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Based on observations, review of the policies and procedures regarding sanitation of the dishes and interviews with the Dietary Manager (DM) and the Maintenance Personnel (MP); the Critical Access Hospital (CAH) failed to ensure the kitchen was in good repair and policies and procedures were being followed pertaining to the sanitation of dishwashing.
The CAH had a census of 3 swingbed patients upon entrance.

Findings are:

A. Observation and interviews with the DM on 11/6/12 from 12:30 PM through 1:30 PM; and the MP on 11/7/12 at 2:00 PM through 2:45 PM revealed acoustical ceiling tiles (approximate footage unknown), located in the kitchen directly above food prep areas to be discolored to a yellowish/brown, with numerous gouges and scrapes on the tiles. Several tiles did not fit securely into the railing of the ceiling nor lay flat, which left open gaps for falling debris. Interview with the DM indicated "some of the ceiling tiles were damaged due to the roof leaking before it was fixed." The entire acoustical ceiling tiles located in the kitchen were held in place with tin runners that had been discolored to a yellowish/brown and displayed scattered rust, making the acoustical ceiling tiles and runners in the kitchen unable to be sanitized or cleaned.

B. The splash board wall located in the kitchen underneath the 4 compartment dishwashing sinks was worn and had underlying material exposed., and did not have a complete seal along the floor boards. The area was approximately 10 feet long and 4 feet high.

C. The following kitchen pots, pans, and baking inventory were observed and identified by the DM to be dented, blackened along the inside the edges with food debris, and were missing the manufacturer's seal exposing the underlying metal:

1. 3-8 quart pots.
2. 4-2 quart pots with handles.
3. 4-3 quart pots with handles.
4. 1-12 x 18 inch baking pan.
5. 1-6 quart pot with handle.
6. 1-11 x 16 inch baking pan.
7. 1-12 x 18 inch baking pan.
8. 4-9 x 13 inch cookie sheets.
9. 3-9 x 13 inch cake pans.
10. 2-bread loaf pans.
11. 2-18 quart roasters.
12. 1-12 x 18 inch baking pans.
13. 1-16, 12 and 4 quart double broilers.
14. 1 big commercial mixer (exact size was unknown to DM) had paint and food debris fall out of the agitator when this surveyor turned the agitator, which left the potential for cross contamination of food served to the patients.

D. One 8 x 2 feet sheet of wall board located on the north wall of the kitchen had holes of various sizes and shapes and lacked a large portion of the original manufacturer's finish which exposed the underlying material. This did not allow for proper sanitation of the wall.

E. Two 4 x 8 feet sheets of wall board located on the south and east corner of the kitchen had scratches and lacked the manufacturer's finish. This did not allow for proper sanitation of the wall.

F. A 50 pound box of open potatoes were stored underneath the food prep table. This allowed for rodent infestation. The DM acknowledged the potatoes "were old and needed to be thrown out."

G. One 50 gallon open bucket of pickles lacked the date the pickles were opened. The DM identified that the pickles came to the facility on 10/26/12.

H. The commercial dishwasher had an excessive buildup of of lime deposits on the top, on the inside and outside of all 4 corners. DM was unsure as to when the dishwasher was last cleaned properly.

I. The walkin refrigerator had a kitchen employee's lunch stored on the same shelf that food stored for the patients. The DM acknowledged the employee's lunch and stated "she knows she cannot put lunch in refrigerator".

J. Review of the policies and procedures for the usage of dishwasher test strip/temperature procedure reads "A daily check of chemical strength in the dishwasher and sanitizer chemical will be done. The daily check of the chemical strength in the dishwasher is to be done to the first (1st) wash. Temperatures of the dishwasher will be done at all three meals".

Review of the dishwasher test strip/temperatures were not done on a consistent basis for the AM Temp, noon temp, PM temp, dishwasher Strip test, or the usage of a STER bacterial test strip for the month of October or November. This practice did not ensure the required sanitation or sterilization of the dishes used by the patients. Interview with the DM acknowledged "The kitchen serves the residents in the long term care facility (LTC) and the CAH patients and staff are not doing it the way they are supposed to, but were out of sanitation strips for awhile."

Based on a review of the physician's reappointment files, Governing Body meeting minutes, Medical Staff meeting minutes, Medical Staff By- Laws, Rules and Regulations and staff interview, the Governing Body failed to follow the By-Laws during the reappointment process.

Findings:

A. A review of the Medical Staff By-Laws, Rules and Regulations (regarding active medical staff membership) stated, in Article II, "To assure a high level of professional performance of all practitioners authorized to practice in the hospital, through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital, and through an ongoing review and evaluation of each practitioner's performance in the hospital."

