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Based on observation, policy review and staff interview the Critical Access Hospital (CAH) failed to provide for the safety of patients and staff by not maintaining the hot water temperatures in the building at acceptable levels (less than 120 degrees) and by not storing six compressed gas cylinders in the proper manner.

Failure to ensure hot water temperatures were in the safe range according to the CAH policy and to secure the compressed gas cylinders according to the CAH policy has the potential to cause harm to patients and staff.


Findings include:


1. Water temperatures at the sink in patient rooms 103 and 111 exceeded the safe temperature range of at or below 120 degrees.

2. CAH staff left Nitrous oxide (a gas used to put patients to sleep during a surgery or procedure) cylinders and a carbon dioxide cylinder unsecured.


Refer to C-0222 for further details.

Based on observation, policy review and staff interview the Critical Access Hospital (CAH) failed to provide for the safety of patients and staff by allowing water temperatures to be above 120 degrees in two of two patient rooms tested (#103 and #117) and by storing six compressed gas cylinders improperly (5 in the storage area and 1 in the Operating Room area). This deficient practice has the potential to cause harm to patients and staff.

Findings include:

- Observations during tour of the facility with staff N maintenance administrative staff on 7/18/17 between 11:00am to 1:55pm revealed a room where the two hot water tanks that provide hot water to the building were housed. Review of the "WATER HEATER TEMPERATURE LOG" dated July 2017. On July 11, 2017 they increased the water temperature in the tanks from 120 degrees to 140 degrees. A note in the comment section read, "Changed set point to 140 degrees Fahrenheit (F) per staff P (laboratory director)." Review of the temperature logs from 7/11/17 to 7/18/17 revealed the water temperature for both tanks read 140 degrees F.

-Observation in the patient rooms revealed a small yellow sign attached to the mirror above the sink that read, "Caution very hot water". Observation of patient room 117 revealed the hot water coming out of the tap read 129 degrees F and in patient room 103 the hot water coming out of the tap read 128 F degrees.

Staff N explained on 7/18/17 at 11:20am the hot water temperatures in the tanks should be set at 120 degrees F. It was explained the hot water temperatures need to be turned down to 120 degrees F and staff and patients need to be told not to use the hot water until maintenance notifies them they can use it again.

Staff T Administrative staff interviewed on 7/18/17 at 12:20pm explained the CAH received the mandate from CMS (Center for Medicare and Medicaid Services) to have in place a plan to decrease the potential of a Legionaire's disease outbreak and have been working on the plan and the CAH increased the temperatures in the hot water tanks to assure no growth of the Legionaire's bacteria.

Staff N explained on 7/18/17 at 12:40pm they tested the temperatures in the patient rooms at the hot water coming from the tap read 109 degrees F.

- Observation in room 104 on 7/18/17 at 12:55pm revealed the hot water coming out of the tap read 109.8 degrees F.

- The CAH's policy titled "Water Heater Temperatures" on 7/18/17 at 2:00pm directed, " ...the water heaters that supply the patient rooms are designed to maintain a temperature at or below 120 degrees F.



- Observation in the compressed gas storage area on 7/17/17 at 1:50pm revealed five large cylinders containing the gas nitrous oxide (a gas used to put patients so sleep during surgery or a procedure) unsecured.

Staff M, administrative staff interviewed on 7/17/17 at 1:50pm acknowledged the unsecured cylinders and explained they must be secured all times.


- Observation in the operating room area on 7/18/17 at 10:20am revealed a small cylinder containing the gas carbon dioxide (used in anesthesia during a surgical procedure) in a closet unsecured.

Staff L Administrative staff interviewed on 7/18/17 at 10:20am acknowledged the unsecured tanks are to be secured at all times.

- The CAH's policy titled "Compressed Gas Cylinders Safety Policy" reviewed on 7/20/17 at 1:40pm directed " ...cylinders may be attached individually to a wall, and or placed in a rack or carrier. Chains or study straps must be used to secure the cylinder."

Based on document review and interview the Critical Access Hospital (CAH) failed to provide requirements for membership admission to the hospital medical staff and failed to outline the CAH admitting privileges in the Medical Staff Bylaws. Failure of the CAH to have Medical Staff Bylaws that systematically regulate and oversee Medical Staff places all patients at risk for receiving insufficient, inadequate, and unsafe medical care.

