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Based on observation, interview, and record review, the facility failed to ensure expired medications and supplies in the emergency crash cart were replaced prior to the expiration date. This deficient practice had the potential to affect any emergency room patient requiring the use of these supplies. Findings include:

During an observation on 5/6/24 at 1:43 p.m., the following items were found to be expired in the emergency room crash cart:

- Dopamine 800/500 ml IV bag, expiration 5/1/24
- Intranasal Mucosal Atomization Device, expiration 3/29/24

During an interview on 5/6/24 at 1:58 p.m., staff member C said all emergency medication was located within the emergency crash cart and the pharmacy was responsible for stocking medications within the crash cart. Staff member C said nursing staff were assigned, each shift, to ensure supplies and emergency equipment were available and ready for use.

Review of a facility policy, "Removing Outdated Products," dated 2/26/20, showed:

" ... All drug storage areas of the hospital will be inspected for drugs that are unusable. These areas of inspections shall include emergency carts, automated dispensing machines, Anesthesia drug boxes, and other patient care unit stock areas, if applicable. The nursing staff will remove all unsuitable drugs from each area. ..."

Based on observation, interview, and record review, the facility failed to establish written policies and procedures for establishing strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility to include critical care equipment not managed by an alternative equipment management (AEM) program; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy when not maintained by an AEM program. The accumulative effect of this deficiency had the potential to affect all patients' services with these devices. Findings include:

1. Established Equipment Maintenance Policy and Procedures

A review of the facility's policy and procedure titled Equipment Maintenance, with a review date of 5/16/22, failed to include strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility was established; and failed to include equipment which would not be managed by an AEM program.

During an interview on 5/7/24 at 3:00 p.m., staff member F stated there were no additional policy and procedures established for the periodic maintenance of medical equipment.

2. Periodic Maintenance of Patient-Care Equipment not on AEM

During an observation and interview on 5/6/24 at 1:43 p.m., the portable ventilator located within the emergency department failed to contain a biomedical sticker. Staff member C said the biomedical checks were a contracted service and the company providing the service was responsible for maintaining the biomedical equipment checks.

Review of the facility's Active Equipment list maintained through the facility's established AEM program, showed: Hamilton Medical, Vent Support System, Serial number 1275, was listed on the active equipment list. However, there was no corresponding equipment maintenance ticket for the Hamilton Vent Support System.

During an interview on 5/6/24 at 3:15 p.m., staff member F stated although the ventilator, located in the emergency department, was identified on the facility's active AEM list; the AEM management program did not manage equipment considered "anesthesia" equipment. Staff member F stated since the ventilator in the emergency department was considered "anesthesia" equipment it was not maintained by the AEM program. Staff member F stated he did not have an alternative means in place for the periodic maintenance of such equipment. He stated it was the responsibility of the department heads to ensure that equipment was maintained and working correctly.

Review of the Hamilton - 1 Service Manual, Chapter 6, Preventative Maintenance and Testing, dated 10/26/20, showed, "... Preventative maintenance ensures that the unit is kept in optimal condition and that any defective parts are replaced before they can cause a loss of service. It also ensures that you have the latest software version. You must perform the preventative maintenance schedule:

- after replacing a component;
- once a year or every 5000 operating hours, whichever comes first. ..."

During an interview on 5/7/24 at 9:38 a.m., staff member B stated the department heads run safety checks on the equipment, but they do not ensure the periodic maintenance of the equipment in the departments. Staff member B stated they checked with the Hamilton servicing department for the ventilator in the emergency department, and that ventilator had not had a periodic maintenance in over a year.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for the Provision of Services.

Based on observation, interview, and record review, the facility failed to:

- Develop policies and procedures that reflect goals and processes for the Quality Assurance Performance improvement (QAPI) program; and failed to develop policies and procedures that reflect the services provided and processes in place for the pain management program (See C1006).

- Ensure the facility's established group of professionals reviewed patient care policies for their radiological patient care services biannually (See C1008).

- Establish and implement policy and procedures for following provider ordered diets; and failed to ensure staff followed dietary orders as ordered by the provider (See 1020).

- Develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted on the entrance to the radiology department, identifying a hazardous radiation area (See C1030).

- Ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service providers prior to the implementation of the menu (See C1040).

Based on interview and record review, the facility failed to develop policies and procedures that reflect goals and processes for the Quality Assurance Performance improvement (QAPI) program; and failed to develop policies and procedures that reflect the services provided and processes in place for the pain management program. These deficient practices had the potential to affect patients receiving pain management treatment and all patients receiving care within the facility. Findings include:

1. A request was made on 5/6/24 at 10:11 a.m., for the facility Quality Assurance plan. The documentation was not received by the end of the survey.

During an interview on 5/8/24 at 12:21 p.m., staff member B said he was unable to locate the policies and procedures for the Quality Assurance program for the facility.

2. Review of a facility policy, Interventional Pain Procedures, did not contain an effective date, a revision date, a review date, or an approval by any individual. The policy did not contain patient care requirements, preprocedural requirements, a list of procedures performed, protocols for all procedures performed, patient consents and releases, patient identification procedures, patient scheduling, personnel policies unique to the procedure, housekeeping requirements, and safety practices.

During an interview on 5/8/24 at 11:11 a.m., staff member K said he remembered the board discussing the development of the pain management program but did not remember policies or procedures being discussed with the board.

During an interview on 5/8/24 at 11:49 a.m., staff member C said there was a detailed process that each patient goes through prior to a pain procedure being performed. She was not aware the process was not contained withing the policies and procedures until she provided the surveyor with the policy for pain management.

Based on interview and record review, the facility failed to ensure the facility's established group of professionals reviewed patient care policies for their radiological patient care services biannually. This deficient practice had the potential to affect all patient care services provided by the facility's radiology department. Findings include:

A review of the facility's patient care policy and procedures on 5/8/24, for section, Medical Imaging, showed the following policy and procedures were last reviewed by the facility's Policy Committee on 3/21/22:

- Continuing Education, code number: 11.100,
- Department Cleaning, code number: 11.101,
- Diagnostic Materials, code number: 11.102,
- Radiology Dress Code, code number: 11.103,
- Scope and Services, code number: 11.104,
- Electrical Safety, code number: 11.105,
- Enforcing Standards, code number: 11.106,
- Hours of Operations, code number: 11.107,
- Maintenance, code number: 11.108,
- Portable Exams, code number: 11.109,
- Provider Orders, code number: 11.110,
- Release of Information, code number: 11.111,
- Reports, Confidentiality, Retention, code number: 11.112,
- Operation of Machines, code number: 11.114,
- Trauma CT Scanning, code number: 11.115,
- Radiation Safety of Pregnant Patient, code number: 11.116.

During an interview on 5/7/24 at 10:23 a.m., staff member C stated the facility had a group of professionals who were responsible for reviewing the patient care policy and procedures at least, every two years, or based on a review schedule. Staff member C stated she was not sure why the policy and procedures for the imaging services were not reviewed in the last two years.

Based on observation, interview, and record review, the facility failed to establish and implement policy and procedures for following provider ordered diets; and failed to ensure staff followed dietary orders as ordered by the provider for 1 (#12) of 20 sampled patients. Findings include:

1. A request for the facility's policy and procedure for following provider ordered diets was submitted on 5/8/24 at 4:00 p.m. A policy and procedure was not provided by the end of the survey.

During an interview on 4/8/24 at 4:45 p.m., staff member C stated the facility did not have an established policy and procedure for following diet orders as ordered by the provider.

2. During an observation on 5/8/24 at 9:21 a.m., patient #12 was in his room. There was a tray with food placed next to his bed. The tray was observed to have scrambled eggs on the plate.

Review of patient #12's provider orders showed a full liquid diet was ordered on 4/23/24. A review of the patient's provider orders from, 4/23/24 to 5/8/24, did not show the provider changed the patient's order from a full liquid diet to a regular diet.

