HospitalInspections.org

Based on record review and confirmed by interview, the Critical Access Hospital failed to assure the development of a care plan for one patient (Patient #11) admitted with a skin wound.

Based on record review, Patient #11 was admitted in spring of 2024 with a pressure wound on their coccyx. Although nursing started a wound care regimen, and obtained physician orders for the wound care five days after admission, the patient's care plan was not updated to reflect the wound, wound care interventions, and progress of healing. Based on review of the "Wound Management Protocol" developed by the Nursing Department and reviewed in January 2023, Nursing is responsible to assure that care plans are updated to reflect any alteration in skin integrity. Per interview on 5/7/2024, at 4:35 PM, the Nurse Manager confirmed that nursing staff should have updated the patient's care plan to reflect the wound, interventions, and progress of the wound.

Based on observation, interview, and policy review the CAH failed to ensure the methods for preventing and controlling the transmission of infections are followed related to the cleaning/disinfecting of re-useable tourniquets after blood is drawn for lab testing. Findings include:

During a tour on 5/6/24 at 3:20 PM of the room in which blood is drawn in the lab, a re-useable tourniquet was found on the top of a cart with the blood drawing supplies. The Lab Director stated that the patients preferred these types of tourniquets because they didn't pinch skin and stated, "We've had these for years." When the surveyor asked the Lab Director how this tourniquet was cleaned, S/he stated that it was wiped down with a bleach-type wipe that was used throughout the hospital for cleaning re-useable equipment.

Per review of the packet insert for the tourniquet, the manufacturer's directions for cleaning and disinfection states the following: "Cleaning: Do not apply mechanical cleaning processes. Wash the product with commercial washing agents that are gentle on fabrics at up to 60 degrees Centigrade (hand wash). Disinfection: We recommend disinfection with a liquid disinfectant (e.g. CIDEX OPA solution) ...Place the tourniquet in a container (non-metallic), cover it completely with the solution and leave it in the solution for at least 5 minutes. After the contact time rinse it with plenty of fresh water (at least 3 rinsing rounds of at least 1 minute) and let it dry afterwards. Do not use chlorine-based release agents or aromatic hydrocarbons."

During an interview on 5/6/24 at 3:30 PM with the Lab Director and the Director of Quality/Infection Control, they confirmed that the staff were not cleaning/disinfecting the tourniquets per the manufacturer's recommendations and should be.

Per review of the policy "Cleaning Reusable Equipment"-reviewed 2/13/23, it states, "Policy: In accordance with existing infection control policies and procedures, GCFHH G will implement and maintain processes to ensure all reusable patient care equipment is routinely cleaned before reuse ...Procedure: 2. Use a hospital-grade disinfectant per manufacturer's recommendations. Dwell and drying times vary, see disinfectant info sheet".

Based on record review and confirmed by interview, the Critical Access Hospital failed to conduct a full-scale exercise within its annual cycle for 2023.

Based on review of the facility's Incident Command System (ICS) meeting notes, the Critical Access Hospital enacted their emergency plan in March of 2020. Further review of the ICS minutes confirmed that the ICS was disbanded in 2022. On 5/7/2024, the Director of Inpatient Nursing, who is also in charge of Emergency Planning, confirmed that the hospital did not participate in a full scale exercise in 2023.