HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer expiration date.

Failure to establish a systematic process for ensuring patient care supplies do not exceed their expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. On 07/28/21 at 8:50 AM, Surveyor #3 and the Quality/Case Manager (Staff #301) inspected the Emergency Department. The observation showed the following:

a. Two adult lumbar puncture trays with an expiration date of 06/31/21.

b. Three 1000 ml evacuated bottles with an expiration date of 05/31/21.

c. One multi-lumen central venous catheter kit with an expiration date of 03/21.

d. Two epistaxis balloon catheters with an expiration date of 05/20/19.

e. One 15 mm 15-gauge intraosseous kit with an expiration date of 01/31/21.

2. On 07/28/21 at 10:00 AM, Surveyor #3 interviewed the Acute Care/Emergency Department Manager (Staff #306) about the expired patient care items found in the Emergency Department (ED). Staff #306 stated that staff check for outdated patient care items during times where there is few or no patients in the ED.

3. On 07/27/21 at 3:00 PM, Surveyor #6 toured the Imaging Department with a Radiology Technologist (Staff #610). The observation showed three 950 mL bottles of CCI (Columbus Chemical Industries) X-Ray Detector Coolant. The labels stated the shelf life is 1 year unopened, 6 months after open. Each bottle showed a manufacturer fill date: 06/04/15, 12/19/17, and 03/28/18.

4. At the time of the observation the surveyor asked Staff #610 about the bottles of X-Ray Detector Coolant. Staff #610 stated she did not work in mammography and had never seen the bottles.

5. On 07/28/21 at 9:30 AM, Surveyor #6 interviewed the Imaging Department Manager (Staff #611) about the X-Ray Detector Coolant. Staff #611 stated he did not think it had been used recently.

6. On 07/28/21 at 8:50 AM, Surveyor #6 toured the Central Sterile Department with a Surgical Technician (Staff #609). The observation showed:

a. 2 of 2 gallon containers of Getinge Clean Power Con Instrument Lubricant with label Use By dates of 09/18

b. 2 of 2 gallon containers of Getinge Clean Power Con Alkaline Detergent Concentrate with label use by dates of 08/17 and 11/18.

7. At the time of the observation, Staff #609 stated that the expired supplies would be discarded immediately.
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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff maintain supplies and equipment to meet patient needs during an emergency for 4 of 4 emergency carts inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings Included:

1. Document review of the hospital policy and procedure titled," Crash Cart," policy number 9937420, last approved 06/21, showed that crash carts will be checked once a day to ensure that equipment necessary to perform resuscitation is available at all times. The crash cart must be checked monthly for outdates and replacements obtained.

2. On 07/27/21 at 10:30 AM, Surveyor #3 and the Quality/Case Manager (Staff #301) inspected the Acute Care Unit emergency cart. The observation showed the airway box with one nasal pharyngeal airway with an expiration date of 05/21 and a LMA Mad Nasal device with an expiration date of 06/18/20.

3. On 07/28/21 at 8:50 AM, Surveyor #3 and the Quality/Case Manager (Staff #301) inspected the Emergency Departments emergency carts. The observation showed the following:

a. Cardiac Room Emergency Cart - Two pediatric multifunctional defibrillation pads with an expiration date of 04/30/21, and one pediatric end tidal C02 detector with an expiration of 01/31/21.

b. Obstetric Emergency Cart - Two pediatric multifunctional defibrillation pads with an expiration date of 04/30/21.

c. Trauma Room Emergency Cart - Two pediatric multifunctional defibrillation pads with an expiration date of 04/30/21

3. At the time of the observation, Surveyor #3 interviewed the Quality/Case Manager (Staff #301) about the checking of emergency carts. Staff #30 stated the emergency carts are checked daily and confirmed the expired items found by the surveyor.
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Based on observation and interview, the Critical Access Hospital failed to store food at appropriate temperatures to ensure compliance with the 2009 Food and Drug Administration (FDA) Food Code.

Failure to store time/temperature control for safety (TCS) foods at appropriate temperatures places patients and staff at increased risk of foodborne illness.

