HospitalInspections.org

Based on interview and document review the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water and fuel availability in the event of an emergency. This had the potential to affect all patients, staff and persons who come to the CAH in need of care during emergencies.
Findings include:
Upon review of the facility Utility Emergency Procedures initiated 5/1/07, it was discovered that in the event of a gas emergency the staff were to notify maintenance, the administrator, charge nurse, gas company and fire department. In the event of a water disruption, the staff were to again notify maintenance, the administrator, charge nurse and if unable to fix the problem, notify the city and the emergency water supplier.
Review of the facility Water Supply policy initiated 5/1/07, revealed water was obtained through the city water supply and emergency water was obtained from a private vendor. The policy indicated the emergency vendor would provide a 1500 gallon tank, which would be filled with potable water. Information was lacking which identified whether the 1500 gallons would be sufficient for CAH patients, staff or other persons who come to the CAH in need of care during emergencies. The policy lacked reference to the amount of non-potable water required in the event of loss of water and failed to address a plan in the event of a disruption in supply (e.g. disruption to the entire surrounding community).
During interview on 3/11/15, at approximately 1:30 p.m. maintenance (M)-A identified the facility had enough bottled water on site to last approximately four days during normal use periods. However, M-A was unable to identify whether it would be sufficient in the event of an emergency. Also during the interview, M-A indicated the facility used natural gas and had 4,600 gallons of diesel fuel on site for a backup which would last about three to four days. M-A confirmed there was no documented policy, procedure or arrangement which gave direction for emergency gas and/or disruption in supply.

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K-0018, K-0050, K-0056, K-0067.

Based on interview and document review the Critical Access Hospital (CAH) failed to have an effective quality assurance (QA) program which evaluated on a continuous basis the quality of all patient care services, including the areas of laboratory services, organ. tissue and eye procurement, maintenance and contracted laundry services. This had the potential to affect all present and future patients who receive services at the CAH.

Findings include:

When interviewed on 3/10/15, at 2:15 p.m. the laboratory director confirmed the laboratory department currently did not have any formal QAPI program to evaluate their services. There was not documents available for review.

Interview with the QAPI (Quality Assurance/Performance Improvement) coordinator on 3/11/15, at 11:00 a.m. confirmed the organ, tissue and eye procurement program did not have a formal QAPI program to evaluate their services.

During interview on 3/11/15, at 8:30 a.m. the Director of Maintenance (DM) stated there was no formal document QAPI program which included data, goals, analysis or communication to evaluate their ongoing services.

In addition, during interview on 3/11/15, at 2:00 p.m. the Housekeeping Director (HD) stated laundry services had been a contracted service for approximately two months, however there had been no formal QAPI program implemented to evaluate current services.

Interview with the chief clinical officer (CCO) on 3/11/14 at 2:30 p.m. confirmed the CAH lacked current programs for the identified areas listed above. The CCO indicated that each department was responsible to provide annual QA documentation and had been aware that not all departments currently had a formal QAPI program in place to evaluate the CAH services provided.

Based on interview and document review, the facility failed to ensure 9 of 9 employees who provide direct patient care (E-A, E-B, E-C, E-D, E-E, E-F, E-G, E-H, E-I) received training related to the Critical Access Hospital (CAH) organ, tissue and eye procurement program.

Findings include:

On 3/12/15, at 9:30 a.m. employee (E-A, E-B, E-C, E-D, E-E, E-F, E-G, E-H, E-I) records were review with human resources (HR)-A for compliance with organ, tissue and eye procurement education requirements. Nine nursing employee records lacked documentation of education related to the CAH organ, tissue and eye procurement program.

Interview on 3/12/15, at 10:00 a.m. with the chief clinical officer (CCO) who leads the organ procurement program at the CAH, confirmed there was no formal training to employees on orientation or on an an annual basis.

Review of the policy for Organ/Tissue/Eye Donation dated 1/2014, indicated the CAH will work with the OPO (Organ Procurement Organization) and Tissue and Eye banks to provide regularly scheduled staff education programs regarding organ/tissue/eye donation.