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The Critical Access Hospital (CAH) reported a census of three patients, one acute care patient and two swing bed patients. Based on observation, document review and staff interview the CAH failed to develop and implement written health care policies for their outpatient services (refer to C-273), failed to ensure that unusable drugs and biologicals are not available for patient use (refer to C-276), failed to ensure the infection control officer developed an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel (refer to C-278), and failed to develop a program of activities that includes large groups, small groups, one-to-one, and self-directed activities in an ongoing program of activities, and the development, implementation, and evaluation of the activities provided to the patients (refer to C-385).

The cumulative effect of the CAH's systemic failure to develop policies and procedures for their outpatient services, failure to ensure outdated drugs were not available for patient use, failure to ensure the infection control officer developed an active infection control system, and
fail to develop a program of activities resulted in the CAH's inability to provide care in a safe and effective manner.

The Critical Access Hospital (CAH) reported a census of three patients, one acute care patient and two swing bed patients. Based on document review and staff interview the CAH failed to develop and implement written health care policies that describes the outpatient services provided by the CAH.

Findings include:

- Surveyor requested outpatient policies and procedures on 3/23/15. On 3/25/15 at 10:45am requested outpatient policies and procedures. The CAH provided a policy/procedure titled "Outpatient Orders". The policy/procedure refers only to outpatient orders.


Administrative staff A, RN, DON, interviewed on 3/26/15 at 10:45am in their office explained, if the patient has a prescription or seen at the clinic earlier and told to return to the clinic (the patient would be outpatient). When patients present to ER they are treated as ED patients, the Dr. makes decision if the patient is an ED patient or outpatient when he/she are called. Staff A revealed that the isolation ED room if available or one of the patient rooms near the nurse's station can be used as the outpatient rooms. When asked, staff A explained they do not have a formal list of specific services they provide as outpatient services but they provide intravenous therapy, wound dressing changes, injections, wound-vac care, urinary catheter insertions and/or changes, enemas, and porta-catheter/central line flushes. The CAH does not have any set schedules for outpatient services, the patients can come at any time, however if they do have patients on a routine medication or treatment they do have a schedule for these patients.
Administrative staff A, RN, DON, interviewed on 3/25/15 at 10:45am acknowledged the CAH does not have outpatient policies/procedures with set criteria of what patients qualify as outpatients.

The Critical Access Hospital reported a census of three patients two swing bed patients and one acute care patient. Based on observation and staff interview the hospital failed to ensure that unusable drugs and biologicals are not available for patient use in two of two medication storage cabinets and one of two emergency code carts observed. This failure has the potential to effect all patients admitted to the CAH for anticoagulation therapy.

Findings include:

- Observation of the medication storage area on 3/24/15 at 2:15 pm revealed a cabinet with one 1 ml vial of Heparin 10,000 units per ml with an expiration date of 5/2014.

- Administrative Staff A interviewed on 3/25/15 at 2:15 pm acknowledged one 1 ml vial of Heparin 10,000 units per ml found in the medication rooms storage cabinet had an expiration date of 5/2014.

- Observation of the emergency department on 3/25/15 at 2:20 pm revealed a cabinet with an opened bottle of Nitroglycerin sublingual spray with a hand written date of 1/28/15. The emergency code cart revealed one 1 ml vial of Heparin 10,000 units per ml with an expiration date of 5/2014.

- Administrative Staff A interviewed on 3/25/15 at 2:35 pm acknowledged one 1 ml vial of Heparin 10,000 units per/ml found in the emergency department code cart had an expiration date of 5/2014.

- Administrative Staff A interviewed on 3/25/15 at 2:20 pm acknowledged a bottle of Nitroglycerin sublingual spray was dated as opened on 1/28/15 and found in the emergency departments locked medication cabinet. Staff A revealed a medication opened greater than 30 days would be considered expired.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two swing bed patients. Based on observation, staff interview, and document review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel. Observations included one of three observed medication passes, one of one observed bed linen change, one of one observed wound dressing change, one of one terminal cleaning of a discharged patient room, and one of two surgical suite rooms. The CAH's failure to identify failures with infection control practices created the potential for healthcare acquired infections.

