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Based on observation, review of manufacturers maintenance recommendations and interview the facility failed to have a preventive maintenance program for patient care equipment and specimen refrigerator to be maintained in safe operating condition.

Findings include:

During tour on 2/10/15 with Staff A (Unit Manager), it was noted that a specimen refrigerator was located on the medical surgical floor. A "Medical Surgical Unit Specimen Refrigerator" monthly log sheet dated for January was attached. Only two dates were filled in with temperatures. The month of February was not completed. Staff A indicated that the laboratory department may be taking the temperatures and the medical surgical department was not performing the daily temperatures.

Interview with Staff B, (Risk Manager/Corporate Compliance Officer), on 2/13/15, indicated that the laboratory department was not responsible for taking the temperatures of the Specimen Refrigerator.

During tour of the Birthing Unit and Emergency Room on 2/10/15, the "Olympic Warmette" blanket warmer was observed. On the door of the Warmette there were instructions that stated "Clean the lint filter every three months. It is located under the bottom shelf on the left." During interview with Staff C, (Licensed Nursed Assistant), Staff C stated that they had no knowledge of the staff cleaning the lint filter of the Warmette and there are no logs maintained.

Reviewing the "Olympic Warmette Models 48/49 and 55/56 manufacturer's Instruction Manual", page 4-2, reveals under the section Quarterly Maintenance,"Cleaning the Lint Filter The Warmette has a lint filter located on the inside left wall of each warming module under the bottom tray (see Figure 4.2). Clean the filter at least once every three months, or more often if it becomes blocked."

Interview with Staff D, (Plant Operations) and Staff E (Biomed Engineer) on 2/13/15, indicated that the Warmette's are about 2 years old and no one has cleaned the lint filters since the units arrival. During tour is was revealed that one unit in the Emergency Room was clean and the unit on the Birthing Unit had a small amount of light gray matter on the lint filter.

During tour of the Rehabilitation Unit on 2/10/15 with Staff F, (Rehabilitation Manager Inpatient), it was noted that the rehabilitation treatment bed had an area covered with tape. When Staff F removed the tape it revealed a tear in the treatment bed. Staff F indicated that that they did not know about the area.


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Observation during tour of Operating Room on 2/10/15 with Staff H, (Director Surgical Services), revealed in room 2 the cart and Valley Lab Cautery equipment had rusted areas on both the cart and on the cautery unit itself.

Interview with Staff H on 2/10/15 confirmed the equipment and cart are rusted and therefore porous and an infection control breech.

Based on observation and interview the Critical Access Hospital failed to secure biohazardous sharps containers from access by unauthorized personnel.

Findings include:

Observation on 2/10/15 at 2:30 p.m. revealed biohazardous sharps containers in the 3 operating rooms, pre op area, and post op area were not secure and do not have a secure top to prevent access by unauthorized personnel.

Interview with Staff H, (RN Director of Surgical Services), on 2/10/15 at 2:30 p.m. confirmed that sharps containers in the 3 operating rooms, pre op area, and post op area were not secure and do not have a secure top to prevent access by unauthorized personnel.

Based on record review and interview the Critical Access Hospital failed to maintain documented evidence of implementation of Emergency Preparedness through drills and community involvement.

Findings include:

Review of Emergency Preparedness plans on 2/12/15 revealed that the Emergency Preparedness plan had not been implemented nor was there documented evidence of drills and involvement of the community officials.

Interview on 2/12/15 with Staff D, (Plant Operations Director), confirmed that drills of the Emergency Preparedness Plan were not conducted and that there was not any involvement of community officials in their Emergency Preparedness Plan.

Based on observation, Policy & Procedure review, and interview it was identified that not all staff were familiar with the Policy & Procedure relating to dating the control solution vials.