Findings included:

1. On 07/28/21 at 10:40 AM, during an inspection of the patient nutrition refrigerator in the Clean Utility room, Surveyor #6 used a thin stemmed thermometer to assess the temperature of Time/Temperature Control for Safety Foods {(formerly potentially hazardous food -PHF}. The assessment showed the following TCS foods held above 41 degrees Fahrenheit:

a. hard-boiled egg - 47.7 degrees Fahrenheit

b. cream cheese packet - 49 degrees Fahrenheit

c. deli meat & cheese sandwich - 46.8 degrees Fahrenheit

2. At the time of the observation, the Environmental Services (EVS) Manager (Staff #606) confirmed the temperatures.

3. On 07/29/20 at 3:50 PM, Surveyor #6 reviewed the cold holding temperatures of the TCS foods in the patient nutrition refrigerator with the Dietary Manager (Staff #607). Staff #607 stated she would adjust the temperature of the refrigerator and monitor food temperatures to ensure TCS foods are held below 41 degrees Fahrenheit.

TCS foods that are held cold must be held at 41 degrees Fahrenheit or below.

Reference: Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. 2009 FDA Food Code 3-501.16, Washington State Retail Food Code, WAC 246-215-03525
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report found at Shell J6JD21.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff followed the hospital's policy when caring for the patients placed in restraints for 1 of 2 medical records reviewed (Patient #302).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints," policy number 9499409, last approved 03/21, showed that patients in restraints shall be observed at frequent intervals being every 15 to 30 minutes or more frequently if indicated. Assessment of the patient in restraints will document clinical condition, circulation, condition of skin and attention to hydration, elimination, and nutrition.

2. 07/28/21 at 1:20 PM, Surveyor #3 and the Clinical Informaticist (Staff #302) reviewed the records of two patients who were restrained during their hospital stay. The review showed:

a. Patient #305 was a 15-year-old patient who was treated in the Emergency Department on 04/30/21 for suicide attempt by drug overdose. The patient became combative and was deemed a danger to self. The patient was placed in 4-point restraints on 05/01/21 at 12:00 AM (midnight) and released from restraints at 05/01/21 at 3:30 AM. The patient's record showed no documentation that the patient was assessed during this period (a total of 3 hours and 30 minutes) as required by hospital policy.

b. The record did not include documentation that less restrictive alternatives to restraints had been attempted and had failed. The record did not indicate that the patient was released from restraints at the earliest possible time.

3. At the time of the review, the Clinical Informaticist (Staff #303) confirmed the findings and stated that the clinical staff had not followed the hospital policy as required.
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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that outdated or unusable medications were not available for administration to patients.

Failure to ensure medication storage areas do not contain outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, and efficacy.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Area Inspection," policy number 87659417, last approved 11/20, showed that all areas where medications are stored or used will be inspected by pharmacy. Outdated items and punctured multi-dose vials without a "beyond use date" labeling will be removed during the inspection.

Document review of the hospital inspection sheet titled "North Valley Medication Area Inspection" showed the items to be checked included floor stock items are in-date and usable. Multi-dose vials of sterile drugs are dated with appropriate expiration date and not stored beyond use date specified in hospital pharmacy policy.

2. On 07/27/21 at 3:15 PM, Surveyor #3 and the Quality/Case Manager (Staff #301) inspected the Emergency Department medication room. The inspection showed one bottle of ethyl chloride topical spray (anesthetic skin refrigerant) with an expiration date of 04/21.

3. On 07/28/21 at 10:15 AM, Surveyor #3 interviewed a Pharmacy Technician (Staff #303) about the monthly medication inspections. Staff #303 stated that she only checks medications located in the pyxis machines (automated drug dispensing machine). She acknowledged that she does not check for expired or unusable medications stored outside of the pyxis machine.

4. On 07/29/21 at 8:35 AM, Surveyor #3 and the Nurse Manager of Surgical Services (Staff #304) inspected the Operating Room suites and associated perioperative areas. An inspection of the anesthesia cart in the procedure room showed the following:

a. One 10 ml vial of etomidate 20mg/ml with an expiration date of 01/21.

b. One 50 ml vial of lidocaine 0.5% with an expiration date of 02/25/21.

c. One 20 ml vial of labetalol which was opened and not dated.

d. One 50 ml vial of lidocaine 0.5% which was opened and not dated.

e. Two 50 ml vial of lidocaine 2% which was opened and not dated.

5. On 07/29/21 at 8:35 AM, Surveyor #3 interviewed a nurse anesthetist (Staff #305) about the expired and opened and not dated multi-dose vials found in the anesthesia cart. Staff #305 stated that she throws away all undated vials when working at this hospital. When asked who checks the anesthesia cart for outdates, Staff #305 stated she was unsure but thought pharmacy personnel did this during their monthly inspection.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 4 patients reviewed (Patient #303, #304).

