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Based on observation and interview the hospital failed to ensure instruments and supplies necessary for patient care and life support were not expired in the patient care areas.

These failures had the potential for all patients receiving care in the hospital to be exposed to instruments and supplies that were beyond the manufacturer's use by date (expired), to result in a hospital acquired infectious process and an unnecessary prolonged hospitalization. (Refer to C-278)

Findings:

a) During an observation on April 29, 2019 at 2:15 PM, in the Emergency Department, a cart designated as "OB (Obstetrics) Cart" (a cart containing specialty supplies and equipment), contained the following items:

1) Three (3) Urine Specimen Culture Kits (diagnostic test kit for urine), lot number 177354HA with an expiration date of March 31, 2019.

2) Two (2) Urine Specimen Culture Kits, lot number 191389A with an expiration date of February 28, 2019.

During an interview with the Chief Nursing Officer on April, 29, 2019 at 2:20 PM, the CNO confirmed the identified items in the OB Cart were expired, stating "The cart should have been checked and those should have been replaced."

A review of the facility policy and procedure titled "Outdated Supplies" with a written date of April 2016, had a policy statement as follows: "It is the policy of Southern Inyo Hospital Emergency Room that all equipment, instruments and supplies are checked and re-ordered on a regular basis by the Emergency Room (ER) personnel...Procedure:

· Supplies are checked for outdates monthly,
· Sterile instruments are checked for outdates monthly,

Date and signature will be logged on the monthly check form."

Based on interview and record review the facility failed to ensure the Condition of Participation for Provision of Services was met by failing to ensure they had an Infection Control system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. (Refer to C-0278)

The cumulative effect of this deficient practice had the potential to result in problems in health outcomes, patient safety and quality of care, to go unrecognized and unresolved and resulted in the facility failing to meet the Condition of Participation Provision of Services.

Based on interview and record review, the facility failed to develop a system for identifying, reporting, investigating and monitoring, for control of infections and communicable diseases, for all patients admitted to the hospital who are receiving care, and for all personnel who work in the facility and visitors, who could be exposed to hospitalized patients.

This failure had the potential for patients and personnel to develop illnesses caused by infectious agents or toxins that occur through the direct or indirect transmission of the infectious agent or its products from an infected individual or via an animal, vector (an organism, typically a biting insect or tick, that transmits a disease or parasite from one animal or plant to another) or the inanimate (not alive) environment.

Findings:

During an interview on May 1, 2019, at 10:25 AM with the Chief Nursing Officer (CNO) she stated "The facility does not have a designated Infection Control Program or an Infection Control Officer. We collect and track infections but we do not have a formal program." The CNO stated the collected data is not disseminated to any other member of the staff or other departments, nor to hospital leadership. The CNO confirmed the facility does not have a designated infection preventionist (an individual who's main responsibility is to prevent and control the spread of infections) in the facility at this time.

A review of the facility policy and procedure titled "Infection Prevention and Control Plan" undated, revealed the following, "Policy:

Southern Inyo Hospital's Infection Prevention and Control Plan ensures that this organization develops, implements and maintains an active, organizationwide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors, and healthcare workers, and to optimize use of resources.

The Administration of Southern Inyo Hospital shall delegate the oversight and management of the Infection Prevention and Control Plan to the Infection Control Committee (ICC) and Infection Control Professionals...

Southern Inyo Hospital's Prevention and Control Plan includes goals and measurable objectives addressing the highest priority risks and directs the Infection Control Professional(s) and Infection Prevention Committee where to focus infection prevention and control activities..."

Based on interview and record review the facility failed to ensure the physician telephone orders were signed and dated. This failure had the potential to affect the health and safety of all patients receiving services in the facility.

Findings:

During a review of Patient 2's medical record, it showed the patient was admitted to the facility on July 8, 2018, with a diagnosis of pyelonephritis (inflammation of the kidney primarily caused by bacteria).

A review of the facility document titled "Physician's Order Sheet" revealed the physician (MD) verbal telephone order, received by the documenting Registered Nurse (RN), for Patient 2, dated July 8, 2018, at 12:30 PM as:

"NS (normal saline) IV (through the vein) to run at 62 mls/hr until 1 liter (unit of measure) completed.

Monitor I (intake) and O (output) q (every) 1 hour until fluids completed, the q 4 hours after.

