freezer is where a moisture absorber filter that absorbs water from the system was installed. He stated that the absorber had to be installed because the doors of the freezer were being left open for extended periods of time and water was dripping on the floor and freezing which created an employee hazard. He stated that staff leave the door to the refrigerator and the freezer propped open when they are getting stuff out and for an extensive period when the food truck delivers. He stated that food is delivered weekly and when the truck is bringing food into the kitchen they leave the outside door propped open, the door to the kitchen propped open, and the doors of the walk-in refrigerator and the door to the walk-in freezer propped open for an hour or more. He stated that he and the dietician disagreed on who is responsible for cleaning the ice in the freezer and he does not feel comfortable being around food products due to the nature of his position and things he comes in contact with on a daily basis. He stated that he had not received a work order for the ice in the freezer until 8/19/14 and that he had not yet corrected the issue. He stated that he had gone and looked at the ice and stated that it is worse than he has ever seen it and the pattern of the ice on the shelf appeared in a pattern as if the ice had thawed and then refrozen. He stated that he looked around and noticed that the seal on the door of the freezer was damaged so he ordered the part and would do all repairs at once.

Based on record review and interview, the facility failed to maintain a record for 3 of 7 patients reviewed (#11, #12, & #14) that included a pertinent medical history, health status, and brief summary of the episode within the twenty four hour timeframe specified by the facility bylaws.

Findings:

On 8/21/14, a record review was conducted on the medical records of seven patients.

The medical record for patient #11 showed that the patient had been admitted to the hospital on 5/10/14 and was discharged from the hospital on 5/13/14. The patient's history and physical showed that it had been dictated on 5/12/14 and was transcribed on 5/13/14.
The medical record for patient #12 showed that the patient had been admitted to the hospital on 3/31/14 and discharged on 4/3/14. The history and physical for the patient showed that it had been dictated on 4/10/14 and transcribed on 4/11/14.

The medical record for patient #14 showed that the patient had been admitted to the hospital on 4/10/14 and discharged from the hospital on 4/12/14. The medical record also showed that the patient's history and physical had been dictated on 8/18/14 and transcribed on 8/19/14.

Review of the hospital bylaws conducted 8/21/14 at 11:50am showed that a complete history and physical examination shall be reported within 24 hours of admission.

On 8/21/14 at approximately 11:45am an interview was conducted with the facility risk manager. The risk manager confirmed the findings of the record reviews for patients #11, #12, and #14. She stated that she was aware that a few patients had not had a history and physical conducted within the facility bylaw timeframe.