Failure to follow blood transfusion procedures acceptable to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital policy and procedure titled, "Blood/Blood Products Transfusion," policy number 10109351, last approved 07/21, showed that a baseline set of vital signs will be completed before beginning infusion of blood. After 15 minutes of starting the transfusion, another set of vital signs will be taken. At 30 minutes from the start of the infusion, vital signs will be taken and every 30 minutes until the transfusion is complete.

2. On 07/28/21 at 1:20 PM, Surveyor #3 and the Clinical Informaticist (Staff #302) reviewed the records of four patients who received blood administration during their care at the hospital. The review showed the following:

a. Nursing staff caring for Patient #303 failed to document a complete set of vital signs which included a temperature at the required time intervals for the first unit of blood to include prior to starting the blood transfusion, the initial 30-minutes after starting the infusion, and upon completion of the blood product administration as required by policy.

b. Nursing staff caring for Patient #303 failed to document a complete set of vital signs which included a temperature at the required time intervals for the second unit of blood to include prior to starting the blood transfusion, the initial 15-minute and 30 minute time intervals after starting the blood product administration as required by policy.

c. Nursing staff caring for Patient #304 failed to document a complete set of vital signs which included a temperature at the required time interval for the first 15-minutes after starting the infusion as required by policy.

3. At the time of the review, the Clinical Informaticist (Staff #302) confirmed the findings and stated the hospital staff had not followed the policy as required.
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Item #1 - Handwashing station

Based on observation and interview, the facility failed to provide a handwashing station in the soiled utility room used for high-level disinfection (HLD) of shared patient care equipment.

Failure to provide hand-washing stations places staff at increased risk of exposure to infectious microorganisms during reprocessing of contaminated patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.8.1 Soiled workrooms shall contain (1) A clinical sink (or equivalent flushing-rim fixture) and a hand-washing station. Both fixtures shall have a hot and cold mixing faucet.

Findings included:

1. On 07/29/21 at 9:45 AM, Surveyor #6 observed a Surgical Technician (Staff #609) reprocess a colonoscope. The observation showed that the decontamination room used for reprocessing endoscopes did not have a handwashing station. The room contained a hopper sink (commonly used for infectious waste handling) and a utility sink. A sign above the utility sink stated the sink was not to be used for handwashing.

2. At the time of the observation the surveyor interviewed Staff #609 about hand-hygiene opportunities during endoscope reprocessing. Staff #609 stated that the hospital had been cited during a previous survey for use of the utility sink for handwashing and reprocessing. In response to the citation, staff had been directed to remove the soap and paper towel supplies and hang a sign stating the utility sink could not be used for handwashing. Staff #609 directed the surveyor to an Alcohol Based Hand Sanitizer (ABHS) dispenser outside the perioperative area.

Item #2 - Cleanable surfaces

Based on observation and interview, the Critical Access Hospital failed to maintain a clean and sanitary environment by not ensuring environmental surfaces were easily cleanable.

Failure to maintain a clean environment in perioperative settings puts patients and staff at increased risk of exposure to harmful microorganisms.

Reference: Association of periOperative Nurses (AORN) Guidelines for Perioperative Practice: Design and Maintenance of the Surgical Suite (2020), Recommendation 12.2 Maintain the integrity of structural surfaces (e.g., doors, floors, walls ceilings, cabinets) and have surfaces repaired when damaged. 12.2.1 Report damage to floors, walls ceilings, cabinets, and other structural surfaces according to the health care organization ' s policy. Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning.

Findings included:

1. On 07/29/21 at 10:30 AM, during the between case cleaning of the endoscopy room, Surveyor #6 observed the following irregular surfaces:

a. a sheet of paper board approximately 6" by 9" was taped to the floor with green adhesive tape. Areas of the tape were peeled away from the floor and pulled away from the paper board.

b. a section of wall coving at the floor, approximately 5" by 2" was missing. The exposed concrete had an irregular, rough surface.

c. several strips of green tape covered an electrical box in the wall near the door.

2. At the time of the observations, Surveyor #6 interviewed the Surgical Technician (Staff #603) who was performing the between case cleaning. The surveyor asked how the irregular surfaces were cleaned and disinfected. Staff #603 stated she had not noticed the paper board on the floor or the exposed concrete. Staff #603 stated that she disinfected the surfaces and supplies that she knew had been touched during the preceding endoscopy.

