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Based on record review and interview the CAH (Critical Access Hospital) failed to ensure that inpatients and outpatients received a notice stating that the CAH does not have a MD (Doctor of Medicine) or a DO (Doctor of Osteopathy) present in the CAH 24 hours per day, 7 days per week and failed the obtain a signed acknowledgement from patients stating that the patient understood that a MD or a DO may not be present during all hours services are furnished to the patients.

Findings:
A review of the policy titled, "Criteria and Process Plan: Admission Folder Packets", provided by administration as a current admission packet, revealed in part: At first contact, the Admissions Personnel will begin obtaining signatures on conditions of admissions/consent to treat. The Admissions Personnel will create admission folders and ensure the appropriate documents are signed and given to the patient: Advance Directives, Patient Rights, Notice of Privacy practices, Patient Complaint and Grievance Process, and Visitation Policy. There was no documented evidence in the Admissions Process policy that the patient (inpatient/outpatient) would receive a notice stating the CAH did not have a MD or a DO present in the CAH 24 hours per day, 7 days per week.

During a review of the medical records for Patient #11- Patient #15, the medical record revealed no documented evidence that the patients signed an acknowledgement stating that the patient understood that a MD or a DO may not be present during all hours services are furnished to them.

In an interview on 07/05/22 at 2:45 p.m. Staff B indicated that it was not the protocol for the CAH or the Admissions Personnel to present a notice to the patients (inpatients/outpatients) or to obtain a signed acknowledgement from the patients stating that the patient understood that a MD or a DO may not be present during all hours services are furnished to them. Staff B indicated she was not aware of that CAH requirement.

Based on record review and interview the CAH failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient's nursing care needs and not solely those needs related to the admitting diagnosis for 5 of 5 (Patient #11- #15) current inpatients reviewed for nursing care plans.

Findings:
A review of the hospital policy titled, "Care Plans", provided by administration as a current policy, revealed in part: The care plan for each patient will be individualized to the patient's needs.

A review of Patient #11 medical record revealed in part: Patient #11 was admitted to the hospital on 06/27/22 by Staff J with a diagnosis of postoperative left total knee arthroplasty. A review of the patient's medical history revealed the patient also had a present history of malnutrition, diabetes, hypertension, congestive heart failure, and gastric reflux. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans for falls, impaired mobility, toileting, and discharge planning. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs for malnutrition, pain, diabetes, hypertension, congestive heart failure, and gastric reflux.

A review of Patient #12 medical record revealed in part: Patient #12 was admitted to the hospital on 06/29/22 by Staff J with a diagnosis of left shoulder and hip pain. A review of the patient's medical history revealed the patient also had a present history of pneumonia, alcohol abuse, deep vein thrombosis, cholecystitis, and hypertension. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans for falls, impaired mobility, decreased breathing pattern, and discharge planning. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs for alcohol abuse, pain, deep vein thrombosis, cholecystitis, and hypertension.

A review of Patient #13 medical record revealed in part: Patient #13 was admitted to the hospital on 06/29/22 by Staff J with a diagnosis of pneumonia. A review of the patient's medical history revealed the patient also had a present history of hypothyroidism, obesity, seizure disorder, congestive heart failure, dysphagia, and diabetes. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans for impaired resilience, falls, impaired skin integrity, decreased airway clearance, and discharge planning. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs for hypothyroidism, obesity, seizure disorder, congestive heart failure, dysphagia, and diabetes.

A review of Patient #14 medical record revealed in part: Patient #14 was admitted to the hospital on 06/29/22 by Staff J with a diagnosis of patella fracture and dehydration. A review of the patient's medical history revealed the patient also had a present history of hypertension, atrial fibrillation, gastric reflux, and arthritis. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans for falls, activity intolerance, and acute pain. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs for hypertension, atrial fibrillation, fluid and electrolytes, and gastric reflux.

A review of Patient #15 medical record revealed in part: Patient #15 was admitted to the hospital on 06/23/22 by Staff J with a diagnosis for sepsis, altered mental status, pneumonia, and respiratory acidosis. A review of the patient's medical history revealed the patient also had a present history of chronic obstructive pulmonary disease, joint pain, falls, burns, and laceration. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans for impaired skin integrity, gas exchange, and discharge planning. A further review of the nursing care plan revealed no documented evidence that the patient's care plan goals and treatments had nursing care needs for joint pain, infection, falls, and altered mental status.

In an interview on 07/05/22 at 3:45 p.m. Staff E indicated that the nurses developed the patient's care plans based on the admitting diagnoses and the care plans were not based on any current diagnoses.