Findings include:

- The CAH's job description for the Infection Control Practitioner reviewed on 3/25/15 at 1:00pm directed, "...The Infection Control Practitioner...is qualified individual with knowledge of CDC guidelines and definitions of nosocomial infections, federal and state regulation. She/he is responsible for identification, investigation, reporting, preventing of nosocomial infections among patients and personnel..."


- The CAH's policy for Infection Prevention reviewed on 3/25/15 at 1:00pm directed, "...The Infection Prevention Program at this hospital incorporated the following...surveillance, prevention and control of infection throughout the organization..."


- Infection Control Officer staff B interviewed on 3/25/15 at 10:15am verified they were responsible for the management of the infection control program. Staff B indicated they track patient through reports from laboratory received at the end of the month. Staff B acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control practices. Staff B indicated they could not remember when they last conducted an Infection Control Meeting and provided the last Infection Control meeting minutes for 3/26/2013.


- Observations during the survey process revealed the following breaches in infection control practices.


- The CAH's policy for hand hygiene reviewed on 3/25/15 at 1:00pm directed, "...Indications for handwashing and hand antisepsis...before and after direct patient contact, before and after donning gloves, before and after contact with patient's intact skin, when moving from a contaminated body site to a clean body site during patient care, and after contact with inanimate objects in the immediate vicinity of the patient..."


- Licensed Practical Nurse (LPN) staff C observed on 3/24/15 at 9:30am during medication pass revealed staff C entered patient #28's room to provide oral medications. Staff C entered patient #28's room and failed to perform hand hygiene when entering the room and when leaving the room.

Staff C interviewed on 3/24/15 at 9:45am acknowledged they failed to perform hand hygiene when they entered and exited patient #28's room.

- Certified Nurse Aide (CNA) staff D observed on 3/24/15 at 9:30am during the changing of pillowcases to patient #28's pillows revealed staff D placed three of patient #28's soiled pillows under their chin and against their uniform to place a clean pillowcase over the pillow. Placing soiled patient items under their chin and against their uniform has the potential to transmit potential microorganisms to themselves and other patients.

- Staff D interviewed on 3/24/15 at 9:45am acknowledged she placed patient #28's pillow under their chin and against their uniform and indicated they "knew better".

- The CAH's policy for Standard Precautions reviewed on 3/25/15 at 1:00pm directed, "...Standard precautions apply to all patients regardless of their diagnosis of suspected infection status...Standard precautions include...Gloves are to be worn when touching blood, body fluids, secretions, excretions, and other contaminated items. Clean, non-sterile gloves with be adequate. Gloves shall be changed between task and procedures on the same patient, after contact with materials that may contain high concentrations of microorganisms...Mask, Eye protection, face shields when performing procedures that may be likely to generate splashes or sprays for blood, body fluids, secretions or excretions, wear a mask and eye protection or a face shield. This will protect the mucous membranes of the eyes, nose, and mouth...Gowns when performing procedures that may be likely to generate splashes or sprays of blood, body fluids, secretion or excretions , wear a gown to protect the skin and to prevent soiling of clothing..."


