HospitalInspections.org

Based on observation, interview and record review the Critical Access Hospital (CAH) failed to ensure the proper disposal and containment of medical waste in one of one observed medical waste container.

Findings included:

- Review on 3/30/11 at 11:30am of the CAH's medical waste management plan directed "...Biohazard wastes are stored in a locked and secured holding area ...warning signs are posted ...Caution biohazardous waste storage area-unauthorized persons keep out ..."

- Observation on 3/29/11 at 8:50am of the unsecured trash dumpster area outside the CAH's back doors revealed a large red trash container. The trash container lacked a label identifying the contents. The trash container lid removed easily revealing biohazard (medical waste) bags.

Staff O interviewed on 3/29/11 at 8:50am acknowledged the unlocked red trash container contained red-bagged medical waste and unauthorized persons could access the area without hospital staff knowledge.

Staff B and staff C interviewed on 3/30/11 between 10:10am and 10:30am acknowledged the large red trash container outside the CAH's backdoor contained medical waste including used needles and syringes. Staff B and staff C acknowledged unauthorized persons could remove the lid to the red trash allowing access which created a safety hazard and potential for the spread infections.

Based on observation, staff interview, and document review the Critical Access Hospital (CAH) infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for two of two observed cleaning of a discharged patient room, two of two observed staff removing linen from a discharged patient room, and two of two observed blood glucose monitoring.

Findings include:

- Review on 3/29/11 at 11:15am of the CAH's job description for the Infection Control Chairperson directed "...The Infection Control Chairperson supervises the infection surveillance program ...Developing a system for identifying, investigating, reporting, and preventing the spread of infections and communicable diseases among patients and personnel ..."

- Staff E observed on 3/29/11 at 9:40am cleaned room #7 after a patient discharge. Observations during the room cleaning process revealed breaches in infection control practice regarding hand hygiene. During the room cleaning process Staff E put on clean gloves to clean the room. Staff E stepped out of the room to obtain supplies and/or cleaning clothes eight times then re-entered the room to clean without changing their gloves which created the potential to spread infections.

- Staff E observed on 3/29/11 at 11:47am cleaned room #2 after a patient discharge. Observations during the room cleaning process revealed breaches in infection control practice regarding hand hygiene. During the room cleaning process Staff E put on clean gloves to clean the room. Staff E stepped out of the room to obtain supplies and/or cleaning clothes eight times then re-entered the room to clean without changing their gloves which created the potential to spread infections. Staff E finished cleaning room #2 at 1:30pm and failed to perform hand hygiene.

Staff E interviewed on 3/29/11 at 1:35pm acknowledged they failed to change their gloves or perform hand hygiene each time they left the patient room.

- Review on 3/29/11 at 11:30am of the CAH's policy for hand hygiene direct staff to perform hand hygiene after contact with inanimate objects in the immediate vicinity of patients.

- Staff E and Staff F observed on 3/29/11 at 12:15pm entered the hallway with their hands full of linens from room #2. Staff E and Staff F failed to place the soiled linens inside a linen bag before carrying the linens through the hallway to the Utility room potentially spreading patient's germs.

Staff E interviewed on 3/29/11 at 1:35pm acknowledged they and staff F carried linens from a patient room down the hallway without placing them in a linen bag.

- Staff G observed on 3/28/11 at 11:30am performed blood glucose testing on patient #21. Staff G gathered all equipment and supplies and put on gloves. Staff G removed the glucometer for it case, laid the glucometer (a machine to test blood sugars) and case on the bedside table without a protective barrier and completed the blood sugar test. Staff G removed their gloves, washed their hands, picked up the glucometer, returned the glucometer to the case and returned the glucometer to the nurses station. Staff G failed to clean the glucometer after use.

- Staff H observed on 3/29/11 at 11:25am performed blood glucose testing on patient #21. Staff H gathered all equipment and supplies and put on gloves. Staff H removed the glucometer from the case laid the glucometer and case on the bedside table without a protective barrier, moved the glucometer to the patient's lap and completed the blood sugar test. Following the test staff H placed the glucometer on the bedside table. Staff H removed their gloves, washed their hands, picked up the glucometer, returned the glucometer to the case, placed the case in their pocket and returned the glucometer to the nurses station. Staff H failed to clean the glucometer after use.

Staff H interviewed on 3/29/11 at 11:34am acknowledged they failed to clean the glucometer after use.

Repeated breaches in infection control and the failure to follow manufacturers directions for cleaning procedures created the potential for the spread of bloodborn infections to hospitalized patients and staff.

- Review on 3/30/11 at 11:30am of the manufacture's direction for Accu-Chek glucometer directs to clean with 70% alcohol or 10% household breach solution. The CAH failed to have a policy directing staff to clean the glucometer between patients.

Based on policy and procedure manual review and staff interview the Critical Access Hospital (CAH) failed to ensure patient care policies and procedures were reviewed by a group of professional personal on an annual basis for 10 of 10 policy and procedure manuals reviewed.

Findings include:

- Review of the policy and procedure manuals provided during the survey between 3/28/11 and 3/30/11 lacked evidence the manuals were reviewed annually by a group of professional personnel that included at least one doctor of medicine or osteopathy, at least one midlevel practitioner (Advanced Registered Nurse Practitioner or Physician Assistant).

Staff A interviewed on 3/29/11 at 4:30pm acknowledged the CAH failed to perform an annual review of the patient care policy and procedure manuals by a group of professional personnel.

Based on the annual program evaluation documentation and staff interview the Critical Access Hospital (CAH) failed to include review of the health care policies and procedures as part of their annual program evaluation.

Findings include:

- Review of the CAH's annual program evaluation documentation, reviewed on 3/30/11 at 10:00am lacked evidence the health care policies were included in the annual program evaluation.

Staff A interviewed on 3/30/11 at 4:30pm acknowledged the CAH failed to include a review of the health care policies and procedures in their annual program evaluation.