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Based on policy and procedure review, observation, interview and quality assurance reports, it was determined the facility failed to follow its policy and procedure in that there was no mechanism to store breast milk. Failure to ensure the facility provided a means to store breast milk had the potential to deter patients from breast feeding. The failed practice had the potential to affect any patient who desired to breast feed. Findings follow:

A. Review of the policy and procedure titled "Breast Milk Collection, Storage and Administration," received from the Obstetrics (OB) Manager at 2:55 PM on 09/13/18 showed breast milk was to be stored in refrigerators designated "For Breast Milk Only" in the main compartments of the refrigerator, at recommended temperatures of 39 degrees Fahrenheit, upon patient request.
B. Observation of the Nursery and the Medical/Surgical Unit at 3:00 PM on 09/10/18 showed no refrigerator or other means to store breast milk.
C. During an interview with the Chief Nursing Officer at 3:00 PM on 09/10/18 the findings in A and B were verified.
D. Review of the Labor and Delivery/Nursery Quality Assurance reports, received on 09/10/18 showed in July 2018 there were two breast fed babies, in June 2018 there was one breast/bottle fed baby, in April 2018 there was one breast/bottle fed baby, and in March 2018 there was one breast fed baby.

Based on review of United States Pharmacopeia Chapter 797, 2008 and interview, the facility failed to follow professional acceptable standards in that they did not have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for one of one (Director of Pharmacy) personnel trained to compound medications in the Compounding Aseptic Isolator (CAI) per United States Pharmacopeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the CAI. Findings follow:

A. Review of United States Pharmacopeia Chapter 797, 2008 showed that compounding personnel should be monitored for successful completion of gloved fingertip sampling and media-fill testing, annually.
B. During an interview on 9/19/18 at 10:10 AM, the Director of Pharmacy verified the facility did not have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for personnel trained to compound medications.

Based on review of policy, Medication Variance Report, review of clinical records and interview, it was determined the facility failed to have policies and procedures to maintain accurate records in that one of one (#1) incident of medications given to a wrong patient was not documented in the chart of the patient that received the medication in error. By not documenting the medications the patient received, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Review of facility policy titled, "Errors: Drug Administration," showed the only documentation will be a Medication Error Report, which is not part of the patient's medical record. It also showed reports to the practioner responsible for the patient or personnel who treat the patient will be verbal.
A. Review of Medication Variance Report showed that on 12/30/17 in the AM, Patient #23 received the following medications in error:
1) Lisinopril 20 mg (milligram);
2) Tikosyn 500 mg;
3) Lasix 40 mg;
4) Eliquis 5 mg;
5) Potassium 20 mEq (milliequivalent);
6) Carvedilol 12.5 mg; and
7) Digoxin 0.25 mg
B. Review of clinical record for Patient #23 showed no evidence of the medications they received in error.
C. During an interview on 09/12/18 at 10:57 AM, the Chief Nursing Officer verified there was no evidence in Patient #23's clinical record indicating they received the medications that were not prescribed for them.

Based on observation and interview, it was determined the facility failed to prevent and control infections for isolation precautions in that isolation bins were not set-up at the entrance/exit into one (Room #223) of two Isolation (Room #220 and #223) Rooms. Failure to ensure the bins were located next to the exit did not ensure staff were protected by gowns and gloves all the way to exit of the room. The failed practice had the potential to affect all patients, staff, and visitors on the Medical/Surgical Unit on 09/13/18. Findings follow:

A. Observation of the Isolation set-up at 9:30 AM on 09/13/18 in Room #223 for C-diff (Clostridium difficile) precautions showed two red bins underneath the wall-mounted television, which was halfway of one wall, and not at the entrance to the room.
B. During an interview with the Infection Control Nurse at 10:15 AM on 09/13/18, she stated that the red bins should be as close to the door as possible and not as far into the room as the ones in Room #223 were.