Findings include:

- Medical Staff Bylaw Rules and Regulations reviewed 7/19/2017 at 1:30 pm revealed no guidelines evident for credentialing of medical staff.

- Bylaws of Stevens County Hospital Board of Directors reviewed 7/19/2017 at 12:00 pm directed in part: " ....7.01 The Board of Directors shall consider the recommendation of the Medical Staff and appoint to the Medical Staff, in numbers not exceeding the Hospital's needs, physicians and dentists whom in the opinion of the Board meet the qualifications for membership as set forth in the Bylaws of the Medical Staff ..."

CEO Staff T interviewed 7/19/2017 at 9:00 am confirmed the Medical Staff Bylaws do not contain statements regarding medical staff credentialing or re-credentialing. S/he stated new Medical Staff Bylaws are being developed but are not ready for review by the Medical Staff or Governing Board yet.

Based on observation, documentation review and staff interview the Critical Access Hospital (CAH) failed to provide the following in accordance with acceptable standards of practice and protection of the health and safety of patients: an annual review of their policies, an infection control program that minimizes the risk of transmitting infections and communicable diseases; management of outdated medications; management of expired supplies; hand hygiene; managment of outdated food items, failed to monitor and document daily temperatures of the physical therapy paraffin bath and hydrocullator and (7) failed to ensure outdated medications were made unavailable for patient consumption (Refer to tag C0276) . The cumulative effect of these deficient practices placed all patients at risk of unsafe, inadequate patient care, infection, contraction of communicable diseases, food poisoning, burns, and consumption of ineffective medications.


Findings include:

1. The CAH failed to have a group of professionals conduct an annual review of all patient care policies (Refer to C-0272).

2. The CAH failed to ensure outdated medications were not available for use (Refer to C-0276).

3. The CAH failed to maintain an infection control program that mimizes the risk of transmitting infections and communicable diseases (Refer to C-0278).

Based on record review, staff interview, and policy review, the Critical Access Hospital (CAH) failed to document performance of annual review of all CAH patient care policies by the Medical Staff. The deficient practice can lead to the delivery of unsafe, inappropriate care to all patients receiving services at the CAH.

Findings include:

- Review of the Medical Staff 2016 and 2017 meeting minutes revealed lack of documentation of annual policy review with medical staff approval for all patient care policies.

- Review of the Medical Staff Bylaws on 7/18/2017 at 4:00 pm revealed no evidence of an annual policy review as part of the Medical Staff bylaws. Medical Staff Bylaws directed in part: "Medical Staff meetings will be held monthly as set forth in the Medical Staff Bylaws of Stevens County Hospital ... ...The following designated areas will be discussed as deemed both necessary and appropriate: Surgical cases ... ...Mortality review ... ...Transfusions ... ...Risk Management ... ...Infection Control ... ...Pharmacy and Therapeutics ... ...Utilization Review ... ..."

- Review of the Governing Board Bylaws on 7/18/2017 at 3:45 pm directed in part: " ...The Medical Staff shall seek to improve the quality of medical practice in the Hospital and shall act in an advisory capacity to the Board. In the professional care of patients, individuals of the Medical Staff shall have full authority, subject only to the policies stated by the Board and the rules and regulations of the Hospital ..."

- Review of the "2016 Evaluation of Total Critical Access Hospital Program" revealed "...All policies are reviewed with nursing staff prior to implementation. The Director of Nursing reviews and revised policies annually and as needed. In 2016, 15 policies and procedures were updated and revised ... ...The Laboratory Director added, reviewed and updated seven policies and procedures ... ...Human Resources reviewed and updated two policies ... ...Health Information Management Department (HIM) updated the following polices ... ...Physical Therapy updated 5 policies ..."

CEO Staff T interviewed on 7/19/17 at 9:00 am acknowledged the Medical Staff does not perform an annual review of patient care policies. The Medical Staff review only those policies that have been revised and are brought the Medical Staff Meetings for approval. S/he stated the facility does not have a formal policy committee.