Findings include:

During tours of the inpatient care unit and off-site locations it was observed that, not all staff were familiar with the policy & procedure for the dating of blood glucose control vials and were unsure if the date on the bottles were the "discard" or "opened on" dates which would impact when the solution would be discarded. Review of the facility policy and procedure entitled "Blood Glucose Testing Procedure ... ", instructs on page 2 of 8 under section 4(c) "Date each vial when opened with a 3 month expiration date" . Interview with Staff A (Unit Manager) confirmed the above findings.

Based on observation, interview, and tour of the kitchen facility there was a failure to follow the guidelines for kitchen sanitation.

Findings include:

During observation of the dish washing process it was noted that the rinse cycle water temperature only reached the temperature range of 160-165 degrees, short of the required 180 degrees. Examination of the water temperature logs for the month of February confirmed that rinse cycle water temperature did not reach 180 degrees. During interview with Staff I (Director of Nutrition Services), Staff I reported that a repair order was made that morning to assess the cause for the failure of the rinse cycle temperature to achieve 180 degrees.

Based on observation, interview, and tour, the medical records storage area and medical information is not protected from unauthorized access in several settings on the hospital campus.

Findings include:

During tour on 2/11/2015 of the Medical Records (MR) section, Surveyor was able to access the MR storage area unescorted via an elevator from outside the building. There were no safeguards in place preventing use of the elevator by unauthorized persons. The elevator terminated at the front desk of the MR section. Later in the tour with one other Surveyor and Staff B (Director of Risk Management/Corporate Compliance Officer), it was discovered that there was a stairwell in the back of the MR storage area that went to an upper entry door. On investigation the door was prevented from fully closing and locking due to the buildup of ice. It could not be determined how long the door had been open.

During tour on 2/11/15 of the Women's Care Clinic, a "white board" in a room labeled "STAFF ONLY" contained considerable health information regarding several pending births. Full names were used as patient identifiers. Door to this room was open. No safeguards were in place to prevent unauthorized access or the information on the board being viewed by the public and/or unauthorized staff. The room is accessed by contracted housekeeping staff in the evenings after clinic hours, at which time there is no clinical/supervisory staff in the clinic.

During a tour on 2/11/15 of the orthopedic clinic the survey team identified a fax machine that received fax's through the night and contained health information that could be accessible to unauthorized staff.

Based on record review and interview it was determined that the Critical Access Hospital failed to maintain complete patient medical records. (Patient identifiers are #26, #29 and #30.)

Findings include:

Record review on 2/11/15 and 2/12/13 of ten emergency room patient records revealed three emergency room patient's (#26, #29 and #30) were transferred to another hospital with incomplete documentation on the required transfer certificate.

During interview with Staff G (Registered Nurse) on 2/11/15 at approximately 2:00 p.m., after Staff G reviewed the above listed patient records, Staff G verbally confirmed that the emergency room transfer certificates for Patient's #26, #29 and #30 were not complete.

Based on interview it was determined that the Critical Access Hospital failed to have a designated requestor who has completed an approved organ procurement training course.

Findings include:

During interview on 2/10/15 with Staff A (RN Unit Manager) responsible for the Critical Access Hospital (CAH) organ procurement program, Staff A verbalized that the CAH did not have a "designated requestor" for the organ procurement program who has completed an approved Organ Procurement Organization (OPO) training program.

Based on record review and interview the Critical Access Hospital failed to distinctly discharge patients from acute status and then admit to swing bed status in 2 of 7 patients admitted to Swing Bed status in a standard survey sample of 21 patients. (Patient identifiers are #12, and #13).

Findings include:

Review of clinical records revealed that 2 patients were admitted to acute care and then transferred to swing bed status and lacked a distinct physician order discharging the patient from acute care and admitting to Swing Bed status. A clear physician order to admit to Swing Bed status was not found. One physician order found was to change to Swing Bed status. The other physician order was for SNF stay.

Interview on 2/12/15 with Staff A, (Unit Manager), confirmed the absence of a distinct order to discharge patient from acute care and admit the patient to Swing Bed status.