During an interview on 5/8/24 at 4:00 p.m., staff member E stated she had observed patient #12 eating a regular diet that morning when she observed the patient eating scrambled eggs for breakfast. Staff member E stated there was not a provider order in the patient's medical record to change the patient's diet from a full liquid diet to a regular diet. Staff member E stated it was the expectation for nursing staff to follow dietary orders as ordered by the provider. Staff member E stated it appeared the nurse put in a meal request for a regular diet instead of the ordered full liquid diet.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted on the entrance to the radiology department, identifying a hazardous radiation area. This deficient practice had the potential to affect all patients and staff utilizing the radiation services. Findings include:

1. On 5/7/24 at 4:00 p.m., a request was made for a policy regarding signage for radiation hazards in the diagnostic imaging department. No policy was provided by the end of the survey.

During an interview on 5/8/24 at 9:00 a.m., staff member C stated she could not find a policy and procedure regarding identifying hazardous radiation areas for the radiology department.

2. During an observation on 5/7/24 at 1:30 p.m., there were no signs showing radiation hazards that included the universal sign for radiation in the diagnostic imaging department for either entrance to the diagnostic imaging department.

During an interview on 5/7/24 at 2:10 p.m., staff member I stated they did not have universal signage posted at either entrance of the diagnostic imaging department to identify potential radiation hazards.

Based on observation, interview and record review, the facility failed to ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service providers, prior to the implementation of the menu. This deficient practice had the potential to affect all patients receiving meal services provided by the facility. Findings include:

During an observation and interview on 5/6/24 at 11:48 a.m., staff member M was observed removing a plastic cover from a plastic disposable bowl, then placing the container and its contents in a microwave oven for reheating. Staff member M said meals were provided for patients from an outside source, and the facility did not have kitchen or dietary staff. Staff member M said the facility lunch meal was provided by the community senior center and the breakfast and dinner meals were provided by the community long-term care facility. Staff member M said meals were delivered to the facility and had lost their warmth, so they were reheated in the microwave prior to serving. Staff member M stated if a patient had special dietary needs, the facility would notify the center and provide the information. The meal would be delivered and noted with the appropriate diet.

During an interview on 5/6/24 at 12:53 p.m., staff member B said he was not sure if the facility contracted dietician approved the menu for the meals provided by the community senior center. Staff member B stated the long-term care facility menus were overseen by the dietitian contracted from another facility and provided oversight for the long-term care facility.

During an interview on 5/7/24 at 10:35 a.m., NF1 said the senior center did not have a dietician to provide oversight of the senior center menu. NF1 said she would use the nurses to help her with what was needed to provide any specialized diets.

During an interview on 5/7/24 at 10:48 a.m., NF2 said the long-term care facility menus were approved by a contracted dietitian that comes to the facility once a month. NF2 said the dietitian was available by phone when staff had questions and was available to the facility for an onsite visit within an hour if needed.

During an interview on 5/8/24 at 12:52 p.m., staff member Z said he did not provide oversight of the senior center or long-term care menus. Staff member Z stated he was contracted to provide nutritional services to the facility swing bed patients. Staff member Z said he provided all services to the facility via zoom and had not physically been to the facility.

During an interview on 5/8/24 at 1:59 p.m., NF3 said the facility had contracted their services to provide nutritional evaluations and management for swing bed patients. No services for menu approvals or oversight were contained in the contract services provided.

Review of a facility document, "Dietitian Services Agreement," signatures dated 1/18/22, showed:

" ... Exibit A, Description of Services

... 5. Assist with changes to, substitutions of, and approval of all regular and therapeutic menus used in the facilities, including annual reviews thereof. "

Based on interview and record review, the facility failed to follow their established policy and procedures for ensuring nursing requirements for Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS) certifications; and failed to ensure nursing staff assigned to work in the emergency department with the potential of administering emergency care services for pediatric and adult patients maintained an active ACLS and PALS certification for 4 (staff members B, Q, R, X) of 16 reviewed staff members. This deficient practice had the potential to affect all adult and pediatric patients in need of emergent advanced life support. Findings include:

A review of the facilities personnel requirements document titled, [Registered Nurse] Job Description, showed,

"The Registered Nurse is responsible for the administration of professional nursing care to all patients in the hospital, including acute care patients, swing bed patients, and patients presenting to the Emergency and Out-Patient departments either personally or by delegation and supervision of supporting nursing personnel. The Registered Nurse works under the direction of the Chief Nursing Officer and practitioners granted privileges by the Board of Directors...