Call Dr. if temperature over 100.5"

There was no MD dated and timed signature to indicate the MD gave the RN the telephone order.

A review of the facility document titled "Physician's Order Sheet" revealed the MD verbal telephone order, received by the documenting Registered Nurse (RN), for Patient 2, dated July 8, 2018, at 3:50 PM as,

"May give [brand name of drug] 325 milligrams (MG - unit of measure) suppository q 4 hours PRN (whenever necessary) for temperature greater than 100.5.

Give Ibuprofen 200 mg liquid 40 minutes after [brand name of drug]once.

There was no physician dated and timed signature to indicate the physician gave the RN the telephone order.


A review of the facility document titled "Physician's Order Sheet" revealed the MD verbal telephone order, received by the documenting Registered Nurse (RN), dated July 9, 2018 at 1:40 AM as:

"Discontinue MD notification of a temperature greater than 100.5".

There was no physician dated and timed signature to indicate the physician gave the nurse the telephone order.

In an interview with RN 1 on May 1, 2019, at 3:20 PM, when shown the telephone orders not signed by the MD she stated, "Oh, that's not good."

A review of the Medical Staff Rules and Regulations adopted by the Governing Body on February 28, 2015, showed the following:

"General Conduct of Care:..
5. ...All orders dictated over the telephone shall be signed by the appropriately authorized person who received the dictation, with the name of the attending physician per his/her own name. The attending physician shall sign, date and time such orders within twenty-four hours, or if on rotation, within 24 hours of return to the facility."

Based on interview and record review the facility failed to ensure the Condition of Participation for Periodic Evaluation and Quality Assurance Review was met by failing to ensure they had a quality assurance (QA) program that effectively evaluated the quality and appropriateness of the care provided to its patients and the outcomes of the care provided. (Refer to C-336)

The cumulative effect of this deficient practice had the potential to result in problems in health outcomes, patient safety and quality of care, to go unrecognized and unresolved and resulted in the facility failing to meet the Condition of Participation Periodic Evaluation and Quality Assurance.

Based on interview and record review, the facility failed to ensure they had a quality assurance (QA) program that evaluated the quality and appropriateness of the care provided to its patients and the outcomes of the care provided. This failure had the potential to result in problems in health outcomes, patient safety, and quality of care, to go unrecognized and unresolved for all patients who receive services within the facility.

Findings:

The CAH (Critical Access Hospital) was unable to provide a policy and procedure and/or a plan for a quality assurance program.

The CAH was unable to provide documented evidence to show quality indicators had been chosen to track, in order to identify problems in the facility.

During a review of the Governing Body minutes for the past year, there was no documentation that a QA program plan was developed or approved.

During an interview with the Chief Nursing Officer (CNO) on April 30, 2019, at 4:30 PM, the CNO brought the D/P SNF QA minutes and stated that they did not have a QA program for the hospital yet.

A review of the facility document titled "Bylaws of the Medical Staff - Southern Inyo Healthcare District" with an adoption date of March 3, 2015, and signed by the Chief of Staff for the Committee of the Whole of Medical Staff, and approved by the Governing Body of Southern Inyo Healthcare District, revealed the following:

"Preamble...Article IX...Committees...9.03 Other Medical Staff Committees - General Provisions...9.03-3 Duties (a) Each Staff committee is responsible to:
1. Develop policies and procedures describing how it will carry out its purpose...9.04 Committee of the Whole...9.04-2 Purpose - The purpose of the Committee of the Whole shall be to develop, implement, and maintain a well-defined plan for supervision of the following Medical Staff committees: Medical Records, Forms, Quality Assurance...9.07 Quality Assurance - 9.07-1 Composition - the Quality Assurance Committee will be comprised of the Committee of the Whole and/or their designees. 9.07-2 Purpose - The Quality Assurance Committee shall be responsible for the development of Quality Assurance Plans that demonstrate a consistent endeavor to deliver optimal patient care, with the available resources, consistent with achievable goals. The Quality Assurance Committee shall establish, support and document evidence of an ongoing program that includes effective mechanisms for reviewing and evaluating patient are for appropriate response to findings to establish priorities for problem resolution of known or suspected problems that impact directly or indirectly on patient care and/or by focusing on areas with potential for improvements in patient care..."