HospitalInspections.org

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide a visual mechanism for monitoring the air pressure of the room at one of one (Patient Room 328) airborne infectious isolation room. The failed practice had the likelihood to affect all patients and staff in that an incorrect air pressure of the isolation room would not be detected, allowing an infectious disease to be transmitted through the air going out of the room. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 44:C.7 showed each airborne infection isolation room shall have a permanently installed visual mechanism for monitoring the pressure status of the room when occupied by patients with an airborne infectious disease.

B. Observation of Patient Room 328 on 9/20/22 at 10:00 AM showed the room was an airborne infection isolation room and was not provided with any mechanism for monitoring the pressure of the room while occupied. This finding was verified with the Facilities Manager at the time of observation.

Based on review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines review of policy and procedure, observation, and interview, it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to provide evidence of screening of visitors, patients, and personnel for signs and symptoms of COVID-19. The failed practice did not allow for tracking of visitors for signs and symptoms of COVID-19 and had the likelihood to affect all patients, staff, and visitors. Findings included:

A. Review of the current CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance updated 02/02/22 showed the following:
The facility should establish a process to identify anyone entering the facility regardless of their vaccination status.
B. Review of the CDC COVID-19 Interim Infection Prevention and Control Recommendations Management of Visitors to Healthcare Facilities in the Context of COVID-19, updated Sept. 15, 2020, provided by the facility showed the following:
1. Facilities should designate an entrance that visitors can use to access the healthcare facility.
2.Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms.
3. Signage should include signs and symptoms of COVID-19 and who to notify if visitors have symptoms.
C. Review of Policy on 09/19/22, titled "COVID-19 Visitation Policy" revised 09/10/22, showed upon entry, all visitors and patient will be directed to the Care AI kiosk for symptom screening and to obtain a visitor sticker.
D. Observation upon entering the facility on 09/19/22 through 09/20/22, showed the following:
1. On 09/19/22 through 09/20/22, upon entering the facility, there was no evidence of signage designating the location for visitor to be screened for signs and symptoms of COVID-19. screening.
2. On 09/19/22, upon entering the facility, Surveyors #1-#3 were not screened for signs and symptoms of COVID-19.
3. On 09/19/22 two of two visitors stated they had not been screened for signs and symptoms of COVID-19.
4. On 09/20/22, upon entering the facility, Surveyors #1-#4 were not screened for signs and symptoms of COVID-19.
E. During the interview on 09/20/22 at 10:15 AM the Infection Preventionist (IP), the following was stated:
1. Surveyor #2 asked, What were the processes being followed for the process for screening visitors for signs and symptoms of COVID-19, IP stated, "CHI Morrilton follows the CDC guidelines for screening visitors for signs and symptoms of COVID-19."
2. Surveyor #2 asked, What was the process for screening visitors for signs and symptoms of COVID-19, IP stated, "Visitors were to use the Care AI kiosk at the front desk, but it has not been functioning correctly since 05/10/22."
3. Surveyor #2 asked, What was the process for screening visitors for signs and symptoms of COVID-19 when the Care AI kiosk is not functioning properly, IP stated, "There has not been implementation of alternate methods for screening for COVID-19."
F.Findings in A-E were confirmed on During the interview on 09/20/22 at 12:15 PM with the IP, the findings were confirmed for A-E.


Based on interview and observation, it was determined that Procedure Room with one of one oxygen extension tubing was not being changed after each patient use. Failure to provide new oxygen extension tubing to each patient did not follow manufacture's instruction for use as a single-use item and had the potential to allow contaminated equipment used on multiple patients. The failed practice had the potential to affect all patients who required oxygen during a procedure. Findings follow:

A. Review of manufacturer's packaging showed the oxygen extension tubing was for single patient use.
B. Observation of Procedure Room, in the Surgical Suite, on 09/21/22 at 10:00 AM showed one of one opened oxygen tubing extension set connected to the oxygen regulator on the wall and extended around a mobile vital sign monitor handle.
C. During an interview on 09/21/22 at 10:11 AM, Registered Nurse (RN) #3 stated that RNs connect the same extension tubing to each patient's nasal canula tubing. Surveyor #2 asked how often the extension tubing was changed for new extension tubing, RN #3 stated, "it is cleaned between each patient and replaced at the end of each day."
D. On 09/21/22 at 10:45 AM, Surveyor #2 confirmed the oxygen tubing extension set packaging stated single-use and should be discarded after each use with the Infection Preventionist (IP).
E. Findings A-C were confirmed on 09/21/22 at 10:45 AM with the Infection Preventionist.

Based on policy review, clinical record review, and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the plan of care (POC) for 5 of 5 Swing Bed patients (Patient #18- #22). The failed practice had the potential to effect continuity of care within the IDT and had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:
A. Review of policy titled, " Comprehensive Care Plans-Swing Bed-Morrilton," date d 09/20/20, showed:
1) IDT were to develop and implement a comprehensive person-centered care plan on each patient with measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
2) IDT included the attending physician, Registered Nurse (RN) responsible for the patient, nurse aide (NA), Nutrition services, professional staff identified from the comprehensive assessment, and patient or patient representative.
3) The POC was to be revised after each assessment including both the comprehensive and quarterly review assessments.
B. Findings in A were confirmed on 09/21/22 at 10:45 AM with the Market Director Quality.
C. Review of clinical record of Patient #18 on 09/21/22, admitted 08/20/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT revised the patient's plan of care after the assessments.
3) Findings in C 1-2 were confimed on 09/21/22 at 12:45 PM with the Market Director Quality.
D. Review of clinical record of Patient #19 on 09/21/22, admitted 03/28/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT revised the patient's plan of care after the assessments.
3) Findings in D 1-2 were confimed on 09/21/22 at 1:15 PM with the Market Director Quality.
E. Review of clinical record of Patient #20 on 09/21/22, admitted 08/25/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT revised the patient's plan of care after the assessments.
3) Findings in E 1-2 were confimed on 09/21/22 at 1:45 PM with the Market Director Quality.
F. Review of clinical record of Patient #21 on 09/22/22, admitted 08/16/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT revised the patient's plan of care after the assessments.
3) Findings in F 1-2 were confirmed on 09/22/22 at 8:45 AM with the Market Director Quality.
G Review of clinical record of Patient #22 on 09/22/22, admitted 07/14/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT revised the patient's plan of care after the assessments.
3) Findings in G 1-2 were confimed on 09/22/22 at 9:15 AM with the Market Director Quality.