No policy was provided directing the annual review of policies by a group of professional personnel.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure outdated, unusable medications are unavailable for patient use in one of two Emergency (ED) Department rooms, one of one Nursing Station Medication rooms, one of one observed fluid warming cabinet, and one of one radiology storage closet. The deficient practice of failure by the CAH to remove outdated medications places all patients at risk for receiving ineffective medications resulting in unsafe care.

Findings include:

- Observation of the Emergency Department (ED) East Patient Room Cabinets on 7/17/2017 at 3:45 pm revealed the following outdated medications and medications opened without a labeled expiration date.

-1, Package Levalbuterol Inhalation Solution 0.63mg (milligrams)/3ml (milliliter)(bronchodilator used to treat asthma and chronic obstructive pulmonary disease (COPD), with an expiration date of 4/2017.
-1, Bottle Eye Stream Eye Wash 1 ounce, opened, no expiration date noted.
-1, Pour bottle Sterile Water, 1000ml, opened 6/2017, no expiration date noted
-1, Pour bottle 0.9% Sodium Chloride, 1000ml, opened 7/9, no expiration date noted


- Observation of the ED West Patient Room Cabinets on 7/17/2017 at 4:15 pm revealed the following medications opened without labeled expiration date.

-1, Albuterol 0.5% multi dose dropper bottle, open 1/24/17, no expiration date noted
- Observation in radiology on 7/18/17 at 3:20pm revealed a storage closet with seven- 450 ml (milliliters) bottles of "Redi Cat" (a liquid barium sulfate suspension) (used to coat the esophagus, stomach, and small intestine, when performing a Computerized Tomography (CT) scan) with an expiration date of 4/17.

Staff DD Administrative staff, radiology interviewed on 7/18/17 at 3:20pm confirmed the expired "Redi Cat" bottles.

Policy "Emergency Crash Cart/Defibrillator Checks, and Outdates of Medication and Supplies" policy for all departments, directed in part: " ...Medication and supply outdates must be checked the last week of every month by Pharmacy or an RN/LPN in the crash carts, ambulance box, and all other appropriate areas. The date the medication/supplies are checked shall be documented on the crash cart log and on the Outdates Monthly Log Sheet kept in the nursing lounge."

Policy "Unusable and Outdated Drugs" directed in part: " ...All expired/outdated drugs, contaminated drugs, defective drugs, improperly stored drugs, and drugs in containers with worn, illegible or missing labels shall be returned to Pharmacy for proper disposal ..."

The CAH lacked a policy related to the labeling and disposal of multi-dose medication containers that staff opened.
Centers for Disease Control and Prevention (CDC) Basic Infection Control and Prevention Plan revealed: " ...Medications should always be discarded according to the manufacture's expiration date (even if not opened) ..."


- Observation of the Nursing Station Medication Room on 7/18/2017 at 8:30 revealed the following medications in a clear plastic cup labeled "Billie Crane":

-5, Ondansetron 4mg tabs, outdated 1/17. The tablets lacked labeling identifying patient name, date, medication, dose, frequency of administration, and pharmacist identification.
-1, Imitrex nasal spray, 20mg outdated 3/18. The spray lacked labeling identifying patient name, medication, date, dose, frequency of administration, and pharmacist identification.


- Observation of the Nursing Station Medication Room on 7/18/2017 at 8:40 am revealed the following medication in Patient Bin #16:

-1, 1 bottle Miralax, 4.5 ounces. The bottle lacked labeling identifying patient name, date, medication, dose, frequency of administration, and pharmacist identification.

RN Staff S interviewed on 7/18/2017 at 8:30 am acknowledged the medications and stated they were home medications left by the patient. RN Staff S further stated the CAH policy is to send medications left by patients to the pharmacy after dismissal. RN Staff S was confirmed the medications lacked patient identification label and stated un-assurance how long the medications had been in the nursing unit medication room.

DON RN Staff A interviewed on 7/18/2017 confirmed home patient medications are to go to the pharmacy after if left by the patient at dismissal. DON RN Staff A confirmed all patient home medications brought to the CAH are to be reviewed and labeled by the pharmacy with the patient name, date, medication, dose, frequency of administration, and pharmacist identification. S/he acknowledged the Pharmacy and Therapeutics (P & T) committee is currently addressing home medications.