Based on policy and procedure review, manufacturer's instructions for use, observations and interview, it was determined the facility failed to prevent and control infections in that it failed to ensure laryngoscope blades in three of three Intubation Boxes (Emergency Room (ED) Adult Intubation Box, Pediatric Intubation Box and the Nursery Intubation Box) utilized by the Respiratory Therapy (RT) Department were pre-cleaned prior to high level disinfection per policy and manufacturer's instructions. Failure to ensure laryngoscope blades were pre-cleaned did not ensure the laryngoscope blades were effectively disinfected during the high level cleaning process and had the potential to allow for cross contamination between patients. The failed practice had the potential to affect all patients whose care required the use of the laryngoscope blades utilized by the RT department. Findings follow:

A. Review of the policy and procedure titled "Cleaning Laryngoscope Blades and Handles" showed dirty laryngoscope blades were to be transported in a biohazard bag to the cleaning/sterilization room located in the OR (Operating Room) Department. The blades were to be removed from the handles and scrubbed with soapy water and a brush to remove residue. The blades were then to be rinsed in clean tap water and dried. Pre-cleaned blades were then to be placed in Cidex OPA and allowed to soak for at least 12 minutes.
B. Record review of the WelchAllyn Laryngoscope Blade manufacturer's instructions for use showed:
1) The manual cleaning process of:
a) Immerse all components in a neutral ph enzymatic cleaning solution as directed by solution manufacturer's instructions.
b) While components are immersed in the cleaning solution, use a soft-bristled brush to clean all component surfaces (blade, retaining screw, and fiber optic light carrier) until all visible contamination is removed.
c) Thoroughly rinse all components in one of the following: potable filtered water, softened water, or per cleaning solution manufacturer instructions, or per facility instructions to remove cleaning solution.
d) After cleaning, dry all components with a clean cloth or allow to air dry.
e) After cleaning, choose either cold solution high level disinfection method or one of four sterilization methods.
2) The Cold solution high level disinfection instructions showed:
a) Select a neutral ph ortho-phthalahyde (OPA) or glutaraldehyde disinfectant.
b) Prepare disinfecting solutions per disinfectant solution manufacturer instructions.
c) Disassemble the blade and immerse all components in disinfectant solution for the time duration specified by the disinfectant manufacturer to achieve high level disinfection.
d) Thoroughly rinse all components in one of the following: potable water, softened water, deionized water, or high purity water or per disinfectant solution manufacturer instructions.
e) After cleaning, dry all components with a clean cloth or allow to air dry.
f) Reassemble the blade assembly.
g) Package the clean and disinfected blade assembly per facility practice for return to service. Store packaged blade assembly per facility practice to allow device to remain clean, dry, and ready for service.
C. During an interview on 09/10/18 at 1:12 PM the RT Manager stated that all laryngoscope blades were soaked in Cidex OPA for 10 minutes and then rinsed.
D. During an interview on 09/12/18 at 2:27 PM the RT Manager stated that the laryngoscope blades were wiped off if visible soiling present but were not pre-soaked in an enzymatic cleaner. Laryngoscope blades were not stored packaged to prevent re-contamination.
E. During an interview on 09/12/18 at 2:51 PM the Operating Room/Central Sterile Manager stated that the laryngoscope blades were to be cleaned and soaked in the Medline Duel Enzymatic cleaner, rinsed and then dried prior to high level disinfection. The solution of Cidex OPA was to be tested (for the MEC) prior to the cleaned and dried laryngoscope blades being placed in the solution.
F. During an interview with the RT Manager on 09/12/18 at 2:53 PM she verified (in the presence of the Operating Room/Central Sterile Manager and Surveyor #1 and Surveyor #2) that the laryngoscope blades were not being pre-cleaned according to manufacturer's instructions.


Based on observation and interview, it was determined the facility failed to identify and control the spread of infections in that only clean, unopened and currently dated supplies were available for patient care use in four of four patient care units (Emergency Department (ED), Operating Room (OR), Nursery and Medical Surgical Unit). The failed practice had the potential for cross contamination in that it was not certain that the dirty equipment and opened packages were clean and ready for patient use; and the integrity of the packaging and the efficacy of the expired supplies could not be assured. The failed practice had the potential to affect any patient whose care required the use of laryngoscopes, any ED patient requiring the use of catheters and suctions, any OB patient requiring the use of the uterine contraction monitor, and any nursery patient requiring the use of laryngoscopes. Findings follow:

A. Observation of the ED Supply Cart at 1:10 PM on 09/10/18 showed:
1) Three of 4 8 French catheters expired 08/18,
2) Three of 10 French catheters expired 10/16,
3) One of 12 Argyle Yankauer suction tip expired 5/17 and
4) Two of 12 Argyle Yankauer suction tips expired 2/18.
B. During an interview with the Chief Executive Officer (CEO) at 1:10 PM on 09/10/18, the findings in A were verified during the observation.
C. Observation in ED Room A at 1:05 PM on 09/10/18, showed 2 of 2 Yankauer suction tip package label showed the tips were sterile, RX (prescription) only and single use. Observation of the Yankauer packages showed they were opened and could not be determined to be sterile. During an interview with the ED Manager at 1:05 PM on 09/10/18 the above findings were verified.
C. Observation in one of one ED Trauma Room at 1:19 PM on 09/10/18 showed the following in the Adult Intubation Box:
1) Four of four laryngoscope blades were stored unpackaged and not protected from potential contamination.
2) One of two 7.5 mm (millimeter) cuffed Oral/Nasal Tracheal Tube with the package open, syringe and stylet attached.
3) One of three 7.0 mm cuffed tracheal tube with the package open. Review of the Oral/Nasal Tracheal Tube package showed it was sterile, by RX only, single use and do not use if the package was open. The cuffed tracheal tube package stated the contents were sterile unless opened or damaged and to discard after single use.
D. During an interview with the RT Department Manager at 1:19 PM on 09/10/18, the findings in C were verified.
E.. Observation in one of one ED Trauma Room at 1:23 PM on 09/10/18 showed the following in the Pediatric Intubation Box:
1) Four of four laryngoscope blades which were stored unpackaged and not protected from potential contamination.
2) Two of two 5.5 mm cuffed tracheal tubes with the packages opened.
3) One of two Yankauer suction tip opened and available for use.
F. During an interview with the RT Department Manager at 1:23 PM on 09/10/18, the findings in E were verified.
G. Observation of the Endoscopy Room anesthesia cart at 1:28 PM on 09/10/18 showed one of one Ambu Mask, size 5, lying on the anesthesia cart which could not be determined to be clean or dirty. During an interview with the CEO (Chief Executive Officer) at 1:28 PM on 09/10/18, the findings in G were verified.
H. Observation of the Endoscopy Room at 1:35 PM on 09/10/18 showed the anesthesia cart had four of four unpackaged 10 ml (milliliter) syringes lying on the bottom shelf of the anesthesia cart and one of one CO2 (carbon dioxide) indicator opened. It could not be determined if the syringes or the CO2 indicator was clean or dirty. During an interview with the Operating Room/Central Sterile Manager at 1:35 PM on 09/10/18 the findings in H were verified.
I. Observation in the OR at 1:57 PM on 09/10/18 showed one endotracheal tube opened and lying on the anesthesia cart, and one of one CO2 indicator opened and connected to the Anesthesia machine. It could not be determined if both were clean and dirty. During an interview with Certified Registered Nurse Anesthetist #1 at 1:57 PM on 09/10/18, the findings I were verified.
J. Observation in the OR at 2:10 PM on 09/10/18 showed:
1) Five laryngoscope blades lying unpackaged and unprotected from contamination in the first white plastic bin which also contained one AA battery.
2) Four nasal trumpets lying unpackaged and unprotected from contamination in a second white plastic bin.
3) Five laryngoscope blades lying unpackaged and unprotected from contamination in a third white plastic bin.
4) Four fiber optic blades unpackaged and unprotected from contamination in a fourth white plastic bin which also contained one laryngoscope handle.
K. During an interview with the CNO at 2:10 PM on 09/10/18, the findings J were verified.
L. Observation in Room 214 at 2:50 PM on 09/10/18 showed the surface of two of two uterine contraction monitors had multiple brown and gray stains on them. During an interview with the CNO at 2:50 PM on 09/10/18, the findings in L were verified.
M. Observation in the Nursery at 2:55 PM on 09/10/18 showed one of one Pediatric Ambu CO2 Detector expired 5/17 and three of three laryngoscope blades unpackaged and unprotected from contamination lying in the bottom of a tackle box marked as the Nursery Intubation Kit. During an interview with the CNO at 2:55 PM on 09/10/18, the findings in M were verified.