Article III Membership Section 1: General Qualifications: "Practitioners shall be qualified for membership on the Medical Staff only if they:
a. Document their...demonstrated ability..with sufficient adequacy to demonstrate that any patient treated by them will receive medical care of the generally recognized professional level of quality... established by the hospital..."
Article III Section 1.4 Organized Health Care Arrangement "Qualify to participate in Hospital health care operations, such as Hospital and Medical Staff quality improvement, utilization management, peer review and other functions..."
Article IX. Meetings, Section 4: Attendance at Meetings, 1. "All members of the Active Medical Staff shall be required to attend all meetings. Absence for three consecutive meetings or from one-third of the regular meetings of the year, without acceptable excuse, shall be considered as resignation from the Active Medical Staff."

B. A review of 4 of 4 Active Medical Staff member's reappointment files lacked evidence of meeting attendance, Quality Assurance activities, or Peer Review results.

C. A review of the Medical Staff Meeting minutes and Governing Body Meeting minutes for the time period January 2012 through October 2012 lacked evidence of review of meeting attendance, quality improvement activities, and peer review by each practitioner reappointed to the Medical Staff.

D. Interviews conducted with the hospital staff member responsible for oversite of the Medical Staff reappointment process and the Quality Assurance Coordinator on 11/6/12 at 2:45 PM confirmed meeting attendance, quality assurance and peer review information was not included in the Medical Staff reappointment files.



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Based on staff interviews, review of the January, 2012 quarterly report, and operating/procedure room logs, the Critical Access Hospital CAH) failed to ensure quality tracking indicators were met for temperatures and humidity were in acceptable parameters to ensure the safety of all patients. Facility census was 3 swingbed patient's. Findings include;

A. Interview with the Maintenance Personnel (MP) on 11/7/12 at 10:30 PM revealed the CAH has 1 operating/procedure room. It was identified in 2009 that the temperature and humidity unit on the roof did not maintain the operating/procedure room within acceptable parameters (Temperatures of 68-73 degrees F and humidity of 30-60%) as indicated within the standard of care established by AORN. The project to replace the heating/humidity unit was completed on 4/10/12.

B. Review of the Department Quarterly Quality Report dated January, 2012 for evaluation and actions reads; "Monitoring of temperatures during the summer months indicated that they were not with in the standards of care established by AORN (68-73 degrees F). Temperature and humidity standards are established to ensure the most stable environment to minimize risk and prevent the growth of bacteria and mold and yet maintain patient normal thermal temperatures. In our OR, when we would adjust the room temperature to acceptable standards, the humidity would rise. In reviewing the situation with Heating and Cooling specialist and architects, it was discovered that our current unit is oversized and does not run long enough to pull the humidity. Solution: install components to the unit to ensure dehumidification process. We will need to monitor effectiveness of solution. Daily monitoring to ensure room temperature is kept between 68-73 degrees F. Monitoring of humidity and overall environment during the summer months indicated that the OR was not within acceptable humidity ranges as established by AORN (30-60% relative humidity). Solution as written above. Will monitor stability of room on a daily basis insuring humidity is kept between 30-60%."

C. Review of the surgical suite humidity/temp log and interview with the Director of Nursing (DON) and MP on 11/7/12 acknowledged the operating/procedure room humidity/temp was not checked on a daily basis -- only checked when there are patient procedures scheduled in the operating/procedure room, as the temperature was set "but does not hold, and requires temperature adjusting."

D. Interview with the DON on 11/7/12 at 10:30 AM revealed the DON checked the temperature to be 60 degree F, and the humidity to be 29% in the operating/procedure room. The DON acknowledged the temperature was set at 72 degree F and the humidity set at 30-40% and let MP know. The DON thought the system was working and did not know why the temperature dropped when checked today.

Based on staff interviews, record review for Patient 17, contract review for the Nebraska Organ Retrieval System (NORS), review of personnel record of RN (Registered Nurse)-1, and review of policies and procedures, the Critical Access Hospital (CAH) failed to follow the policies and procedures for the notification of NORS upon a patient death. The CAH had a census of 3 swingbed patient's.

Findings are:

A. Review on 11/7/12 at 9:00 AM revealed the CAH did have a contractual agreement with NORS dated January 1, 2011. Review of the policies and procedures pertaining to the notification of NORS at 3/G reads: "WMH: Complete the paperwork and make the call to the Nebraska Organ Recovery System (NORS) within one hour of the death to assess suitability for organ donation. (This is expected if the facility is associated with a hospital that receives funding from CMS). Body should not be released to the mortuary until NORS responds with determination if the patient is or is not a donor candidate. NORS will contact the family if the patient is a donor/donor candidate. NORS will contact the family if the patient is a donor candidate. (Nurses/staff DO NOT relay NORS information to the family)."