Policy "Patient Home/Own Medications" directed in part: "...In the interest of safe patient care and quality, all medications brought in by the patient are required to be identified by a professional staff. A new label will be applied to the medication with the following information included: 1) Name, strength, dosage, form of the medication, 2) Direction of the original medication, 3) NDC, 4) Patient Name, 5) Date of identification, 6)Name/initial of the person identifying the medication ..."


- Observation of a fluid warming cabinet on 7/18/17 at 8:20am revealed the warming cabinet contained two 1000ml plastic pour bottles of sterile water for irrigation (the bottles started to bulge) with a date of 6/5 on them, five intravenous (IV) bags of Lactated Ringers (an IV solution use for fluid replacement in the body) with a date on it of 8/4/17, and five IV bags of 9% sodium Chloride (an IV salt solution for fluid replacement in the body) with a date on it of 8/4/17.

Staff A, Administrative staff interviewed on 7/18/17 at 8:20am explained the fluids are kept in the fluid warmer for a month "per protocol" and replaced at the end of that month. Staff A explained they were unaware of the manufacturer's guidelines for the proper storage if fluids in the warmer.

- The CAH's policy titled "FLUID/BLANKET WARMER" reviewed on 7/19/17 at 9:00am directed " ...all solutions will be checked for outdates on the last week of the month and then replaced with new IV solution ...at the end of the month when the fluids are replaced, each bag/bottle of fluid will have the date the fluid is to be replaced written on it."

- "Icumedical connections" manufacturer's guidelines reviewed on 7/19/17 at 9:00am directed " ...solutions for injection may be warmed at a temperature not to exceed 40 degrees Celsius (C) (104 degrees Fahrenheit) and for a period no longer than two weeks (14 days) ...solutions for irrigation may be warmed at a temperature not to exceed 40 degrees C (104 degrees F) and for a period no longer than two weeks (14 days)."

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to: (1) ensure outdated, unusable medical supplies are unavailable for patient use in two of two Emergency (ED) Department rooms, one of one Nursing Station Medication rooms, two of three crash carts (Nursing Station Crash Cart and ED East Crash Cart), one of one surgical room and one of one procedure room, (2) perform daily temperature checks of the paraffin bath (melted wax) and hydrocullator(thermostatically controlled water bath for placing cloth heating pads) in physical therapy, (3) ensure staff performed appropriate hand hygiene (Staff K), and (4) failed to remove outdated food from one of one patient nourishment room and (5) date open food packages in one of three kitchen freezers. These deficient practices placed all patients at risk of unsafe, inadequate patient care, infection, contraction of communicable diseases, and consumption of ineffective medications, burns and food poisoning.

Findings include:

- Observation of the ED East Room on 7/17/2017 at 2:40 pm revealed the following outdated supplies:

-13, Vaseline gauze 3 x 9, outdated 6/2017
-1, Clave Connector, outdated 5/2016
-4, Betadine Swab sticks, outdated 12/2016
-2, Adult Colorimetric CO2 Detector (detects the amount of carbon dioxide), outdated 11/2016
-4, Adult Colorimeteric CO2 Detector, outdated 7/2016
-2, Thoracentesis trays, 8Fr (needle inserted into the chest wall to remove fluid), outdated 2/28/2017
-2, Triple Lumen CVC insertion line tray (intravenous access in the central circulatory system), outdated 6/30/2017
-1, Ophthalmic Foreign Body Magnet, outdated 4/12/2017
-1, Bottle 70% Alcohol, 16 ounce, no open date, no expiration date
-1, Bottle Betadine Solution, 8 ounces, no open date, no expiration date


- Observation in the West ED room on 7/17/2017 at 3:00 pm revealed the following outdated supplies:

-9, Vaseline gauze 3 x 9 dressing, outdated 6/2017
-1, Open 5cc syringe in IV Start Tray rendering it unsterile


- Observation in the West ED room on 7/17/17 at 5:00pm revealed the following outdate supplies:

1-20 cc (cubic centimeter) syringe with an expiration date of 4/13
2-20cc syringes with an expiration date of 1/15
5-20cc syringes with an expiration date of 1/16
1-60cc syringe with an expiration date of 8/2010
4-packages of steri-strips (a tape to close wounds) 1/8 inch x 3 inches with an expiration date of 4/17
2-packages of steri-strips ¼ inch x 1and ½ inch with an expiration date of 4/17
2-bottle of Iodofrom packing strips (a gauze with antibacterial solution in it for placing in infected wounds) ¼ inch x 5 yards with an expiration date of 1/16

DON RN Staff A on 7/17/17 at 5:00pm confirmed the outdated supplies.

