HospitalInspections.org

The Critical Access Hospital (CAH) reported five swing bed patients. Based on observation and document review, the CAH failed to store intravenous fluids according to manufacturer's directions in one of two warming cabinets.

Findings include:

- The CAH's emergency room warming cabinet, observed on 4/8/13 at 10:30am revealed a warming cabinet with blankets and two bags of intravenous (IV) fluids. The cabinet's temperature setting read 130 degrees Fahrenheit (54 degrees Celsius). The IV fluids lacked evidence of the day they were placed in the cabinet or the date they were to be removed.

- IV fluids warmed to 130 degrees Fahrenheit and administered to a patient could potentially cause a burn injury to the patient.

- Quality Assurance staff B, interviewed on 4/8/13 at 10:30am acknowledged the IV fluids lacked the date they were placed in the cabinet or the date the fluids were to be removed from the cabinet.

- The manufacturer's instructions, reviewed on 4/10/13 at 8:30pm directed "... fluids may be warmed to 104 degrees Fahrenheit and stored for up to two weeks. The warmed fluids must be removed from the cabinet if not used within two weeks, the fluids may be returned to 77 degrees Fahrenheit with a reduced shelf life and may not be returned to the warmer..."

- Director of Nursing staff A, interviewed on 4/8/13 at 11:30am confirmed the fluids are stored at a temperature which exceeds the manufacturer's instructions, failed to date when the fluids are placed in the warmer or when they are to be removed, failed to note the changed manufacturer's expiration date and failed to ensure the fluids are not placed in the warmer again.

The Critical Access Hospital (CAH) reported five swing bed patients. The CAH's data base worksheet completed by hospital staff reported the CAH staffed 18 acute and swing beds and provided the following services: x-ray, emergency department, laboratory, inpatient and outpatient surgery, and outpatient treatments. Based on observation, document review and staff interview, the CAH failed to develop a system to identify and control infections or staff practices which could contribute to healthcare acquired infections of patients and personnel. Observations included one surgical procedure, staff cleaning a discharged patient room, staff performing a glucometer test, staff administering medications to four patients, and staff in the laundry area. The CAH ' s failure to identify failures with infection control practices, failure to follow manufactures guidelines, and acceptable professional standards of practice created the potential for healthcare acquired infections.

Findings include:

- The CAH's policy titled "Infection Control Policies and Procedures", reviewed on 4/10/13 at 2:30pm directed, "...All patient care and patient care support services/departments...are included in the hospital wide infection control plan..."

- Nursing staff R observed on 4/8/13 at 11:10am entered patient #27's room to obtain a glucometer (a machine used to test a patient's blood sugar level) test. Staff R placed a green basket with equipment and supplies on the bedside table without a protective barrier. After performing the blood sugar test staff R returned the green basket to the nurse's station without cleaning the green basket. The failure to follow acceptable infection control standard of practice while using a point of care device in a patient room created a potential for healthcare acquired infections.

The CAH's policy titled Hand Hygiene, reviewed on 4/9/13 at 2:30pm, directed, hand hygiene is to be performed "...upon entering and exiting the patient's room ..."
- Nursing staff R observed on 4/8/13 at 11:45am entered patient #26's room to provide personal cares. Staff R failed to perform hand hygiene when entering patient #26's room.

- Nursing staff S observed on 4/8/13 at 11:45am administered two units of Humalog insulin to patient #27. Staff S failed to perform hand hygiene when entering patient #27's room.

- Nursing staff S observed on 4/8/13 at 11:55am administered two oral medications to patient #27. Staff S failed to perform hand hygiene when entering patient #27's room. The failure of two staff members to follow hospital policy and acceptable standards of practice for hand hygiene created the potential for the spread of healthcare acquired infections between patients in the hospital.

- Patient #11's medical record revealed an admission date of 3/9/13 for an Esophagogastroduodenoscopy (EGD) (a test to examine the lining of the esophagus, stomach, and first part of the small intestine using a small camera (flexible endoscope) that is inserted down the throat) and a colonoscopy is test to examine the large and small intestine using a small camera on a flexible tube passed through the anus.
- Observation of the procedures on 3/9/13 between 8:35am and 9:55am revealed the following breaches in infection control practices:
1). The EGD procedure began at 8:35am. Physician P, nurse anesthetist Q, registered nurses (RN's) C, N and O wore scrub clothes. Staff C, N, O, P and Q failed to cover their scrub clothing during the procedure and continued to wear the scrub clothes in the hospital after completing the procedure. Staff C, N, O and P failed to wear hair coverings. Staff C, N, O, P and Q failed to apply a facemask and shoe covers during the procedures.
The CAH's policy titled "O.R. (operating room) Attire", reviewed on 4/9/13 at 2:30pm directs " ...3. During invasive operation, no one is allowed in O.R. without proper attire- e.g. cover gown, cap, mask, shoe covers, etc ..."