- Licensed Practical Nurse (LPN) staff C, Registered Nurse (RN) staff F, and RN staff G observed on 3/24/15 between 10:30am and 11:00am provided a "Wound Vac" (a machine used for negative pressure wound therapy) dressing change to patient #28. Staff C wearing gloves removed the soiled dressing from patient #28's coccyx area. Staff C failed to change their gloves and perform hand hygiene and flushed and cleaned the wound with soiled gloves. Staff C used scissors to cut black foam used in the wound and laid the scissors on the over-the-bed table which lacked a barrier. Staff C, wearing the same soiled gloves reached into the supply basket and returned to the dressing change. Following the dressing change staff C disposed of the trash in the trash can and wearing the same soiled gloves went to the dresser drawers and opened the drawers. Staff C then removed and disposed of their gloves but failed to perform hand hygiene. Staff C reapplied gloves and assisted staff F, wearing gloves, to clean patient #28's bottom soiled with bowel movement (BM). Staff C removed their gloves and without performing hand hygiene straightens up patient #28's bed, repositions patient #28, and repositioned pillows. Staff F removed their gloves and without performing hand hygiene went to the window and opened the window blinds before performing hand hygiene. Staff C, staff F, and staff G failed to follow standard precautions and wear mask, eye protection/face shield or a gown to protect skin and clothing when performing a procedure that may generate splashes or sprays of body fluids, secretions or excretions. Staff C, staff F, and staff G failed to clean the over-the-bed table used during patient #28's dressing change.


- The manufacturer's information sheet for "Super HDQL 10" disinfectant cleaner reviewed on 3/25/15 at 1:00pm directed "...To disinfect inanimate hard non-porous surfaces...allow to remain wet for 10 minutes..."


- The manufacturer's information sheet for "NABC" disinfectant bathroom cleaner reviewed on 3/25/15 at 1:00pm directed "...One-step disinfecting and cleaning toilet bowls and urinals: empty toilet bowl or urinal and apply product to exposed surfaces with a brush or swab mop...let stand for 10 minutes...One-step disinfecting ceramic tile, porcelain, show walls and other hard nonporous surfaces...treated surfaces must remain wet for 10 minutes..."


- The CAH's information on hospital mattresses reviewed on 3/24/15 at 12:40pm directed, "...after cleaning the bed wipe all surfaces with sodium dichloroisocyanurate (Chemical compound widely used cleansing agent and disinfectant)..."


- Housekeeping staff E observed on 3/24/15 between 11:05am and 12:25pm cleaning room 103, a discharged patient room revealed the following breaches in infection control practices regarding manufacturers ' guidelines, hand hygiene and cleaning from dirty areas to a less dirty area. For example:


Staff E, wearing gloves applied "Super HDQL 10" disinfectant cleaner to the cabinets, closet, chair, and bedside table. The cabinets, closet, chair and bedside table remained wet for five to nine minutes not the required ten minutes for disinfection. Staff E obtained "NABC" from the cleaning cart and poured some into the toilet bowl without emptying the toilet bowl and using a toilet mop cleaned the inside of the toilet. Staff E returns to the cleaning cart and without changing their gloves or performing hand hygiene obtained a spray bottle labeled "Peroxy" but explained the spray bottle contained "NABC" and cleans the toilet seat and pedestal. Staff E then emptied the cleaning bucket of "Super HDQL10", rinsed the bucket, and wearing soiled gloves used to clean the bathroom; leaves room 103, went down the hallway to the nutrition room and squirted some "Dawn" dish soap into the bucket, returns to room 103, added water to the "Dawn" dish soap and cleaned the patient bed, mattress, frame, and the Ergo-nurse (a lift used to move patients). Staff E returned to the cleaning cart wearing the same soiled gloves, obtained some "NABC" wipes from a bucket and cleaned the bathroom sink, grab bars, and shower walls. The surfaces of the sink, grab bars and shower walls remained wet between five and seven minutes not the required 10 minutes for disinfection. Staff E then cleaned the bed control and call light with "Dawn" dish soap wearing the same soiled gloves used to clean the bathroom. Staff E returned to the cleaning cart, removed their gloves, failed to perform hand hygiene, went down the hallway to the housekeeping closet, obtained a dust mop, and returned to the room without performing hand hygiene. Staff E mopped half of the room, left the room with pillows without performing hand hygiene, then returned to room 103, applied gloves, cleaned the room sink with "NABC" wipes, removed their gloves, failed to perform hand hygiene, mopped the rest of room 103, and failed to perform hand hygiene when they completed the cleaning of room 103.


