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Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscopy procedure for each patient, in accordance with the manufacturer's directions, for 1 of 1 observed endoscopy room. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The CAH Administration identified that the surgery staff performed an average of 244 endoscopy procedures per year.

Findings include:

1. Observations during a tour of the surgery department on 10/06/2020 at approximately 9:00 AM in Operating Suite B (OR) revealed 1 of 1 bottle Aqualite System/ICU Medical 1000 mL bottle of sterile water for irrigation connected to the endoscopy equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract). Review of the manufacturer's instructions indicated in part... " intended for use only as a single-dose or short procedure. When smaller volumes are required the unused portion should be discarded." (The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.)

2. During an interview on 10/06/2020 at the time of the tour, OR Charge Registered Nurse (RN) B and Licensed Practical Nurse (LPN) C revealed the surgery staff opened a bottle of sterile water for irrigation each day endoscopy procedures are scheduled and connected it to the equipment. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

3. During an interview on 10/06/2020 at the time of the tour, OR Charge (RN) B and Licensed Practical Nurse (LPN) C reviewed the manufacturer's directions for the Aqualite System/ICU Medical 1000 mL bottle of sterile water for irrigation. The OR Charge RN B acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) x-ray staff failed to ensure staff secured 2 of 2 radiation exposure cord to not allow staff access into the x-ray rooms during completion of radiologic tests of patients (Diagnostic Imaging rooms A & B). The CAH administrative staff reported completing an average of 443 x-rays per month in the hospital. Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing an x-ray procedure and exposing staff to unnecessary radiation.

Findings include:

1. Observations during tour of the Radiology department on 10/07/2020 at 9:35 AM, with the Director of Ancillary Services, revealed 2 of 2 unsecured exposure cords in 2 of 2 x-ray imaging rooms (A & B) the staff failed to secure, which allowed a staff member to enter approximately 4 feet into the x-ray room and still activate the x-ray machine.

2. Review of hospital policy "Radiation Safety Guidelines for Diagnostic X-ray Procedures," dated reviewed 10/2019, revealed in part, " ...objective ....is to minimize radiation exposure to the patients to assure quality of patient care and patient safety, associates, and the general public ...with the least amount of human radiation exposure...During all x-ray procedures, operators and associates must stand behind a 0.5mm lead equivalent barrier during each x-ray exposure ....".

3. During an interview at the time of the tour on 10/07/2020 at 9:35 AM, the Director of Ancillary Services confirmed the 2 radiation exposure cords were not secured and would allow staff to access into the x-ray room during x-ray procedures.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged patients that received anesthesia to the company of a responsible adult for 3 of 5 surgical patients reviewed (Patients #5, Patient #6, and Patient #7). The facility staff reported an average of 459 surgical patients that received anesthesia per year. Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed.

Findings included:

1. Review the policy "Post-Anesthesia Care (PACU), revealed in part, "...Discharge to home - transfer to responsible adult."
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2. Review of patient medical records revealed the following:

a. Patient #5 received anesthesia for a surgical procedure on 03/18/2020. The surgical services staff discharged Patient #5 on 03/18/2020 at 11:03 AM. Patient #5's medical record lacked documentation the surgical services staff discharged Patient #5 in the company of a responsible adult.

b. Patient #6 received anesthesia for a surgical procedure on 02/21/2020. The surgical services staff discharged Patient #6 on 02/21/2020 at 9:20 AM. Patient #6's medical record lacked documentation the surgical services staff discharged Patient #6 in the company of a responsible adult.

c. Patient #7 received anesthesia for a surgical procedure on 01/20/2020The surgical services staff discharged Patient #7 on 01/20/2020 at 8:47 AM. Patient #7's medical record lacked documentation the surgical services staff discharged Patient #7 in the company of a responsible adult.


3. During an interview on 10/07/2020 at 3:40 PM, the Chief Nursing Officer (CNO) confirmed Patient #5's, Patient #6's, and Patient #7's, medical records lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the infection preventionist/infection control professional responsible for the infection prevention and control program individual, had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership. Failure to comply with regulations could potentially hinder the infection prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing severe harm to patients and their safety. The CAH Administrative staff identified a census of 4 upon entrance and an average daily census of 4 patients.

Findings include:

1. Review of Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Critical Access Advisory Minutes from September 19, 2019 to September 23, 2020 revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

3. Review of the Governing Board Meeting Minutes from July 1, 2019 to June 30, 2020 revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

4. Interview with Chief Nursing Officer (CNO) on 10/06/2020 at 01:30 PM confirmed that new regulations had been received from CMS and the appointment of the Infection Control Preventionist by the Governing Board had been discussed, however, the Infection Preventionist had not been appointed by the Governing Board.

Based on review of policy/procedure, skilled patient medical records, and staff interviews, the Critical Access Hospital (CAH) nursing staff failed to ensure the interdisciplinary team documented who attended the multidisciplinary care rounding/conference to evaluate/re-evaluate the patient's health needs and plan of care in accordance with the CAH's policy for 1 of 1 open (Patient #1) and 3 of 4 closed skilled patient medical records reviewed (Patients #2, #3 and #4). The CAH administrative staff identified 1 skilled patients at the beginning of the survey. Failure to document who attended the multidisciplinary care conference could potentially fail to ensure all disciplines provided input into the patient's care.

Findings include:

1. Review of the CAH policy, "Interdisciplinary Care Conference," dated 12/2019, revealed in part, "...Care Conference Objectives: To identify the patient's health needs and plan of care. To promote continuity and coordination of care. To share clinical information between disciplines. To identify patients with complex needs. To identify discharge needs. To identify patient's goal length of stay ...Documentation of Interdisciplinary Care Conference, dated 11/2019, will address the present plan of care, the discharge plan, and identification of individuals responsible to gather further information if necessary. Care conference participants will document the information in the patient's E.H.R. [Electronic Health Record]...."

2. Review of skilled patient medical records revealed the following:

a. Review of medical record on 10/06/2020 at 2:30 PM of Patient #1, admitted 09/14/2020, revealed the medical record lacked documentation of who attended the interdisciplinary care rounding/conferences on 10/02/2020 and 10/06/2020.

b. Review of medical record on 10/06/2020 at 2:30 PM of Patient #2, admitted 09/15/2020 and discharged 09/28/2020, revealed the medical record lacked documentation of interdisciplinary care rounding/conferences.

c. Review of medical record on 10/06/2020 at 2:30 PM of Patient #3, admitted 09/10/2020 and discharged 09/28/2020, revealed the medical record lacked documentation of interdisciplinary care rounding/conferences.

d. Review of medical record on 10/06/2020 at 2:30 PM of Patient #4, admitted 07/13/2020 and discharged 08/13/2020, revealed the medical record lacked documentation of who attended the interdisciplinary care rounding/conferences on 07/24/2020 and 08/07/2020.


3. During an interview on 10/7/2020 at 10:45 AM, the Registered Nurse - Informatics/Clinical Liaison confirmed the documentation in the skilled patient medical records lacked who attended the interdisciplinary care conferences for Patients #1, #2, and #3.
During an interview on 10/7/2020 at 3:25 PM, the Chief Nursing Officer (CNO) confirmed the documentation in the skilled patient medical records lacked who attended the interdisciplinary care conferences for Patients #1, #2, and #3.