HospitalInspections.org
Bringing transparency to federal inspections
MASSAC MEMORIAL HOSPITAL
INFECTION PREVENT SURVEIL & CONTROL OF HAIs
Tag No.: C1208
Based on observation, document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure sharps containers were removed from patient care areas when full, to avoid a transmission of infection. This has the potential to affect all staff employed at the CAH. (average census of 6 patients).
Findings include:
1. On 10/19/2020 at 12:00 AM, a tour of the Wound Clinic was conducted. There were 4 sharps containers mounted on the wall that had dermal curettes sticking up past the "full" line.
2. On 10/20/2020 at 8:00 a.m., the policy "Guidelines for Disposal of Needles, Syringes, Sharps" (reviewed 10/19), indicated "To prevent healthcare associated infections (nosocomial) and protect employees and patients from injury. 6. Check point of use disposal systems are checked daily by housekeeping personnel; remove, seal close and replace when they are 1/2 to 3/4 full ...."
3. During an interview with the Wound Care Advanced Practice Nurse (E #2) on 10/19/2020 at 12:30 a.m., it was confirmed that the sharps containers had curettes sticking up above the full line. E #2 stated "we need to get bigger sharps containers and dispose of the curettes in a larger container."
Plan Based on All Hazards Risk Assessment
Tag No.: E0006
Based on document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure the emergency preparedness plan (EP) include "pandemic" as one of its facility-based and community-based risks. This has a potential to affect all patients receiving care from the CAH, and the surrounding community. (average patient census of 6 patients).
Findings include:
1. On 10/19/2020 at 11:00 a.m., the CAH "Emergency Operations Plan" (Revision 2) was reviewed. Under "2.1 Risk Assessment and Emergency Planning, Table 2.2 and Table 2.3", it lists the highest internal and external hazards. Pandemic was not listed as a hazard.
2. On 10/19/2020 at 11:05, an interview with the Executive Assistant (E #1) was conducted. E #1 confirmed the EP plan was current and that it did not contain "Pandemic" as one of the internal or external risks.