- The Association of periOperative Registered Nurses (AORN) 2012 periOperative Standards & Recommended Practices reviewed on 4/10/13 directed, " ...Recommended practice for surgical attire, recommendation II: Clean surgical attire, including shoes, head covering, masks, jackets, should be worn in semirestricted and restricted areas of the surgical or invasive procedure setting ... "

Director of Nursing A, interviewed on 4/10/1113 at 11:30am acknowledged the staff failed to follow the CAH policy for invasive procedures performed in the surgical suite.
2). After the EGD, registered nurse C placed the scope in the surgical hand scrub sink. The sink contained an unmeasured amount of water and enzyme cleaner. At 9:55pm, RN C placed another scope in the second scrub sink, which contained an unmeasured amount of water and enzyme cleaner. RN C, interviewed on 3/9/13 at 9:55pm acknowledged they failed to measure the water or enzyme clearer for correctly dilution.
Director of Nursing staff A, interviewed on 4/10/13 at 11:30pm acknowledged the use of the scrub sinks for cleaning the scopes renders the sink unusable for hand washing and has the potential for cross contamination.
3). Staff C, N, O and P removed their protective gloves multiple times during the procedures and put on a clean pair of gloves. Staff C, N, O and P failed to perform hand hygiene after removing the gloves. For example: Physician P applied gloves, inserted the scope, removed the scope, removed the gloves and applied another pair of gloves. RN N, who was handling specimens, removed their gloves and put on another pair of gloves. Staff N removed their gloves, exited the surgical room and obtained supplies from the clean storage room, returned to the surgical room and put on another pair of gloves several times.
The CAH's policy titled "Hand Hygiene", reviewed on 4/9/13 at 2:30pm, directed hand hygiene is to be performed " ...before putting gloves on and after removing them ..."
Director of Nursing A, interviewed on 4/10/13 at 11:30am acknowledged staff are to perform hand hygiene before and after gloving.
4). RN N, was observed removing items from the surgical room on 4/9/13 at 9:50am, revealed a large glass suction container with contaminated body fluids. Staff N, wore scrub clothes and gloves emptied the container of contaminated fluids in the flush rim sink. Staff N failed to wear personal protective equipment including hair covering, mask, eye protection and cover gown to protect themselves from potential splash exposure to the contaminated fluids.
5.) Staff C placed the contaminated biopsy snare, used during the colonoscopy, in the trashcan. Staff C, at 9:14am removed the biopsy snare from the trash for reuse during the colonscope to obtain additional samples.
- Nursing staff S observed on 4/9/13 at 10:00am administered an intravenous medication to patient #26. Staff S failed to perform hand hygiene when entering patient #26's room.

- Observation on 4/9/13 at 11:05am during environmental tour revealed one gray plastic bag with soiled linens and one clear plastic bag with soiled mop heads resting directly on the floor in the soiled laundry room.

Maintenance Staff E interviewed on 4/9/13 at 11:05am acknowledged the trash bags have the potential for contamination due to leakage and verified the bags should not be on the floor.

- Nursing staff T observed on 4/9/13 at 11:45am administered a breathing treatment to patient #27. Staff T failed to perform hand hygiene when entering patient #27's room.

- The manufacturer's information sheet for "HB Quat Disinfectant Cleaner" reviewed on 4/10/13 at 11:35am directed "...Disinfection: Apply solution to hard inanimate, nonporous surfaces thoroughly wetting surfaces ...treated surfaces must remain wet for 10 minutes..."

- The manufacturer's information sheet for "Non-Acid Disinfectant Bathroom Cleaner" reviewed on 4/10/13 at 11:35am directed for disinfection "...apply solution ...allow surfaces to remain wet for 10 minutes..."

- The manufacturer's information sheet for "Lysol Toilet Bowl Cleaner" reviewed on 4/10/13 at 11:35am directed "...To clean and disinfect ...wet all surfaces of bowl interior, including sides of bowl and under the rim with at least 4 ounces of liquid, let soak for 10 minutes..."

