HospitalInspections.org

Based on policy review and staff interview the CAH (Critical Access Hospital) failed to develop their patient care policies with the advice of a group of professionals that included at least one non-member of the CAH staff.

Findings include:

- Review of the patient care policies manuals revealed signature pages signed by the department directors, the CEO (Chief Executive Officer) and the Chief of the Medical Staff that they approved the policies.

Administrative nurse D interviewed on 11/20/13 at 2:50pm acknowledged the CAH staff developed the patient care policies without the advice from at least one non-member of the CAH staff.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, policy review, documents review and staff interview, the CAH failed to develop and implement a system to control infections.

Findings include:

- The CAH's policy titled "Patient room cleaning after dismissal", reviewed on 11/20/13 at 3:00pm, directed staff to put on disposable protective gloves and damp dust the area. Use microfiber cloths soaked with disinfectant to clean the bed and allow the surface to remain wet with the disinfectant for 10 minutes. Wipe other furnishings in the room, dust mop and wet mop the room floor.

The CAH's policy titled "Hand Hygiene Policy/Procedure", reviewed on 11/20/13 at 11:30am failed to direct staff to wear protective gloves when handling soiled linens. The policy directed "G. 2. Hospital personnel adherence to hand hygiene practices will be monitored" and the results of the CAH's hand hygiene compliance will be reported to the staff.

Physical therapy staff A, observed on 11/20/13 at 9:00am, cleaned a patient treatment table in Physical Therapy after a patient treatment. Physical therapy staff A removed the soiled linens from the treatment table, held the soiled linens next to their clothing and placed the linens in the soiled linens bin. Physical therapy staff A obtained clean linens from the cabinet and placed the linens on the treatment table in preparation for another patient. Physical therapy staff A failed to perform hand hygiene after removing the soiled linens from the patient treatment table and before obtaining the clean linens from the cupboard. Physical therapy staff A failed to disinfect the treatment table after the patient's discharge in preparation for another patient.

Registered nurse/education coordinator staff D, interviewed on 11/20/13 at 3:00pm, verified all CAH patient care departments are to follow the patient room cleaning policy. Staff D acknowledged the CAH lacked evidence of monitoring of the staffs' hand hygiene performance compliance.

The CAH's failure to monitor staff's performance of hand hygiene, and failure to follow their procedure for patient room cleaning after the patient's dismissal placed patients at risk for the spread of infections.

Based on policy review and staff interview the CAH (Critical Access Hospital) failed to develop their patient care policies with the advice of a group of professionals that included at least one non-member of the CAH staff.

Findings include:

- Review of the patient care policies manuals revealed signature pages signed by the department directors, the CEO (Chief Executive Officer) and the Chief of the Medical Staff that they approved the policies.

Administrative nurse D interviewed on 11/20/13 at 2:50pm acknowledged the CAH staff developed the patient care policies without the advice from at least one non-member of the CAH staff.

Based on review of governing body meeting minutes and staff interview the CAH (Critical Access Hospital) failed to include the review of health care policies in their periodic program evaluation.

Findings include:

- Review of the July 22, 2013 Board of Trustees Meeting minutes revealed the CAH reviewed their utilization of CAH services. HIM (Health Information Management) staff C provided on 11/19/13 the Medical Record Annual summary of active and closed records for 2012. Review of the Medical Record Annual summary revealed a governing body member, the CEO (Chief Executive Officer) and the HIM director signed they reviewed the summary on 1/17/13 and 2/4/13. The CAH lacked evidence they periodically reviewed their health care policies.

Administrative staff C interviewed on 11/20/13 at 2:15pm verified the CAH failed to include the review health care policies during the annual review of utilization of services or the Medical Record Annual summary.