The following is a list of requirements for licensure and certification for the Registered Nurse to maintain to continue working as an employee of Ruby Valley Hospital:

... Maintains a current Advanced Cardiac Life Support (ACLS) certification.
... Is encouraged to obtain certifications in Pediatric Advanced Life Support, Trauma and Advance Trauma Life Support and any other self-motivated certification to expand the registered nurse's knowledge base in rural health care; ..."

During an interview on 5/7/24 at 10:23 a.m., staff member C stated it was the expectation for staff to have ACLS and PALS certifications if working in the emergency department. She stated nursing staff who worked in the emergency department would be expected to have the appropriate qualifications and certifications for addressing emergent patient care situations for both adult and pediatric patients. Staff member C stated there were currently several nursing staff who had expired PALS certifications, and they were scheduled for the full two-day certification course on 6/18/24, instead of the recertification course.

A review of the facility's personnel files on 5/8/24 at 10:49 a.m., showed the following staff did not have PALS certification on file: Staff members Q, R, and X. Staff member B had a PALS certification on file which had expired on 10/31/22.

A review of the facility's personnel files on 5/8/24 at 10:49 a.m., showed staff member R did not have an ACLS certification on file.

A request was submitted on 5/8/24 at 11:00 a.m., to provide additional PALS and ACLS certifications for staff members B, Q, R, and X. This documentation was not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure timely and routine biological spore testing of the autoclave sterilizers used to sterilize patient care instruments; failed to include chemical indicators within sterilization pouches for verification of sterilization process; and failed to establish a process for identifying equipment processed by the autoclave in the event of a sterilizer malfunction, or for tracking of hospital acquire infections. These deficient practices had the potential to affect all patients receiving care withing the facility that required the use of facility sterilized instrumentation. Finding include:

During an observation on 5/6/24 at 1:58 p.m., multiple sterilization pouches containing sterile instruments were inspected within the emergency rooms. All pouches were observed to not contain a sterilization indicator within the instrument pouch. Some of the pouches contained a load number and initials of the individual that performed the sterilization, other pouches contained only initials, and some of the pouches had nothing written on the pouch.

During an interview on 5/7/24 at 1:38 p.m., staff member AA was observed placing clean and dry instruments into the sterilization pouches. Staff member AA then placed the pouches into the autoclave for sterilization. She had not been instructed to place chemical indicator strips into to the pouches for the purpose of sterilization verification. Staff member AA said she will do biological testing on the autoclaves monthly and does not do a biological test with every load. She stated autoclaves were turned off when not in use. Staff member AA said the biological tests take 24 hours to read the results so she did not do a sterilization load the same day the biological tests were performed. Staff member AA said the autoclave would provide a printout of the sterilization cycle and she would print the load number on the instrument package. She stated she did not have a tracking system for the biological testing with the loads she would run. Staff member AA said she was not aware of any tracking of instruments to patient use for infection control monitoring. Staff member AA said she had not been provided any formal education on sterilization practices and recommendations. Staff member AA stated she was trained by the individual previously responsible for the sterilization of facility instruments.

A request was made on 5/7/24 at 2:40 p.m. for instrument cleaning and processing. A policy titled, Reuseable Articles Requiring Sterile Processing, was provided. The policy stated to refer to the guidelines of "Autoclave Procedure". The Autoclave Procedure guidelines were not provided by the end of the survey.

A record review of the "Tuttnauer Operation & Maintenance Manual," for electronic tabletop autoclaves, showed:

" ... 7. Preparation Before Sterilization
...10. Place a sterilization indicator in each tray or inside each wrapped package.
11. At least once a week use a biological spore test (Bacillus Stearothermophilus) in any load to insure proper sterilization. ..."

Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility's Quality Assurance and Performance Improvement (QAPI) Program. This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include:

During an interview on 5/6/24 at 10:30 a.m., staff member B stated the facility's OPO program was not currently included into their QAPI program.

A review of the facility's QAPI meeting minutes showed no documentation for the inclusion of the OPO program.