3. On 07/28/21 at 4:20 PM, during a tour of the Operating Room (OR) with the hospital's interim Plant Engineering Manager (Staff #602), Surveyor #6 observed the following irregular surfaces:

a. a tear in the ceiling surface outside the OR. The torn area exposed a concrete surface along the edge of a ceiling access panel.

b. the ceiling in the OR above the door had an area of peeling paint

4. At the time of the observations, Surveyor #6 asked Staff #602 about the repair procedures. Staff #602 stated that he did not know whether either observation had been reported and that he would make the necessary arrangements for immediate repair.

5. On 07/30/21 at 8:00 AM, Surveyor #3 and Surveyor #6 observed moisture stains in the ceiling tiles near the door inside Exam Room #205.

6. At the time of the observation, the surveyors interviewed the Clinic Coordinator (Staff #604) and a Registered Nurse (RN) (Staff #605) about the ceiling tiles. Staff #604 and Staff #605 stated that usually in the spring there is a roof leak that causes stained ceiling tiles. They call for repairs every time a leak appears.

Item #3 - Kitchen sanitation

Based on observation, document review, and interview, the Critical Access Hospital failed to maintain a clean and sanitary environment by not ensuring kitchen and food contact surfaces were maintained clean.

Failure to maintain a clean environment in food service settings puts patients and staff at increased risk of exposure to harmful microorganisms.

Findings included:

1. Document review of the manufacturer product label for Clean Quick Broad Range Quaternary Sanitizer shows that it is an effective sanitizer at 150 ppm active quat for use on food contact surfaces in 400 ppm hard water against listed bacteria. Clean Quick sanitizer can be used on food contact surfaces in a concentration range of 150-400 ppm active. The product label provides Wisconsin State Board of Health Directions for Eating Establishments: Sanitize in a solution of ¾ oz. of product per 4 gallons of water (200 ppm active quat).

2. On 07/27/21 at 1:00 PM, Surveyor #6 and the Dietary Manager (Staff #607) toured the ware washing areas of the kitchen. The observation showed a Food Worker (Staff #608) preparing chemical sanitizer for the sanitizer compartment of the three-compartment sink. Staff #608 dispensed 3 pumps from a container of Clean Quick Broad Range Quaternary Sanitizer into a sink containing an uncertain volume of water at 125 degree Fahrenheit water.

3. At the time of the observation, Surveyor #6 interviewed Staff #608 about the observation. Staff #608 stated that he was preparing sanitizer for manual ware washing. Staff #608 stated that he does not measure the water, he knows where the level should be. He stated that he never checks the concentration with a test strip.

Sanitizer solutions must meet specific concentrations for use according to federal regulations and manufacturer instructions.

4. On 07/27/21 at 12:20 PM, Surveyor #6 and the Dietary Manager (Staff #607) toured the automatic dishwasher area of the kitchen. Surveyor #6 observed several blankets on the floor under the dishwasher, a rubber drain mat over standing water, and black growth on the floor and wall surfaces below the dishwasher.

5. At the time of the observation, Surveyor #6 asked Staff #607 about the blankets on the floor and condition of the plumbing. Staff #607 stated she wasn't sure when the blankets were put on the floor and that she would check with the interim Plant Engineering Manager about maintenance and/or repairs.

6. On 07/27/21 at 1:45 PM, Surveyor #6 and the Dietary Manager (Staff #607) toured the food service areas of the kitchen. Surveyor #6 observed a small diameter pipe running from above the ceiling tiles down the wall and discharging to a floor sink. The floor sink, sink grate, and surrounding floor surface had slimy, pink buildup and black growth. The floor sink contained an accumulation of gritty debris.

7. On 07/29/21 at 4:00 PM, Surveyor #6 interviewed the Interim Plant Engineering Manager (Staff #602) about the plumbing at the dishwasher and the drain line to the floor sink. Staff #602 stated that the issue with the dishwasher may have been reported to facilities. He stated that the pipe to the floor sink discharges condensate from an air handler unit above the kitchen ceiling, and the debris might be from cleaning the floor.

Item #4 - High-level disinfection of reusable medical equipment

Based on observation, document review, and interview, the Critical Access Hospital staff failed to use high-level disinfectants according to manufacturer's instructions for use to reprocess ultrasound probes.

Failure to use high-level disinfectants according to manufacturer's specifications risks inadequate disinfection of patient care equipment that increases risk of patient infection.