Based on observation, record review, and interview the CAH failed to ensure a functional and sanitary environment according to acceptable professional standards of practice relating to infection control as evidenced by observation of infection control breaches.

Findings:

Observations on 07/05/22 from 9:30 a.m. to 3:00 p.m. revealed the following infection control breaches:
a) Shower A and Shower B had anti-grip material on the grab bars and on the shower floors that were in disrepair and visibly peeling, potentially harboring pathogens and preventing effective disinfection.
b) The patient Equipment Storage Room, containing cleaned patient care equipment, was overcrowded with equipment preventing the Storage Room door from adequately closing; disrupting the planned airflow within the room and potentially transferring unwanted particles from the floor and from the outside main hallway into the clean storage room.
c) The Nutrition Room's ice machine had sediment on the grates preventing effective cleaning. The patient's freezer in the Nutrition Room contained a large plastic drink cup where the cup was tilted on the shelf and the drink contents had spilled out and froze on the bottom of the freezer shelf.
d) An observation of Staff G entering a patient room without sanitizer her hands first. The sign outside the patient room indicated the patient was on "Contact Precautions". Staff G was also observed not donning the appropriate PPE (personal protective equipment) prior to entering the patient's room.
e) A blue taped line was noted to be present down the patient hallway where the blue tape on the floor was visibly worn and peeling up in several places, potentially harboring pathogens and preventing effective disinfection of the hallway floor.
f) The nurse's station had 3 (three) arm chairs present where the padded arm rests were wrapped with coban and where the coban wraps were visibly dirty and worn, potentially harboring pathogens and preventing effective disinfection.
g) In interviews with staff (Staff B, F, G, K, L) on the use of the EPA (environmental protection agency) disinfectant used by the hospital for disinfecting patient care equipment, the staff did not know or understand the definition of the EPA's "contact time". The staff indicated they frequently disinfected patient care equipment with the EPA disinfectant wipes during the day.
h) An observation of the Central Supply storage room, containing sterile/clean supplies, revealed over 50 boxes, to include loading dock boxes, stored on the floor. The observation also revealed many stored items were not 18 inches from the ceiling in the sprinkled room.


CDC (Centers for Disease Control and Prevention) Guideline for Disinfection and Sterilization in Healthcare Facilities revealed in part: Medical equipment and patient care equipment can become contaminated with infectious agents and contribute to the spread of health-care-associated infections. For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low or intermediate-level disinfectant. EPA -registered disinfectants have contact times of one to three minutes. By law, users must follow all applicable label instructions for EPA-registered products. Disinfect noncritical medical devices with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. The technique of spraying of disinfectants is an unsatisfactory method of decontaminating air and surfaces and is not recommended for general infection control in routine patient-care areas.

A review of the manufacturer's IFU (instructions for use) for the EPA disinfectant wipes used by the CAH to disinfect reusable patient care equipment revealed in part: Use a clean wipe and thoroughly wet surface. Allow treated surface to remain wet (contact time) for 2 (two) minutes. Let air dry

CDC Guideline for Hand Hygiene in Healthcare Settings revealed in part: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient. Before performing an aseptic task. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.

CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings revealed in part: Hospital personnel should adhere to Contact, Airborne, or Droplet Precaution protocols, as specified by CDC guidelines and adhere to patient door signage for isolation precautions, upon entering a patient room to prevent cross contamination.

CDC Guideline for Environmental Infection Control in Healthcare Settings revealed in part: Items should be removed from external shipping containers and web-edged (ie, corrugated) boxes in a breakout area adjacent to a central supply storage area because dust, debris, and insects may enter the container or boxes during shipment ... Clean and disinfect all refrigerators and ice machines on a routine basis according to the manufacturer IFU. Refrigerators and ice machines become contaminated with use. Sediment on ice machines can prevent effective cleaning ... Remove and replace damaged or re-usable equipment. Regular inspection for visible signs of compromise or wear, such as tears, cracks, pinholes or stains, facilitates prompt replacement and prevention of cross contamination resulting from underlying surface exposure. The CDC does not recommend using patches for tears or holes because the patches do not provide an impermeable surface.

To comply with fire code regulations and reduce the risk of contamination, sterile/clean supplies should be stored at least 18 inches from the ceiling, and at least 2 inches from outside walls. Fire codes specify minimum distances below the ceiling to ensure the effectiveness of sprinkler systems.


In an interview on 07/06/22 at 9:30 a.m. Staff D indicated she was the Infection Control Preventionist for the hospital. She was made aware of the above identified infection control breaches. Staff D indicated that she had previously identified many of the observed infection control breaches in her surveillance rounds and had addressed many of those issues in the past. She further indicated that the hospital followed nationally accepted infection control guidelines.