Staff E interviewed on 3/24/15 at 12:25pm acknowledged the spray bottle labeled "Peroxy" actually contained "NABC" and stated "I'm the only one that uses it so I know what is in it". Staff E acknowledged they wore the same gloves during the cleaning of room 103 and they had been instructed to only clean the beds with "Dawn" dish soap. Staff E acknowledged "Dawn" dish soap lacked disinfecting properties.


- Observation of the surgical suite endoscopy room on 3/24/15 at 3:05pm revealed a partially open Yankauer suction tips (a rigid hollow tube made of metal or disposable plastic with a curve at the distal end to facilitate the removal of thick secretions during oral pharyngeal suctioning) ready for use. The package on the suction tips directed sterile unless opened or damaged.


- Administrative Nurse staff A interviewed on 3/24/15 at 3:05pm acknowledged the open Yankauer suction tip.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two swing bed patients. Based on document review and staff interview the CAH failed to ensure the care and treatment of all patients follow written physician orders for one of 5 outpatient medial records reviewed (patient #43).

Findings include:

- The CAH's Medical Staff Bylaws, rules and regulations reviewed on 3/26/15 at 10:15am directed, "...All orders for treatment, laboratory, x-ray, and procedures shall be in writing or electronic..."

- The CAH's policy and procedure titled "Outpatient Orders" reviewed on 3/25/15 at 4:05pm directed, "...The Kiowa District Hospital will have policies in place to assure valid and safe orders from staff and outside practitioners."


- Patient #43's medical record reviewed on 3/26/15 revealed the patient arrived to ER on 2/27/15 at 1:57pm (Friday) with a complaint of cannot urinate. An Emergency Admission Assessment performed by a LPN (staff C) on 2/27/15 at 2:23pm. The nurses notes revealed On 2/27/15 at 1:57pm the patient arrives ambulatory with daughter, patient states had a procedure to remove something from their right ear this am at another hospital. Patient #43 has not been able to urinate since they had the procedure done. Patient went to bathroom and could not urinate. On 2/27/15 at 2:10pm 16 french Bard indwelling catheter placed. On 2/27/15 at 2:18pm emptied foley catheter bag of 650cc (centimeter) of pale yellow urine. On 2/27/15 at 2:30pm they removed the foley bag and a leg bag was placed on the patient, instructed patient and daughter on foley care. On 2/27/15 at 2:35pm reviewed discharge instructions with patient and daughter, to return to clinic on Monday to have foley removed. On 2/27/15 at 2:45pm patient leaves ambulatory to private vehicle with daughter.
Patient #43's medical record lacked a physician's order for placement of the Foley catheter.

The Critical Access Hospital (CAH) reported a census of three patients, one acute care patient and two swing bed patients. The CAH failed to develop a program of activities that includes large groups, small groups, one-to-one, self-directed activities in an ongoing program of activities, and the development, implementation, and evaluation of the activities provided to the patients for two of two active medical records (patient #'s 27 and 28) and three of three closed medical records (patient #'s 26, 29, and 30).

Findings include:

- The CAH's policy titled "Quality of Life" reviewed on 3/26/15 at 1:45pm directed, "...The hospital will provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being of each resident..."

- The CAH's "Swingbed Resident's Bill of Rights" reviewed on 3/26/15 at 10:00am directed, "...The facility will provide an ongoing program of activities designed to meet the interests and physical, mental and psychosocial well-being of each resident..."