- Observation of "Emergency Room Outdate Checks for January through June, 2017," directed in part: "Medication/supply outdates are to be done the last week of each month. Please date and initial the blank line when medication/supply sources have been checked/restocked."



- Observation of the Nursing Station Crash Cart 7/17/2017 at 2:30 pm revealed the following outdated supplies:

-1, Yankauer (oral suction) tip expired 5/2017


- Observation of the Emergency Department (ED) East Crash Cart revealed the following outdated supplies:

-2, Suretrace Adult ECG Electrode (records the electrical activity of the heart, outdated 1/2017
-1, Portex tracheal tube 7.0mm (airway inserted into the windpipe), outdated 2/2017
-1, Epi pen (hormone used to treat airway constriction), opened and ready to use



- Observation of the Nursing Station Med Room on 7/18/2017 at 8:30 am revealed the following outdated supplies:

-1, EDTA 3.0cc lab tube, outdated 4/17
-10, Eclipse Needle, 21g, outdated 4/1
-27 packages 0.27 ounces each of lubricating deodorant for ostomies (a surgically created opening between the intestines and abdominal wall) with an expiration date of 5/17
-6 packages of a skin barrier for ostomies with an expiration date of 5/17

- Observation of "Med/Surg Outdate Checks for January through June, 2017", directed in part: "Medication/supply outdates are to be done the last week of each month. Please date and initial the blank line when medication/supply sources has been checked/restocked."

DON RN Staff A and RN Staff S on 7/18/17 at 8:30am confirmed the outdated medical supplies.

Policy "Emergency Crash Cart/Defibrillator Checks, and Outdates of Medication and Supplies" policy for all departments, directed in part: "...Medication and supply outdates must be checked the last week of every month by Pharmacy or an RN/LPN in the crash carts, ambulance box, and all other appropriate areas. The date the medication/supplies are checked shall be documented on the crash cart log and on the Outdates Monthly Log Sheet kept in the nursing lounge."


- Observation of the surgical suite on 7/18/2017 at 9:45 am revealed the following outdated medical supplies:
Surgical Room Supplies:

-3, Needle Counters, outdated 10/2007
-2, 7 ½ size sterile gloves, outdated 1/2017
-1, 7 ½ size sterile gloves, outdated 5/2017
-1, Adson Brown tweezers, outdated 2/19/2017
-1, McIvor Blades (tongue blade), outdated 2/19/2017
-1, Tongue Blade, outdated 2/19/2017
-2, Adenotome Blade (surgical instrument), outdated 2/18/2016
-2, Cotton Ball, outdated 2/2015
-1, Paper Patch, outdated 1/4/2015
-2, Myringotomy Knife (surgical instrument used in ear surgery), outdated 1/4/2015
-1, McIvor Mouth Gag Blade, outdated 2/26/2017
-1, Pilar Retractor (surgical instrument), outdated 2/2602017
-1, Adenoid (soft tissue located behind the nasal cavity) Curette, outdated 2/2015
-1, Adenoid curette, outdated 2/2016
-1, Tongue Blade, outdated 2/20/2015
-1, Adenoid Instruments, outdated 2/9/2015


- Observation of the Surgical Procedure Room on 7/18/2017 at 10:00 am revealed the following outdated medical supplies:

-2, Disposable varices injector (surgical instrument), 5Fr, 23g, outdated 5/08
-1, Spray bottle fecal odor eliminator Code 4T, outdated 4/17

Surgical RN Staff L confirmed the outdated medical supplies.

- Observation of the anesthesia cart in the operating room on 7/18/17 at 10:00am revealed the following expired medical supplies:
1-package of a gastric tube with a radiopaque strip (a tube inserted into the stomach to suction out the stomach that can be seen with x-ray) with an expiration date of 5/13
1-package of a gastric tube with a radiopaque strip with an expiration date of 12/16
2-packages of a gastric tube with radiopaque strip with an expiration date of 4/13
5-opened (not in the package) 60cc syringes rendering them unsterile
1-box of 25 needles (25 gauge in size) with an expiration date of 6/13

Staff L, Registered Nurse (RN) administrative staff interviewed in the operating room on 7/18/17 confirmed the expired supplies in the anesthesia cart.