The CAH's policy titled "Hand Hygiene"", reviewed on 4/9/13 at 2:30pm, revealed hand hygiene is to be performed "before putting gloves on and after removing them".

- Housekeeping staff F and staff G observed on 4/10/13 between 10:30am to 11:30am cleaned room 10, a discharged patient room failed to follow acceptable hand hygiene, follow manufactures instructions to disinfect surfaces and failed to clean from dirty areas to a less dirty area. For example:

Staff G, wearing gloves applies "HB Quat" disinfection cleaner to the bed mattress, bedside table, recliner, pillow and over the bed table. The surfaces remained wet between two to four minutes, instead of the required ten minutes for total disinfection. Staff G returned to the cleaning cart outside the room and went down hallway to the laundry and to the Long Term Care Unit without removing their soiled gloves.

Staff F wearing gloves removed the room divider curtains, left the room to take the soiled curtains to the utility room. Staff F returned to the cleaning cart in the hallway, removed their gloves, but failed to perform hand hygiene, applied clean gloves, obtained a blue basket with cleaning supplies, and returned to the bathroom

Staff F, entered the bathroom in room 10, and sat the blue basket on the floor of the bathroom. Staff F sprayed the toilet bowl and the sink with "Non-Acid Disinfectant Bathroom Cleaner" and squirted an unmeasured amount of "Lysol Toilet Bowl Cleaner" in the toilet bowl. Staff F, using a toilet bowl mop, mopped inside the toilet bowl then using a wet cleaning cloth cleaned the bathroom sink wearing the same gloves used in cleaning the toilet bowl. The surface of the sink failed to remain wet the required 10 minutes for disinfection. Staff F returned the blue basket that sat on the floor of the bathroom to the cleaning cart and failed to clean the blue basket. Staff F removed their gloves and failed to perform hand hygiene. Staff F mopped the bathroom floor with "HB Quat" the floor failed to remain wet for the required 10 minutes for disinfection.

Staff F returned to the cleaning cart in the hallway, removed their gloves, failed to perform hand hygiene, applied clean gloves, obtained a mop, returned to the room #10, and mopped the floor with "HB Quat" the floor failed to remain wet for the required 10 minutes for disinfection.

Staff F removed and reapplied gloves multiple times but failed to perform hand hygiene. Staff G wore the same soiled gloves during the room cleaning. Staff F and staff G failed to perform hand hygiene after cleaning room #10.

Housekeeping staff F and G interviewed on 4/10/13 at 11:30am acknowledged surfaces failed to remain wet the required 10 minutes for disinfection, they moved from dirty to a less dirty area by cleaning the toilet bowl and then the sink, they wore soiled gloves in the hallway of the hospital, and they failed to perform hand hygiene when changing gloves or when they completed the cleaning of room 10.

The Critical Access Hospital (CAH) reported five swing bed patients. Based on document review and staff interview, the CAH failed to ensure deaths are reported to the Organ Procurement Organization (OPO) for one of two patient deaths reviewed (patient #9).

Findings include:

- The CAH's policy titled "Policy and Procedure for Organ, Tissue and Eye Donation", reviewed on 4/10/13 at 10:30am directs the staff to "...report all deaths to the Midwest Transplant Network Donor Referral network..."

- Patient #11's medical record, reviewed on 4/9/13 at 2:30pm revealed the patient died in an accident on 9/9/12 and was brought to the CAH. The medical record lacked evidence the OPO was notified of the patient's death. Director of Nursing staff A and medical records staff H, interviewed on 4/10/13 at 2:00pm acknowledged the CAH failed to follow the CAH's policy to notify the OPO of patient #9's death.

The Critical Access Hospital (CAH) reported a census of five skilled swing bed patients. Based on document review and staff interview the CAH failed to inform swing bed patients of his or her right to refuse treatment and to refuse to participate in experimental research for five of five skilled swing bed patient records reviewed (#'s 26, 27, 28, 29, and 30).

Findings include:

- Review of the swing bed patient rights on 4/10/13 at 8:30am revealed the document failed to include the right to refuse treatment and to refuse to participate in experimental research.

- Patient #26's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/4/13. The medical record revealed the patient received patient rights that failed to include the right to refuse treatment and to refuse to participate in experimental research.

- Patient #27's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/5/13. The medical record revealed the patient received patient rights that failed to include the right to refuse treatment and to refuse to participate in experimental research.