Reference: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), updated May 2019. Table 4. Comparison of the characteristics of selected chemicals used as high-level disinfectants or chemical Sterilants

Findings included:

1. Document review of the manufacturer's instructions for use for CIDEX® OPA Solution (Orthphthalaldehyde), a high-level disinfectant, showed that after opening the bottle of CIDEX® OPA Solution, solution remaining in the bottle can be stored up to 75 days. It is important to record the date the solution was poured from the original container and the date its reuse life ends (not to exceed 14 days).

Document review of an Environment of Care policy titled, "Safe Use and Handling of Cidex OPA (Glutaraldehyde free) Ortho-Phthalaldehyde," no policy number, no approval date, showed that Cidex OPA Solution should be discarded after 14 days, even if the Test Strips indicate a concentration above the MEC (minimum effective concentration).

2. On 07/28/21 at 9:30 AM, Surveyor #6 and the Imaging Department Manager (Staff #611) observed the high-level disinfection set up for ultrasound probes. The observation showed the container of CIDEX® OPA Solution used to disinfect ultrasound probes did not have a date mark indicating the 14 day use expiration.

3. At the time of the observation, Surveyor #6 reviewed the manufacturer instructions for use with Staff #611. Staff #611 acknowledged that the instructions directed that CIDEX® OPA Solution should be discarded after 14 days.

Item #5 - Hand hygiene

Based on observation, document review, and interview, the hospital failed to ensure that handwashing supplies were available for hand hygiene (HH) according to hospital procedure and accepted standards of practice.

Failure to provide handwashing supplies risks transmission of communicable diseases between staff and patients.

Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), October 25, 2002 / Vol. 51 / No. RR-16, Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Perceived barriers to adherence with HH practice recommendations include inaccessible HH supplies. Easy access to HH supplies is essential for optimal adherence to HH recommendations.

Findings included:

1. Document review of the hospital's policy titled, "Infection Prevention - Hand Washing," policy number 8670085, approved 10/20, showed guidelines and techniques for proper and appropriate hand washing techniques to prevent the spread of infection.

2. On 07/29/21 at 8:00 AM, Surveyor #6 inspected the Oroville Health & Rehabilitation Office. The observation showed 3 of 3 Alcohol Based Hand Rub (ABHR) dispensers did not dispense ABHR.

3. At the time of the observations, Surveyor #6 interviewed the Receptionist (Staff #612) about the hospital's hand hygiene expectations. Staff #612 stated that staff should sanitize their hands frequently and that she did not know the ABHR dispensers were not working. She stated she would ask someone to check the batteries.

Item #6 - Surgery terminal cleaning frequency

Based on interview and document review, the Critical Access Hospital failed to maintain the Operating Room (OR) and Endoscopy Room in clean and sanitary condition by failing to complete terminal clean after the last patient of the day.

Failure to terminally clean the OR and Endoscopy Room after the final patient of the day places patients and staff at increased risk of transmission of infection by exposure to harmful microorganisms.

Reference: Centers for Disease Control and Prevention (CDC), Healthcare-associated Infections (HAI) Best Practices for Environmental Cleaning in Healthcare Facilities Appendix B2 - Cleaning procedure summaries for specialized patient areas. Risk determines cleaning frequency, method, and process in routine and contingency cleaning schedules for all patient care areas: OR - After last procedure (terminal clean); General procedure areas (such as radiology and endoscopy services) - After last patient of the day (terminal clean).

Findings included:

1. Document review of the hospital's policy titled, "Infection Control - Surgery," policy number 9938346, approved 07/21, showed that "dirty" wound examples include abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op; and that the OR crew will wipe down surfaces before each case and wipe down surfaces and mop after each case, and that housekeeping will terminally clean OR once a week, unless specified otherwise.

2. On 07/29/21 at 9:00 AM, Surveyor #6 interviewed the Environmental Services (EVS) Manager (Staff #606) and attempted to schedule observation of an OR terminal cleaning. Staff #606 stated that OR terminal cleaning is done weekly on Saturday and at the end of the day if a procedure is a "dirty case". The surveyor was not successful in scheduling a terminal cleaning for observation.

Item #7 - Supplies protected from sources of contamination

Based on observation and interview, the Critical Access Hospital failed to protect patient care supplies from sources of contamination near handwashing sinks.

Failure to store patient care supplies in dry, clean, and sanitary condition places patients and staff at increased risk of exposure to harmful microorganisms.

Findings included:

1. On 07/28/21 at 10:40 AM, Surveyor #6 and the Environmental Services Manager (Staff #606) inspected the Clean Utility room. The observation showed cans of soft drinks stored beside a handwashing sink.