Policy review on 7/18/2017 revealed the CAH failed to develop a policy regarding outdated surgical supplies.

- Observation in the mammography room in the radiology department on 7/18/17 at 4:10pm revealed two open packages of germicidal disposable wipes with an expiration date of 4/15.

Staff DD, director of radiology interviewed in the mammography room confirmed the expired germicidal disposable wipes.

- Observation of the Physical Therapy (PT) Department on 7/19/2017 at 2:00 pm revealed the presence of a hydrocullator for moist heat and a paraffin wax bath. No temperature logs were available for review.

PT Director Staff F interviewed on 7/19/2017 at 2:30 pm confirmed that daily temperature checks were not logged on either the hydrocullator or the paraffin bath. PT Director Staff F stated they check the temperatures daily, but do not document the temperatures.

Physical Therapy Quality Assurance Calendar reviewed 7/19/2017 revealed they cleaned the paraffin bath and hydrocullator in March and June. The PT department lacked a temperature log.


- Observation of the Kitchen on 7/18/17 at 2:10 pm revealed the following unlabeled food:

-Freezer #1, multiple bags of open vegetables, unlabeled with open /expiration date
Dietary Manager Staff O interviewed 7/18/2017 confirmed the unlabeled frozen vegetables and stated there has been difficulty finding a way to label them because "tape will not stay affixed to the frozen bags."


- Observation of the Nursing Station Nourishment Room on 7/17/2017 at 2:30 pm revealed the following outdated food products:

-1, open 8 ounce can Similac Advance (baby formula), outdated 1/1/2016. No documentation of opening or expiration date.
-13, 0.25 ounce packets of Beneprotein (protein supplement), outdated 8/24/16
-4, Bread slices in plastic bag dated 3/31/17, outdated 5/30/17, not individually wrapped, packaged by dietary
-3, Cranberry juice, 4 ounce containers, outdated 6/29/17
-Unknown number of sliced cheese in plastic bag dated 6/28/17, outdate 7/2017, not individually wrapped, packaged by dietary

Dietary Staff R acknowledged and removed the outdated food.

Document titled "Refrigerator and Freezer Storage Chart" did not provide guidelines for food products that do not contain meat or fish.

Review of The Kansas Food Handlers Code 3-202.15 directed in part "refrigerated, READY-TO-EAT, processed food POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) open and prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the hold cold time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) ingredient or a portion of a refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient."


- Observation in patient room 103 on 7/17/17 at 3:15pm revealed staff K, laboratory technician entered the patient's room placed the tray that contained supplies to perform the drawing of patient's blood for testing on the patient's bedside table. Staff K needing different supplies picked up the tray took it back to the laboratory and set it on a cart without cleaning the tray. Staff K picked up another tray from the laboratory and took it to room 103. Staff K and staff P director of the laboratory performed the blood draw on the patient. Staff K and staff P removed their gloves and exited the patient room without performing hand hygiene.

- Observation in patient room 106 on 7/17/17 at 4:45pm revealed staff K performed a blood draw from the patient, removed gloves and exited the patient's room without performing hand hygiene.

- The Centers for Disease Control (CDC) "Guidelines for Hand Hygiene in Health Care Settings" directed " ...indications for hand hygiene, contact with patient's skin, contact with environmental surfaces in the immediate vicinity of patient's, and after glove removal.

Based on medical record review, staff interview, and policy review the Critical Access Hospital (CAH) failed to document medical staff progress notes and treatment plans throughout the hospital stay for 1 of 2 Intermediate Swing Bed medical records reviewed (Patient #1). Failure of the CAH to perform assessments and ensure oversight of care can result in all patients receiving ineffective, insufficient patient care resulting in poor medical outcomes.