Based on policy and procedure review, observations and interview, it was determined the facility failed to follow its policy and procedure in that the Operating Room (OR) staff were wearing their scrubs from home into the facility and wearing them during surgical procedures. Failure to follow the facility policy and procedure had the potential to allow contamination of the operative suite and area. The failed practice had the potential to affect Patient #22 on 09/11/18. Findings follow:

A. Review of the policy and procedure titled, "Surgical Attire," received from the Operating Room/Central Sterile Manager on 09/10/18, showed all surgical team members who entered the semi-restricted or restricted areas were to be attired in scrub clothing. The policy and procedure stated street clothes were to be removed and stored in designated locker rooms to protect operating room environment from microorganisms inherent in the general public and hospital environment.
B. Review of the OR schedule posted on the white board showed a Cesarean Section was performed on 09/11/18. During an interview with the Operating Room/Central Sterile Manager at 1:30 PM on 09/11/18, she stated she and the scrub technician wore their scrubs from home and into the OR for the surgical procedure performed on Patient #22.


Based on observations and interview, it was determined the facility failed to ensure the Operating Room (OR) table stirrups were free of rips and tears, and failed to remove dead bug traps in the Endoscopy Equipment Room. Failure to ensure the stirrups were not ripped or torn did not assure the stirrups could be cleaned and sanitized to prevent cross contamination; and failure to remove dead bug traps did not provide for a clean and sanitary area in which to store linen and equipment used in the Endoscopy Room. The failed practice affected any patient whose care required the use of the OR stirrups and the use of the equipment and linen stored in the Endoscopy Room Equipment Room. Findings follow:

A. Observation in the Endoscopy Equipment Room showed a vermin trap with multiple dead grasshoppers stuck to it. During an interview at 1:40 PM on 09/10/18 with the Operating Room/Central Sterile Manager, she stated that the Endoscopy Room had an influx of grasshoppers during the recent farming activities in the fields adjacent to the hospital. The Operating Room/Central Sterile Manager stated that she placed the traps there to catch them.
B. Observation in the Operating Room showed two padded foot stirrups, both with rips on the right and left sides of each pad. Observation of one stirrup showed purple thread along the rip on one side which did not completely close the rip. During an interview with the Operating Room/Central Sterile Manager at 1:52 PM on 09/10/18, the findings in B were verified.


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Based on observation, review of policy and interview, it was determined the facility failed to mitigate the risk of health-care associated infections in that they did not identify the practice of utilizing one of one (8+ [plus] gallon) large sharps container that was filled past the "full line" in the Emergency Department Trauma room, which created an unsafe work environment. By not changing those containers out when they reach capacity, there was a risk a healthcare worker could dispose a sharp item and get punctured by a used needle, cut by a scalpel blade or cut by broken glass in the process, exposing them to blood borne pathogens. The failed practice had the likelihood to affect all healthcare workers who worked in the Emergency Department. Findings follow:

A. Record review of the facility's policy titled, "Hazardous Waste," revised 12/2016, showed sharps containers were to be closed and locked when they were filled to the "full line" and taken to the dirty utility room.
B. During a tour of the Emergency Department on 09/10/18 at 1:20 PM, observation showed a large sharps container that was filled past the "full line."
C. During the observation, Registered Nurse #1 verified the large sharps container in use was filled beyond the "full line."

Based on policy and procedure review, clinical record review and interviews, it was determined the facility failed to perform nutritional assessments on seven of seven (#6-12) inpatients and one (#20) of two (#20 and #21) Swing-Bed patients to identify their nutritional needs. Failure to perform nutritional assessments did not ensure the facility was aware of each patient's nutritional risk to determine their need for nutritional care and monitoring. The failed practice had the potential to affect Patients #6-12 and Patient #20. Findings follow:

A. Review of the policy and procedure titled, "Nutritional Screening," received from the Dietary Manager at 10:45 AM on 09/14/18, showed the nurse admitting the patient was to collect patient information and document the Nutritional Screening Risk Factors.
B. During an interview with the Chief Nursing Officer (CNO) at 9:00 AM on 09/14/18, she stated that the nutritional assessments were performed by the Dietary Manager.
C. During an interview with the Dietary Manager at 9:50 AM on 09/14/18, she stated that she performed the Nutritional Screenings, and any patient who scored 4-7 points she checked back on in 7 days; 8-14 points she checked back on in 3 days; and 15 or above the dietitian was consulted.
D. Review of the clinical records of Patients #6-12 and Patient #20 did not show any evidence of nutritional assessments. During an interview at 10:35 AM on 09/14/18, the Dietary Manager verified the findings for Patient #6-#12 and #20.
E. During an interview with the CNO and the Dietary Manager at 11:15 AM on 09/14/18, the CNO stated that the policy and procedure could not be followed due to the Nutritional Screening Risk Factors mentioned in the policy and procedure were not built into the electronic medical record.

Based on review of policy and procedure, nursing certifications, nursing schedules and interview, it was determined competency in CPR (Cardio-Pulmonary Resuscitation) and PALS (Pediatric Advanced Life Support) certifications were not maintained as required by job description in that one (#2) of three Licensed Practical Nurses (LPN) did not have current CPR certification; one (#1) of three (#1-3) LPNs did not have current PALS certification; and two Registered Nurses (RN) #2 and #3) of nine (#1-9) RNs did not have current PALS certification. Failure to ensure nurses maintained current CPR and PALS certification did not ensure staff were competent in life saving measures. The failed practice had the potential to affect any patient whose care required emergency lifesaving efforts. Findings follow:

A. Review of the policy and procedure titled, "CPR Competency," received from the Chief Nursing Officer (CNO) at 10:30 AM on 09/13/18, showed all nursing personnel would have demonstrated competence in CPR at least every two years.
B. Upon request for Licensed Practical Nurse (LPN) #2's CPR certification, review of a CPR Roster presented by the CNO, showed LPN #2 attended a CPR course from 5:00 PM to 7:00 PM on 09/10/18. Review of the nursing schedules, received from the CNO on 09/10/18, dated 08/26/18 to 09/08/18 showed LPN #2 was scheduled to work 08/27/18 through 08/31/18 and 09/03/18 through 09/07/18. During an interview at 10:15 AM on 09/14/18, the CNO stated that LPN #2 worked in the clinic and did have the potential to work in other areas of the facility.
C. Review of the Med/Surg/ED (Medical/Surgical/Emergency Department) LPN job description, received from the CNO at 11:15 AM on 09/10/18, showed PALS certification was required or must obtain within 12 months. Review of LPN #1's PALS certification showed it expired 03/18. During an interview with the CNO at 11:00 AM on 09/14/18, she provided the date of hire for LPN #1 as 06/28/09. Review of the nursing schedules, received from the CNO on 09/10/18, dated 08/26/19 to 09/08/18 showed LPN was scheduled to work 08/26/18, 08/29/18, 08/30/18, 09/01/8 through 09/04/18 and 09/07/18.
D. Review of the OR (Operating Room) Circulating Nurse Job description, received from the CNO at 11:15 AM on 09/10/18, showed PALS certification was required. Review of Registered Nurse (RN) #2's certification showed no PALS certification. Review of the nursing schedules, received from the CNO on 09/10/18, dated 08/26/19 to 09/08/18 showed RN #2 was scheduled to work 08/27/18, 08/29/18, 08/30/18, 08/31/18, 09/04/18 through 09/07/18.
E. Review of the Med/Surg/ED job description, received from the CNO at 11:15 AM on 09/10/18, showed PALS certification was required or must obtain within 12 months. Review of RN #3 certification showed no PALS certification. During an interview with the CNO at 11:00 AM on 09/14/18, she provided the date of hire for RN #3 as 03/23/16. Review of the nursing schedules, received from the CNO on 09/10/18, dated 08/26/19 to 09/08/18 showed RN #3 was scheduled to work 08/27/18, 08/28/18, 08/31/18 through 09/02/18 and 09/05/18 and 09/06/18.