2. At the time of the observation, Surveyor #6 asked Staff #606 about the location of the soft drinks. Staff #606 stated that the cans should be relocated so that they are not within the splash zone of the handwashing sink. Food must be protected from sources of contamination.

3. On 07/29/21 between 10:10 AM and 10:35 AM Surveyor #6 inspected the Endoscopy Room during a between case cleaning by a Surgical Technician (Staff #603). The observation showed that patient care supplies including exam gloves and Alcohol Based Hand Rub (ABHR) were stored adjacent to the handwashing sink in the splash zone and below the paper towel dispenser subject to drips from wet hands.

4. At the time of the observation, Surveyor #6 asked Staff #606 about placement of the supplies. Staff #606 confirmed the finding and stated she would check with the department manager about moving the supplies.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to perform a comprehensive assessment of swing bed patients that included an assessment of cognitive, mood and behavior patterns, and psychosocial well-being for 2 of 3 records reviewed (Patient #301, #302).

Failure to perform a complete comprehensive assessment at the time of admission risks inadequate or ineffective care and delayed treatment.

Findings included:

1. Document review of the hospital policy and procedure titled, "Resident Assessment for Swing Bed Patients," policy number 9539610, last approved 04/21, showed that a comprehensive assessment of each resident will be conducted and include cognitive patterns, mood and behavioral patterns, and psychosocial well-being assessments.

2. On 07/29/21 at 10:30 AM, Surveyor #3 and the Quality/Case Manager (Staff #301) reviewed the records of three patients who were admitted to the swing bed program. The review showed the following:

a. Patient #301 was a 83-year old admitted for rehabilitation following a repair of a femur fracture. The comprehensive assessment did not include an evaluation of the patient's cognitive, mood and behavior patterns, or a psychosocial well-being.

b. Patient #302 was a 96-year old admitted for rehabilitation following a repair of a femur fracture. The comprehensive assessment did not include an evaluation of the patient's cognitive, mood and behavior patterns, or psychosocial well-being.

3. At the time of the medical record review, Staff #301 confirmed the findings. She stated she was newly assigned to the role of overseeing the swing bed program and did not know which service or professional was responsible for conducting those assessments at the time of admission.
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Item #1 - Provision of supplies

Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures for the hospital's emergency preparedness plan to include provisions for food, water, and pharmaceutical supplies for staff and patients whether they evacuate or shelter in place.

Failure to provide provisions for subsistence needs places patients and staff at risk of harm during an emergency event.

Findings included:

1. Document review of the hospital's policy titled, "Disaster/Emergency Preparedness Management Plan," policy number 8725485, approved 10/20, showed that no policies attached to the plan included provisions for food, water, or pharmaceutical supplies. Current Memoranda of Understanding (MOUs) for food delivery and water supplies were attached to the Disaster/Emergency Preparedness Management Plan.

2. On 07/29/21 between 11:00 AM and 12:30 PM, Surveyor #6 interviewed and reviewed the hospital's emergency preparedness plan with the Safety/Security Officer (Staff #601). Staff #601 did not provide a plan to provide provisions for pharmaceutical supplies as required by federal regulations for CAHs. Staff #601 stated that the pharmacist can get any drug with a phone call, but there is no written plan.

Item #2 - Alternate sources of energy to maintain temperature

Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures for the hospital's emergency preparedness plan to include alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.

Failure to provide emergency sources of energy to maintain temperatures for safe and sanitary storage of provisions places patients and staff at risk of harm during an emergency event.

Findings included:

1. Document review of the hospital's policy titled, "Disaster/Emergency Preparedness Management Plan," policy number 8725485, approved 10/20, showed that no policies attached to the plan included maintaining temperatures for the safe and sanitary storage of provisions.

2. On 07/29/21 between 11:00 AM and 12:30 PM, Surveyor #6 interviewed and reviewed the hospital's emergency preparedness plan with the Safety/Security Officer (Staff #601). Staff #601 stated that the hospital had an emergency power generator (epg) as an alternate source of energy.

3. On 07/29/21 between 4:00 PM and 4:45 PM, Surveyor #6 interviewed the hospital's interim Plant Engineering Manager (Staff #602) about the epg for the hospital. Staff #602 stated that in the event of a power outage the epg supplied power to patient care areas and the pharmacy. Staff #602 stated that the epg does not supply power to the dietary department (kitchen refrigeration units) or the operating room (OR) HVAC (heating, ventilation, and air conditioning) system that controls temperature and humidity in the OR.
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