Findings include:

- Medical Record #1 reviewed 7/20/2017 at 8:30 am revealed the patient, 89 years old, was admitted inpatient to the CAH on 11/1/2016 with a diagnosis of essential thrombocytopenia (low platelet count resulting in bleeding) and heart failure. Patient #1 was then moved to swing bed status on 11/4/2016, and finally to intermediate swing bed status for palliative care on 11/23/2016 through 1/16/2017. Medical staff documentation included history and physical written 11/1/2016 and progress notes written 11/1/2016, 11/2/2016, 11/3/2016, a history and physical written 11/4/2016, and progress notes written 11/10/2016, 11/13/2016, 11/14/2016, 11/16/2016, 11/20/2016, and a history and physical written 11/23/2016. No further progress notes were written.

DON Staff A interviewed 7/20/2017 at 8:30 am confirmed the absence of progress notes after 11/23/2016.

Policy "Documentation Requirements" directed in part: " ...Progress notes reflect patient's chronological course in the hospital, any change in patient's condition, and the result of treatment. There must be a progress note daily on Inpatient encounters and at least once a week on Swing bed encounters. Each entry is to be signed, dated, and timed by physician ..."

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to provide a physical environment for the cleaning and decontamination of surgical instruments and endoscopy scopes separate from the clean area of the operating suite and clean supplies and failed to provide a separate room for the recovery of surgical patients. This deficient practice has the potential of cross contamination of clean supplies and aerosols during cleaning and can cause cross contamination and affect all staff and patients entering the surgical suite area.

Findings include:

- Observation of the operating suite area on 7/18/17 at 9:20am revealed a hall way that staff and/or patients can enter from an outside corridor, the procedure room, and the operating room area. In the hall way just outside of the procedure room, there was an area for decontamination and high level disinfecting of the endoscopes. In this area there was a sink for cleaning the endoscopes and an automated reprocessing machine used to disinfect the endoscopes next to the sink that they use to clean the endoscopes. A gray colored hose was lying in the sink that they use to clean the endoscopes that they had attached to the automated reprocessing machine.

Staff L Operating Room, Registered Nurse (RN) interviewed on 7/18/17 9:20am explained the hallway area they clean the endoscopes in, is not closed and they walk the patients from their preoperative room past the area where they clean the scopes and also staff walk back and forth down this hall. Staff L explained they place a red pan in the sink to clean the endoscopes, but the gray hose from the automated reprocessing stays in the sink because it drains the unclean water from the automated reprocessing machine into the sink. Staff L explained they initially wipe off the scope and suction water through the scope in the procedure room, carry the scope to the area were they clean the scope (not in a covered container), clean the scope, put the scope in the automated reprocessing machine, and then hang the scope up in the designated cabinet in the procedure room.

- The Association of perioperative Registered Nurses (AORN) journal May 2016-Volume 103-number 5, "Back to Bases: Flexible Endoscope Processing directed in part " ...Personnel must transport the endoscopes in a closed container or closed transport cart that is leak proof, puncture resistant, and large enough to contain all contents."

- The AORN "guidelines for processing flexible scopes" directed " ...personnel should process flexible endoscopes in an area constructed and designed for that purpose. After precleaning at the point of use, cleaning and processing should occur in a room that is not used for any other purpose and is physically separated from locations where patient care is being performed. Endoscope reprocessing may occur in a single room or two separate rooms. In a one-room design, a minimum of three feet should separate the decontamination area and clean work area. There should be a door that provides access to and from the decontamination area and a separate door that provides access to and from the clean area. There should be a unidirectional workflow from the decontamination area to the clean area and to clean storage in a separate location."


- Observation of the decontamination room in sterile processing on 7/18/17 at 10:20am revealed a room where they clean soiled instruments before the sterilizing process. In the same room directly across from the sinks and counter where they clean instruments stood two shelving units with five shelves in each unit that contained clean supplies for use in the operating room and one shelve contained two sterile packs of suture instruments for the emergency department if needed. The shelving units have a clear plastic curtain which can be lifted up to retrieve the supplies.

Staff L interviewed on 7/18/17 at 10:20am acknowledged the clean supplies are stored in the decontamination room.

- AORN 2011 edition titled "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings" directed " ...The decontamination area should be physically separate from clean areas and include a door ..."


- Observation of the recovery room on 7/18/17 at 9:30am revealed a room with a desk, equipment and supplies used in an office setting. As the patient enters this room directly inside of the door is an area for a surgical cart and on one wall suction equipment and oxygen.

