HospitalInspections.org

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Based on observation, document review and interview, the critical access hospital staff failed to ensure that all medical equipment is maintained and ready for use.

Failure to have a process for hospital-wide preventive maintenance puts patients at risk of equipment malfunction during care.
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Findings:

1. On 11/4/2014 at 1:35 PM, Surveyor #1 interviewed a scrub tech (Staff Member #5) about the preventive maintenance process for equipment located in the sterile processing department. During the interview, the surveyor asked about the maintenance frequency for the department's "Reliance Sonic Cleaner". Staff Member #5 indicated that it was not on a scheduled preventive maintenance rotation.

2. On 11/5/2014 at 2:30 PM, Surveyor #1 interviewed a member of the maintenance department (Staff Member #6) about the hospital-wide inventory of equipment. Staff Member #6 provided the surveyor copies of individual invoices from the contracted service vendor, but there was no evidence of a house-wide inventory of all equipment used in the facility nor their manufacturer's recommendations for use.

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Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.

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Based on interview and Medicare Conditions of Participation (CoP) the critical access hospital failed to ensure patient care policies were reviewed and updated annually as required.

Failure to review and update patient care policies can result in unsafe and inappropriate care to patients.
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Findings:

1. On 11/4/2014 at 10:45 AM, Surveyor #2 reviewed nineteen surgical services patient care policies. The policies effective dates ranged from 2000 to 2013. Overdue polices were also noted for swing-bed/custodial care.

2. On 11/14/2014 at 12:30 PM, Surveyor #2 conducted an interview with the hospital's director of nursing (Staff Member #1), who confirmed the patient care policies were overdue for review.

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Item #1- Employee Health

Based on record review, the critical access hospital staff failed to follow hospital policy for "Employee TB Testing" as outlined in the hospital's Tuberculosis (TB) Exposure Plan.

Failure to properly test staff members for TB infection puts patients, staff and visitors at risk for exposure to M. tuberculosis infection.
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Findings:

1. Hospital Policy #13735 titled "TB Exposure Plan" (effective date: 5/1/2013) states in part: "Lewis County Hospital District No. 1 (MGH) in compliance with WAC 248-18-0404 (4) requires all employees to have a tuberculin skin test by the Mantoux method. Employees shall have a second test one to three weeks after the first test."


2. On 11/5/2014 during review of Human Resource records, Surveyor #1 identified 1 of 7 staff members who did not complete TB testing upon hire. The contracted staff member's record indicates the first test was completed on 4/7/2008, but their file contained no documentation of administration of a second test.


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Item #2- Hand Hygiene

Based on observation, interview, and review of the critical access hospital's policies and procedures, the hospital failed to ensure that staff members performed hand hygiene according to hospital policy and accepted standards of care.

Failure to perform proper hand hygiene can put patients at risk for health care-associated infections and potentially spread infections in hospitals.

Findings:

1. The hospital's policy and procedure entitled "Infection and Prevention Manual" (Last Update/Review March 6, 2013) read in part as follows: "1. Purpose. To remove transient microbial contamination on hands and reduce the risk of transmission of potentially infectious microorganisms. This policy is based on CDC Hand Hygiene. II. Policy. A ...B. Staff Responsibility: Each staff member implements hand hygiene techniques consistent with these procedures. These techniques are particularly important for individuals providing direct patient care, directly supervising patient care or having contact with patient care supplies, equipment or food ...IV. Procedures. A ...B. Decontaminate hands by performing antiseptic hand rub or antiseptic handwash: 1. Before having direct contact with patients ...8. After removing gloves ..."

2. During the survey, Surveyor #2 observed the following:

a. On 11/4/2014 at 11:30 AM, in operating room (OR) #1 during a surgical procedure, the surgical nurse (Staff Member #2) picked up trash off the floor, then took their gloves off donned new gloves and did not perform hand hygiene between glove changes. The nurse then proceeded to pass on sterile surgical supplies onto the sterile instrument table.

b. On 11/4/2014 at 10:10 AM, in the recovery room, a respiratory therapist (Staff Member #3) donned gloves and proceeded to prepare an aerosol breathing treatment. The respiratory therapist applied the breathing equipment to Patient #3's face/nose. The respiratory therapist then removed his/her gloves and without performing hand hygiene, exited the recovery room.

3. On 11/5/2014 at 8:30 AM, during an interview with the director of nursing (Staff Member #1), s/he confirmed that staff members had not preformed hand hygiene according to hospital policy.

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Based on interview and Medicare Conditions of Participation (CoP) the critical access hospital failed to perform an annual evaluation of the hospital's total program including all departments and services affecting patient care, health, and safety.

Failure to conduct an annual total program evaluation can result in underutilized hospital services or lack of needed services, substandard practices, and outdated regulations and/or policies.

Findings:

1. On 11/5/2014 at 11:55 AM, Surveyor #2 reviewed the hospital's annual critical access hospital (CAH) evaluation for 2011. The hospital's director of nursing (Staff Member #1) stated that the hospital may have a current evaluation but that s/he did not have access to those documents.

2. On 11/5/2014 at 9:00 AM, Surveyor #2 interviewed the hospital's Chief Executive Officer (Staff Member #4) who confirmed the hospital has not conducted any annual evaluations since the one completed for 2011.

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