- Patient #28's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/19/13. The medical record revealed the patient received patient rights that failed to include the right to refuse treatment and to refuse to participate in experimental research.

- Patient #29's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/26/13. The medical record revealed the patient received patient rights that failed to include the right to refuse treatment and to refuse to participate in experimental research.

- Patient #30's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 1/8/13. The medical record revealed the patient received patient rights that failed to include the right to refuse treatment and to refuse to participate in experimental research.

Swing Bed Coordinator Staff D interviewed on 4/10/13 at 8:30am acknowledged the swing bed patient rights failed to include the right to refuse treatment and to refuse to participate in experimental research.

The Critical Access Hospital (CAH) reported a census of five skilled swing bed patients. Based on document review and staff interview the CAH failed to inform swing bed patients of his or her right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare for five of five skilled swing bed patient records reviewed (#'s 26, 27, 28, 29, and 30).

Findings include:

- Review of the swing bed patient rights on 4/10/13 at 8:30am revealed the document failed to include the right to be right informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

- Patient #26's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/4/13. The medical record revealed the patient received patient rights that failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

- Patient #27's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/5/13. The medical record revealed the patient received patient rights that failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

- Patient #28's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/19/13. The medical record revealed the patient received patient rights that failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

- Patient #29's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/26/13. The medical record revealed the patient received patient rights that failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

- Patient #30's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 1/8/13. The medical record revealed the patient received patient rights that failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

Swing Bed Coordinator Staff D interviewed on 4/10/13 at 8:30am acknowledged the swing bed patient rights failed to include the right to be informed of who is entitled to Medicaid benefits and of charges for services not covered under Medicare.

The Critical Access Hospital (CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform swing bed patients of his or her right to be informed in advance about care and treatment and changes in their care and treatment for five of five skilled swing bed patient records reviewed (#'s 26, 27, 28, 29, and 30).

Findings include:

- Review of the swing bed patient rights on 4/10/13 at 8:30am revealed the document failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #26's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/4/13. The medical record revealed the patient received patient rights that failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #27's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/5/13. The medical record revealed the patient received patient rights that failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #28's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/19/13. The medical record revealed the patient received patient rights that failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #29's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/26/13. The medical record revealed the patient received patient rights that failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #30's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 1/8/13. The medical record revealed the patient received patient rights that failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

Swing Bed Coordinator Staff D interviewed on 4/10/13 at 8:30am acknowledged the swing bed patient rights failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

The Critical Access Hospital (CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform swing bed patients of his or her right to work or refuse to perform work for five of five skilled swing bed patient records reviewed (#'s 26, 27, 28, 29, and 30).

Findings include:

- Review of the swing bed patient rights on 4/10/13 at 8:30am revealed the document failed to include the right to work or refuse to perform work.

- Patient #26's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/4/13. The medical record revealed the patient received patient rights that failed to include the right to work or refuse to perform work.

- Patient #27's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/5/13. The medical record revealed the patient received patient rights that failed to include the right to work or refuse to perform work.

- Patient #28's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/19/13. The medical record revealed the patient received patient rights that failed to include the right to work or refuse to perform work.

- Patient #29's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/26/13. The medical record revealed the patient received patient rights that failed to include the right to work or refuse to perform work.

- Patient #30's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 1/8/13. The medical record revealed the patient received patient rights that failed to include the right to work or refuse to perform work.

Swing Bed Coordinator Staff D interviewed on 4/10/13 at 8:30am acknowledged the swing bed patient rights failed to include the right to work or refuse to perform work.

The Critical Access Hospital (CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform swing bed patients of his or her right to share a room with their spouse for five of five skilled swing bed patient records reviewed (#'s 26, 27, 28, 29, and 30).

Findings include:

- Review of the swing bed patient rights on 4/10/13 at 8:30am revealed the document failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #26's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/4/13. The medical record revealed the patient received patient rights that failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #27's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 4/5/13. The medical record revealed the patient received patient rights that failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #28's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/19/13. The medical record revealed the patient received patient rights that failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #29's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 3/26/13. The medical record revealed the patient received patient rights that failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #30's medical record, reviewed on 4/8/13 revealed a swing bed admission date of 1/8/13. The medical record revealed the patient received patient rights that failed to inform swing bed patients of his or her right to share a room with their spouse.

Swing Bed Coordinator Staff D interviewed on 4/10/13 at 8:30am acknowledged the swing bed patient rights failed to inform swing bed patients of his or her right to share a room with their spouse.