- Patient #26's closed medical record reviewed on 3/24/15 revealed an admission date of 12/27/14 with diagnoses of anemia (low blood level), congestive heart failure (CHF), the heart fails to function properly), and renal failure (the kidneys are not functioning properly) and discharged on 1/8/15 to home. Patient #26's medical record revealed a "Social Services and Activities Assessment" completed by the registered nurse on 12/28/14 and reviewed by the licensed social worker on 2/25/15 (48 days after the patient was dismissed). The activities plan for patient #26 completed by the RN revealed; TV controls within reach to increase independence, Monitor present level of activities, Provide a calm, restful environment, Orient to season, current events, day time, and place, and 1:1 meetings to discuss concerns. Review of the nursing documentation from 12/28/14 to 1/8/15 revealed a lack of scheduled activities for the patients. The CAH lacked a calendar for patient activities.


- Patient #27's medical record reviewed on 3/25/15 revealed an admission date of 3/23/15 with diagnoses of prolonged ileus (intestinal blockage). Patient #27's medical record revealed an " Activity Assessment completed by the activity director and a " Social History " completed by the licensed social worker on 3/25/15. The CAH lacked a calendar for patient activities.


- Patient #28's medical record reviewed on 3/24/15 revealed an admission date of 2/16/15 with diagnoses of gastrointestinal bleed and a Stage three decubital ulcer on the sacrum (deep tissue pressure sore). Patient #28's medical record revealed a "Social Services and Activities Assessment" completed by the registered nurse on 2/17/15. The medical record lacked evidence the social service designee reviewed the "Social Services and Activities Assessment" completed by the nurse. The activities plan completed by the RN revealed; TV controls within reach to increase independence, provide reading material daily to promote orientation, Monitor level of activities, Physical Therapy, Provide a calm, restful environment, Encourage activities daily to increase awareness/orientation, Orient to season, current events, day time, and place, 1:1 meetings to discuss concerns. Review of the nursing documentation from 2/17/15 to 3/24/15 revealed a lack of scheduled activities for the patients. The CAH lacked a calendar for patient activities.


- Patient #29's closed medical record reviewed on 3/24/15 revealed an admission date of 11/28/14 with diagnoses of COPD, mucus plug in the trachea (windpipe), and worsening of congestive heart failure (CHF). Patient #29's medical record revealed a "Social Services and Activities Assessment" completed by the registered nurse on 12/2/14 and reviewed by the licensed social worker on 2/25/15 (85 days after the patient was discharged). The activities plan completed by the RN revealed; TV controls within reach to increase independence, and 1:1 meetings to discuss concerns. Review of the nursing documentation from 2/17/15 to 3/24/15 revealed a lack of scheduled activities for the patients. The CAH lacked a calendar for patient activities.


- Patient #30's closed medical record reviewed on 3/24/15 revealed an admission date of 1/16/15 with diagnoses of post laminectomy (back surgery). Patient #30's medical record revealed a "Social Services and Activities Assessment" completed by the registered nurse on 1/18/15. The medical record lacked evidence the social services designee reviewed the "Social Services and Activities Assessment." The activities plan completed by the RN revealed; TV controls within reach to increase independence, Provide reading material daily to promote orientation, Monitor present level of activities, Physical Therapy, Provide a calm, restful environment, and 1:1 meetings to discuss concerns. Review of the nursing documentation from 11/28/14 to 12/10/14 revealed a lack of scheduled activities for the patients. The CAH lacked a calendar for patient activities.


Administrative Staff A interviewed on 3/25/15 at 10:25 am revealed the CAH shares an activities director with the CAH owned nursing home. Staff A acknowledged the activity director has not been coming to the hospital for a while. A Registered Nurse (RN) completes the activity sheet and the contracted social worker reviews it and signs the form.

Nursing Staff F and Nursing staff C interviewed on 3/24/15 at 2:15 pm revealed the hospital does not have scheduled activities for their swing bed patients. They do some activities like nail polishing, hair styling when they have time, or going outside when it is nice out.


Administrative staff H, interviewed on 3/25/15 at 5:20pm acknowledged the activity plan did not reflect activities for the patients.