B. Record review revealed Patient 17 arrived at the emergency department (ED) on 3/28/12 at 0154 (1:54 AM) with pertinent diagnosis of Massive Cardiopulmonary Arrest and expired at 0222 (2:22 AM).
Further review revealed the RN-1 on duty did not notify NORS and did approach family concerning organ donation.

C. Interview with the Director of Nurses (DON) on 11/7/12 at 1:00 PM revealed the RN-1 on staff at the time of the incident did not contact NORS of Patient's 17 death as directed in the policies and procedures and did approach the family for organ donation. Further indicating there are no staff members specially trained by NORS to approach family members and RN-1 was orientated to the NORS process through the policies and procedures of the CAH.

Based on staff interviews, record reviews, and review of policies and procedures; the Critical Access Hospital (CAH) failed to initially assess 1 of 3 swing bed patients (Patient 32) to ensure the nutritional needs were met within 7 days as directed by the nutritional screens policy and procedure. Facility census was 3 swingbed patients.

Findings are:

A. Record review on 11/6-7/12 revealed Patient 32 had been in an acute care hospital for the debridement of 4-5 ulcers on right lower extremity on 10/19, 22, 25, 27, and 29. Patient 32 was admitted to CAH on 10/31/12 on a swingbed status for IV antibiotics, dressing changes, diabetes and fluid monitoring. Physical therapy and Occupational therapy to increase strength and mobility. Discharge plan was to return home with home health care, and assistance of spouse. Pertinent diagnoses for Patient 32 consists of 2 plus pitting edema in the lower extremities, infected right lower extremity wound, history of infected hematoma right lower extremity status post multiple debridements with pseudomonas, diabetes mellitus with neuropathy, chronic kidney disease Stage III with calculated creatinine clearance of approximately 39, (normal values for an adult female is 0.5-1.1 mg/dl or 44-97 umol/L (SI units), coronary artery disease, cardiomyopathy with ejection fraction of 20%, status post pacemaker placement, morbid obesity, and chronic venous stasis. Patient 32 also had a Groshong PICC no clamps site, right brachial for IV access, and IV fluids inserted on 10/18/12. Patient's 32 admit weight is 313.5 and on 11/8/12 is 288.7 for a total loss of 24.8 lbs. The medical record for patient 32 lacks documentation if the weight loss is due to water loss or muscle mass.

Diet order is Constant Carbohydrates, and assessed from admitting Registered Nurse (RN-2) as "adequate". Skin integrity assessment upon admission identified the ulceration to right lower extremity to measure 11 CM in length and 6.5 CM in width. There are small abrasions approximately 1 CM in diameter on the lower anterior of the left shin just superior to the ankle and also another of the same size just superior to the ulcer on the right leg.

B. Review of the nutrition screen/dietary policies reads, "Any patient/resident that meets the following criteria will have their nutritional status evaluated by the Designee of CAH/manor/clinic. The Designee shall be the Dietetic Technician, registered or Licensed Medical Nutrition Therapist. The criteria for completion follows > Skilled care for 7 days or more."

C. Interview with the Dietary Manager on 11/6/12 at 4:00 PM revealed the kitchen serves 3 meals a day to the patients in the hospital and long term care (LTC). The CAH provides diets that consist of Cardiac diet, Renal diet, and Constant Carb (carbohydrates). The Constant Carb diet is a regular diet and the only difference from a diabetic diet and constant carb diet is the food portion size. Further interview with the DM revealed the CAH has a Registered Dietitian (RD) that is contracted to the CAH and comes to the CAH once per month, but is available by fax or phone anytime, further acknowledged a formal dietary assessment was not completed for Patient 32 (8 days after admission) and stated; "I just did not do it or get to it. On 10/7/12 the DM did a nutritional assessment. A conversation with the RD found the current diet was not adequate to meet the nutritional requirements for Patient 32. The estimated nutritional needs are 1739 Kcals/d (1.6 BEE based on IBW), 104 g protein/d (08g/kg wt), 3150 cc/d (using formula for obese individuals), and currently on a 1500 cc fluid restriction. The RD acknowledged the diet does not meet the estimated protein an kcal needs. An order was presented to the physician to add an extra ounce of protein at breakfast, 2 extra ounces of protein at lunch and supper, and a multivitamin with minerals to help with healing. The physician acknowledged and approved the RD request on 11/7/12.

D. Interview on 11/7/12 at 10:30 AM with Patient 32 revealed that "sometimes the food is good and other times not so good--and I can't eat it--the other day (could not remember the date) I got a spicy piece of chicken-I ate 2 bites and got sick-so they gave me a hotdog-I couldn't eat that either."






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