Staff L interviewed on 7/18/17 explained that the room is a recovery room and also their office. When they have a patient in recovery they pull a curtain in front of their desk. Staff L explained that operating staff and other hospital staff have access to their office. The CAH failed to follow the requirement that the postoperative care area or recovery room is a separate area of the CAH and access is limited to authorized personnel.

Failure to ensure an area for cleaning of the endoscopy scopes met the standards of practice, failure to ensure the decontamination area for cleaning of instruments and clean supplies met the standards of practice and failure to provide a separate recovery room has the potential for cross contamination of dirty to clean supplies and clean area of the surgical suite that could affect all patients entering the surgical area as well as staff.

Based on medical record review and policy review the critical access hospital (CAH) failed to perform a post anesthesia follow-up in 2 (Patient #9, Patient #11) of 3 surgical medical records reviewed. Failure to perform post anesthesia evaluation places surgical patients at risk of failure of the medical staff to anticipate and assess for potential complications associated with anesthesia.

Findings include:

- Medical record # 9 reviewed 7/20/2017 at 10:00 pm revealed CRNA Staff AA provided the anesthesia during the procedure. The medical record lacked documentation of post anesthesia assessment immediately prior to dismissal from the CAH.

- Medical record # 11 reviewed 7/20/2017 at 10:300 pm revealed CRNA Staff Z provided the anesthesia during the procedure. The medical record lacked documentation of post anesthesia assessment immediately prior to dismissal from the CAH.

OR RN Staff L interviewed on 7/18/2017 at 9:30 confirmed the patients scheduled for colonoscopy are dismissed immediately after the procedure if there are no complications. "They do not go to recovery."
Policy "Postoperative Anesthesia Care" directed in part: " ...The patient will be transferred from the Operating Room at the completion of the procedure when the anesthetist feels that the patient is stable. The anesthetist and an Operating Room RN will accompany the patient to the Recovery Room. The anesthetist will remain with the patient as long as necessary, to ensure the patient's safety. Post procedure status is assessed on admission to Recovery Room ... ...At least one post anesthetic visit will be recorded, describing the presence or absence of anesthesia related complications ... ...Each post-anesthesia visit will be documented on the anesthesia record or in the progress notes. The date and time of each visit will be specified. When the post-anesthesia visit and documentation cannot be completed by the attending anesthetist because of early patient discharge, the attending physician who discharges the patient will be responsible for meeting the same requirements."
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Based on record review, staff interview, and policy review the Critical Access Hospital (CAH) failed to provide an active infection control program as evidenced by (1) failure to perform continuous infection control surveillance, (2) failure to have an infection control committee with scheduled meetings and established functions, and (3) failure to provide evidence of surveillance results to the quality program. Failure by the CAH to provide an active Infection Control program places all patients and staff at risk of exposure to bacterial, viral, and fungal infections resulting in increased morbidity and mortality.

Findings Include:

- Review of the CAH Infection Control Program on 7/18/2017 at 2:00 pm revealed no evidence of active infection control surveillance.

Infection Control Staff Q interviewed on 7/18/2017 confirmed that the CAH is not conducting active surveillance of staff compliance with infection control. S/he stated "we recently purchased a light to use to tell us if we have any contaminants left after cleaning surfaces. We intend to use it in patient care areas and in surgery but that has not been started yet." Infection Control Staff Q further stated that her/his responsibility for infection control monitoring is retrospective and s/he collects culture results of those cultures "I know about, but not all of the cultures gotten are provided to me. I don't review results with the medical staff. I spend an average of 8 hours a week on infection control and have no formal training. I do try to keep up with Association for Professionals in Infection Control and Epidemiology "APIC" as much as possible."

- Review of the CAH Infection Control Program on 7/18/2017 at 2:00 pm revealed no evidence of infection control committee meeting minutes.

Infection Control Staff Q interviewed on 7/18/2017 acknowledged the CAH does not have an infection control committee.

- Review of the CAH 2016-2017 Quality Program on 7/18/2017 at 2:30 pm revealed an infection control report was completed for the April, May, and June 2016 time frame only.

Infection Control Staff Q interviewed on 7/18/2017 acknowledged s/he has not been performing infection control quality reports.

CEO Staff T interviewed on 7/18/2017 acknowledged the lack of infection control surveillance and data collection.