HospitalInspections.org

.
Based on observation, interview, and review of policy and procedures, the Critical Access Hospital failed to ensure that patient care supplies were not available for patient use beyond the manufacturer's expiration date.
.
Failure to properly maintain supplies places patients at risk for infection and delays in treatment.
.
Findings included:
.
1. Record Review of the Critical Access Hospital's policy titled, "MSU Environment Cleaning Policy and Procedure" Policy #5155947 approved 12/07/17, showed that staff perform monthly outdate checks in the supply room, medication room, crash carts and patient rooms.
.
2. On 08/08/18 at 9:15 AM, Surveyor #9 checked the crash cart located in the Post Anesthesia Care Unit (PACU) and found the following:
.
a. Normal Saline 250 cc, expired 02/18
b. Arterial Blood Sampling Kit, expired 07/18
c. Pro Vent, Expired 07/18
.
3. At the time of the finding, the Chief Nursing Officer (Staff Member #901) confirmed that the items were expired and should have been removed from supplies available for patient care.

.

.
ITEM #1 PREVENTIVE MAINTENANCE PROGRAM

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure medical equipment regardless of whether it is leased or owned, is listed in an inventory, that includes a record of maintenance activities.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk of harm from malfunctioning equipment.

Findings included:

On 07/25/18 between the hours of 9:00 AM to 11:00 AM, Surveyor #1 interviewed the hospital's plant manager (Staff #101) about the hospital's preventive maintenance program. The surveyor asked to see the preventive maintenance history for the following equipment:

a. Omnicycle (Hospital ID # 002920) located in the physical therapy department
b. Sterrad Velocity (Hospital ID # 002928) located in the central sterile department
c. Ultra-Sonic (Hospital ID# 001686) located in the central sterile department

The plant manager was unable to locate any maintenance history for these items and concluded that it was not part of the current facility inventory. She reported that the current inventory did not include all medical equipment.

THIS IS A REPEAT DEFICIENCY - PREVIOUSLY CITED DURING CMS RECERTIFICATION SURVEY IN 2015.

ITEM #2 CLEANING FREQUENCY OF EQUIPMENT

Based on interview and document review, the Critical Access Hospital failed to follow manufacturer's instruction in regards to cleaning frequency of medical equipment in the physical therapy department.

Failure to adhere to manufacturer's instructions for cleaning frequency of medical equipment places patients at risk of infection.

Reference: Chattanooga Hydrocollator User Manual page 19-20 part 6, indicated "Regularly clean and drain the tank (every two weeks)."

Findings included:

1. On 7/26/18 at 10:50 AM, Surveyor #1 interviewed a speech therapist (Staff #102) about their process for cleaning and disinfecting the hydrocollator (a liquid heating device used to heat hot packs for physical therapy). The speech therapist stated that the maintenance staff cleans the hydrocollator monthly but could not provide documentation.

2. On 7/26/18 at 3:30 PM, Surveyor #1 interviewed the hospital's plant manager (Staff #101) in regards to the cleaning frequency of the hydrocollator. The plant manager provided a cleaning log that showed the cleaning frequency completed quarterly. Review of the manufacturer's instructions for cleaning showed that the cleaning frequency was every 2 weeks.
.

.
ITEM #1 - CLEANING PATIENT CARE AREAS

Based on observation and document review, the Critical Access Hospital staff failed to prevent cross contamination of soiled and clean items during cleaning of patient care areas.

Failure to prevent cross contamination during the cleaning processes places patients and staff at risk of infection.

Findings included:

1. Document review of the Critical Access Hospital's policy and procedure titled, "Cleaning Patient Area (Emergency-Department)," Policy #4162147 revised 10/24/17, showed that staff should check walls and spot clean, and wipe down high touch areas.

2. On 07/26/18 between 8:15 AM and 9:30 AM, Surveyor #1 observed environmental services staff (EVS) (Staff #103) performing a terminal clean of an emergency room. During the observation, the surveyor observed the EVS staff wiping down equipment attached to the wall an otoscope and an ophthalmoscope (instruments for inspecting the ears and eyes) with a disinfection solution. After completing this task, he then proceeded to clean the walls with a microfiber mop. During this process, the mop head touched the otoscope and ophthalmoscope thereby contaminating the equipment. The EVS staff did not follow the hospital's policy and procedure to prevent cross contamination of equipment.

.

.
Based on document review, and interview the Critical Access Hospital failed to develop policies and procedures for emergency preparedness specifically for provisions of subsistence needs for ensuring adequate energy sources necessary to maintain temperature (heating and cooling), emergency lighting, fire protection and alarm systems, fire suppression system and sewage and waste disposal.

Failure to provide policies and procedures for subsistence needs places patients and staff at risk of harm due to the hospitals inability to provide for safety and care needs during an emergency event.

Findings included:

On 07/24/18 between the hours of 9:15 AM and 3:30 PM, the fire marshal interviewed and reviewed documentation with the hospital's plant manager (Staff #101). The manager was unable to provide the following policies and procedures as required in CMS regulation:

a. Emergency lighting
b. Heating and cooling
c. Fire detection and alarm systems
d. Fire suppression system
e. Sewage and waste disposal

.