Based on clinical record review, Arkansas Rules and Regulations for Critical Access Hospitals 2016 and interview, it was determined the facility failed to ensure the acute care history and physical utilized as the Swing-Bed history and physical was updated to reflect the reasons for admission to the Swing-Bed Program, treatments provided during the acute care stay, family history, and the present illness with date of onset. The failed practice did not allow other practitioners to be knowledgeable and informed of the patient's past and current medical status in the event the patient's physician was not available. The failed practice had the potential to affect Patient #20 and #21. Findings follow:

A. Review of the Arkansas Rules and Regulations for Critical Access Hospitals 2016 showed a history and physical shall contain the following information: family history and review of systems, past medical history, chief complaint, present illness with date of onset, the physical examination, and provisional or admitting diagnosis.
B. During an interview at 11:20 AM on 09/14/18, the Case Manager stated that the acute care hospital history and physical and/or the acute care discharge summary was utilized as the Swing-Bed history and physical. The Case Manager also stated that Patient #20 and Patient #21 came in through the Emergency Department (ED) and the history and physical generated via the ED medical record was different than the admission history and physical.
B. Review of the clinical record of Patient #20 showed an ED history and physical dated 08/17/18 (the acute care history and physical) that did not contain a family history, present illness with date of onset, the reason for admission to Swing-Bed and treatments provided in the acute stay. During an interview at 11:20 AM on 09/14/18, the Case Manager verified the findings for Patient #20.
C. Review of the clinical record of Patient #21 showed an ED history and physical dated 08/17/18 (the acute care history and physical) that did not contain a present illness with date of onset, the reason for admission to Swing-Bed and treatments provided in the acute stay. During an interview at 11:20 AM on 09/14/18, the Case Manager verified the findings for Patient #21.

Based on review of medical staff bylaws, operating room surgery privileges folder and interview, it was determined the facility failed to ensure the Operating Room staff had access to current surgical privileges for three (Physicians #1, #2 and #3) of four (Physicians #1-4) physicians. Failure to ensure the operating room had access to current surgical privileges did not ensure the operating room staff was aware of what procedures the surgeons were credentialed and approved to perform. The failed practice had the potential to affect all patients whose surgical procedures were performed by Physician's #1-#3. Findings follow:

A. Review of the medical staff bylaws, received on 09/10/18, showed all clinical privileges were not for a period of more than two years.
B. Review of the folder containing the surgical privileges, received from the Operating Room/Central Sterile Manager at 2:00 PM on 09/10/18, showed Physician #1's surgical privileges were dated 11/12/13.
C. Review of the folder containing the surgical privileges, received from the Operating Room/Central Sterile Manager at 2:00 PM on 09/10/18, showed two untitled pages, one signed by Physician #2, and one signed by Physician #3. Neither page contained any marks indicating any of the procedures on the pages were approved. Also in the folder were two surgical procedures with marks next to surgical procedures and neither of the pages contained the names of a surgeon, so it could not be determined which page belonged to which surgeon. Neither of the pages were dated.
D. Review of the Operating Room Log showed Physician #1 performed eight procedures from 08/14/18 to 09/07/18; Physician #2 performed seven procedures from 08/17/18 to 09/04/18; and Physician #3 performed three procedures from 08/10/18 to 09/07/18.

Based on clinical record review and interview, it was determined the facility failed to provide separate physical therapy and activities for two of two (#20 and #21) Swing-Bed patients. Failure to ensure the physical therapy and the activities were offered at separate times did not ensure the patient was able focus on the physical therapy and achieve the maximum benefit. The failed practice affected Patient #20 and #21. Findings follow:

A. Review of the clinical record for Swing-Bed Patient #20 showed activities were performed concurrently with physical therapy for two of two (08/23/18 and 08/24/18) therapy sessions, by Physical Therapist Assistant (PTA) #2 at 9:48 AM on 08/23/18, and again by PTA #1 at 12:47 PM on 08/24/18.
B. Review of the clinical record for Swing-Bed Patient #21 showed activities were performed concurrently with physical therapy for four (08/23/18, 08/24/18, 08/29/18 and 08/30/18) of five (08/23/18, 08/24/18, 08/27/18, 08/29/18 and 08/30/18) days by PTA #2 at 9:53 AM on 08/23/18, by PTA #1 at 12:42 PM on 08/24/18, by PTA #2 at 4:18 PM on 08/29/18 and by PTA #2 at 11:17 AM on 08/30/18.