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Based on observation, interview, and review of the manufacturer's instruction, it was determined that the Critical Access Hospital (CAH) failed to have a prevenative maintenance program that ensured the glucometers, in 1 of 5 inpatient departments, and the hydrocollator in the Outpatient Rehabilitation Department, were maintained in a safe operating condition.

Findings include:

Observation on 8/23/23 at approximately 10:00 a.m. in the Emergency Department (ED) revealed that the StatStrip Glucose Hospital Meter Test Strips and the Nova Statstrip Glucose Control Solutions (Level 1 and Level 3) did not have "opened on" or "discard on" dates labeled for each opened bottle/container.

Interview on 8/23/23 at 10:05 a.m. with Staff B (Registered Nurse) confirmed the above findings. Staff B stated the glucose testing strips and solutions should have been dated with an "opened on" or "discard on" date.

Review on 8/23/23 of the manufacturer's instructions (StatStrip Glucose Hospital Meter Test Strips, Nova Biomedical) for the glucose test strips revealed, under Section 11. Expiration "The expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable when stored as indicated for up to 6 months or until the expiration date, whichever comes first."

Review on 8/23/23 of the manufacturer's instructions (Nova StatStrip Glucose Control Solution, Level 1 and Level 3) for the glucose testing solutions revealed, under Section Expiration, "The expiration date is printed on the control vials. Once opened, the solutions stored as indicated will be stable for up to 3 months or until the expiration date, whichever comes first."


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Observation of the offsite rehabilitation on 8/23/23 revealed a Hydrocollator heating unit located in a corner of the outpatient rehabilitation department. Staff E (Director of Compliance and Risk Management) confirmed this unit was plugged in and identified as being used for patients' hot pack treatments.

Review on 8/23/23 of the Hydrocollator's Temperature and Cleaning Logs for January through April 2023 revealed the hydrocollator was cleaned on the following dates:

January: 1/5/23 and 1/19/23
February: 2/10/23 and 2/24/23
March: 3/3/23
April: 4/6/23 and 4/18/23
May: 5/19/23 and 5/26/23
June: 6/9/23 and 6/26/23
July: 7/7/23 and 7/24/23
August: 8/16/23

Review of the manufacturer's operation manual on 8/23/23 titled "HYDROCOLLATOR, HEATING UNITS" for this machine revealed the following:

"MAINTENANCE, Care, and Cleaning; The Hydrocollator is equipped with an immersion type heating element and hydraulic capillary type thermostat which evenly maintains the HotPac temperature in the water and provides a ready supply of heated packs. It is critical to maintain the water level over the top of the HotPac to avoid damage to the heating element, the stainless steel or the HotPac. Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained and cleaned systematically, at a minimum every two (2) weeks... Do regular cleaning and draining of the tank (every two weeks)...
Cleaning Tips. The interior of the unit should be scoured, usually every two weeks, using a low abrasive bathroom cleaner. Check for low or no chlorine content in your cleaner and make sure that the residue is thoroughly rinsed away with water..."

Interview on 8/23/23 at approximately 12:35 p.m. with Staff D (Director of Rehabilitation) confirmed the above findings.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that records were complete and accurate for 2 of 9 patients admitted to swing bed status (Patient Identifiers are #1 and #18).

Findings include:

Patient #1

Review on 8/25/23 of Patient #1's Electronic Medical Record (EMR) revealed that Patient #1 was directly admitted to the CAH on 8/16/23 as a swing status patient. Further review of Patient #1's EMR revealed no documentation that a consent to treat was completed at admission.

Interview on 8/25/23 at approximately 10:50 a.m. with Staff H (Clinical Nurse Educator) confirmed the above finding.

Interview on 8/25/23 at 1:50 p.m. with Staff I (Director of Case Manager) confirmed that Patient #1 did not have a consent to treat completed until 8/25/23 (9 days after admission). Staff I revealed that it was not clear which staff was responsible for obtaining the consent to treat when a patient was a direct admit to swing status.


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Patient #18

Review on 8/25/23 of Patient #18's EMR revealed that Patient #18 was directly admitted to the CAH on 5/23/23 as a swing status patient. Further review of Patient #18's EMR revealed no documentation that a consent to treat was completed at admission.

Interview on 8/25/23 at 2:00 p.m. with Staff I confirmed that Patient #18 did not have a consent to treat completed upon admission on 5/23/23.

Review on 8/25/23 of the facility's 8/30/22 policy titled "Admission of patient" revealed, " ...2. Patient Access staff will obtain ... Proper consents shall be obtained from the patient (or legal substitute) as required ..."

Based on observation, interview, and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that ultrasound equipment was properly cleaned and disinfected and failed to ensure the separation of patient care devices from storage of food items to prevent the potential transmission of infection.

Findings include:

Observation on 8/23/23 at approximately 10:30 a.m. of the Diagnostic Imaging and Radiology Department revealed two Trophon2 machines used to high-level disinfect ultrasound probes.

Review on 8/23/23 of the Diagnostic Imaging and Radiology department's ultrasound disinfection record titled "Trophon2 High Level Disinfection Log," with entries for the two Trophon2 machines within the department dated from 2/8/2023 through 8/17/2023, revealed that the CAH failed to consistently document the results of chemical indicators to validate high-level disinfection of ultrasound probes when using the Trophon2 machine for 16 out of 91 logged disinfection cycles.

Interview on 8/23/23 at approximately 2:05 p.m. with Staff J (Director of Diagnostic Imaging) and Staff K (Lead Ultrasound Technologist) confirmed the above finding.

Review on 8/23/23 of the user manual for the Trophon2 revealed the following: "Chemical indicator use is required with every HLD [High Level Disinfection] cycle."


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Observation on 8/23/23 at 9:32 a.m. of the Medical/Surgical Unit patient kitchenette revealed the patient access food and beverage freezer contained 3 reusable ice packs on the shelf with food products including ice cream and what appeared to be a porous fabric neck wrap, approximately 20 inches long, filled with hard beads and laying on the bottom of the freezer.

Interview on 8/23/23 at 9:32 a.m. with Staff A (Director of Clinical Services) confirmed the above findings and that the ice packs for patient use are being stored in the freezer used for patient food.

Interview on 8/23/23 at 2:55 p.m. with Staff A confirmed that the above should not be stored in the freezer with food items.