HospitalInspections.org

Based on policy review, observation, and staff interview, the Critical Access Hospital (CAH) failed to securely store patient records in 1 of 1 radiology record storage area (in the computed tomography [CT] room). Failure to securely store patient records limited the CAH's ability to ensure against loss, destruction, or unauthorized use.

Findings include:

Review of the policy "HIPAA Policies and Procedures Overview" occurred on 11/08/23. This undated policy stated, ". . . Patient records, medical and billing, should be stored in a secure area and not left unattended. . . ."

Observation of the unlocked CT room on 11/07/23 at 10:20 a.m. showed an open shelving unit containing mammography and bone densitometry patient records.

During interview on 11/07/23 at 10:20 a.m., an administrative radiology staff member (#3) confirmed the facility stored mammography and bone densitometry patient records on an open shelving unit in the CT room which does not have a lock.

Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer's instructions for the use of a chemical for cleaning and disinfecting equipment and supplies for 1 of 1 equipment processing room (central processing). Failure to follow manufacturer's instructions for cleaning and disinfection of equipment and supplies limited the CAH's ability to ensure proper sterilization.

Findings include:

Observation of the central processing room occurred on 11/06/23 at 3:10 p.m. with an administrative nurse (#1) showed a sink for preparation of water with enzymatic detergent solution (Endozime AW) for manual cleaning prior to sterilization. The sink showed a faint black line on the side of the sink approximately 2/3 of the way from the bottom. The administrative nurse (#1) stated she "rarely" performed the process and called the surgical technician (#2). During the telephone interview the surgical technician (#2) described the process used for preparation of the water with enzymatic detergent solution and stated, "I fill the sink about half full of water and add the Endozime to the line in the sink." The surgical technician (#2) confirmed she did not measure the water or the enzymatic detergent.

The Endozime AW detergent manufacturer's instructions, reviewed on 11/06/23 at 3:15 p.m., stated, "use 1/2 ounce of solution per one gallon of water."

During an interview on 11/06/23 at 4:15 p.m., the administrative nurse (#1) confirmed the surgical technician (#2) failed to follow manufacturer's instructions for the Endozime AW detergent and she failed to perform a competency evaluation for the surgical technician (#2) since 2017.

Based on policy review, reports review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated all patient care services affecting patient health and safety for 4 of 4 quarters reviewed (1st, 2nd, 3rd, and 4th Quarters 2023). Failure to ensure all departments participate in QAPI monitoring limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the policy titled "Quality Assurance and Performance Improvement" occurred on 11/07/23. This policy, revised 01/15/18, stated,
"Policy: It is the policy of Ashley Medical Center to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. . . . Policy Explanation and Compliance guidelines: . . . 2. The QA Committee . . . shall: . . . b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program . . . d. Regularly review and analyze data . . . 7. Program design and Scope - a. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by AMC [Ashley Medical Center]. . . ."

Review of the CAH's 1st, 2nd, 3rd, and 4th quarter reports and meeting minutes from 2023 occurred on 11/07/23 and indicated the following:
- The 1st-4th Quarter reports and minutes failed to include reporting from anesthesia and housekeeping.
- The following departments failed to include hospital monitoring in their submitted reports: social services in the 1st Quarter; social services and maintenance in the 3rd Quarter; and dietary in the 4th Quarter.
- The 3rd Quarter Meeting Minutes, dated 07/28/23, indicated the QA Committee failed to meet due to an illness outbreak among staff and patients and staff education for the new electronic medical records. The CAH failed to provide evidence of a rescheduled meeting for the 3rd Quarter. The following departments failed to submit 3rd Quarter reports to the QA Committee: swing bed activities, anesthesia, central supply/operating room, emergency room/trauma, fire and safety, infection control, medical records, physical therapy, radiology, and nursing.
- The 4th Quarter Meeting Minutes, dated 10/31/23, failed to include evidence of reporting or discussion of the missed 3rd Quarter Meeting and reports.

During interview on 11/08/23 at 8:05 a.m., an administrative staff member (#5) confirmed the following: anesthesia and housekeeping failed to conduct QAPI monitoring for the first through fourth quarters in 2023; social services failed to monitor hospital services in the 1st and 3rd quarters, maintenance failed to monitor hospital services in the 3rd Quarter, and dietary failed to monitor hospital services in the 4th Quarter; not all departments submitted 3rd Quarter reports to the QA Committee; the QA Committee failed to reschedule the 3rd Quarter meeting; and the QA Committee failed to include the submitted 3rd Quarter reports at the 4th Quarter meeting.