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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on January 24, 2012, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Recertifcation Survey conducted on Janauary 24, 2012, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 1/24/12.

A. Based on a review of Critical Access Hospital (CAH) policies, a review of dietary temperature logs, a review of sanitizer strength logs, food temperature logs, and staff interview, it was determined that the CAH failed to ensure proper food preparation, served and stored to prevent potential contamination. The Hospital failed to document if any corrective actions were implemented when the results were outside the established parameters.

The cumulative effect of the failure to follow CAH dietary policy and procedures requiring foods to be prepared and held at specified temperatures, stored refrigerated/frozen foods to be maintained within specific temperatures, and the dietary sanitizer (Quat) to be at a specific parts per million (ppm), resulted in the possibility of cross contamination to 3 of 3 CAH patients.

Findings include:

1. The CAH failed to ensure all dietetic services were provided following recognized dietary practices. The CAH failed to ensure all hot food temperatures were monitored and recorded, dishwasher temperatures were recorded and the minimum temperatures were always achieved. The CAH failed to ensure all cooler/freezer temperatures were recorded as required. The CAH failed to ensure the Quat was diluted and tested properly. Please see the deficiencies cited at C-279

A. Based on a review of CAH policy and procedure, medical record review, and staff interview, it was determined that in 1 of 4 (Pt #2) medical records reviewed in which the patient received insulin injections, the CAH failed to ensure the injections were appropriately documented.

Findings include:

1. The CAH policy and procedure titled, "Injections," last revised 10/13/06, was reviewed on 12/8/11. It indicated under, "General Information: 2. Injection sites should be rotated for patients requiring repeated injections." and "Documentation: Documentation should include the following: 1. Site of injection..."

2. The medical record of Pt #2 was reviewed on 12/8/11. It indicated that Pt #2 was admitted on 12/28/10 with a diagnosis of Gastroenteritis. Documentation indicated that between 12/28/10 and 1/1/11, Pt #2 received 16 subcutaneous injections of insulin. There was no documentation that indicated the site of the injection on 14 of the injections.

3. During an interview with the Chief Nursing Officer, conducted on 12/8/11 at 2:15 PM, the above finding was confirmed.

A. Based on a review of policy and procedure, food temperature logs, and staff interview, it was determined that the CAH failed to ensure all hot food temperatures were monitored and recorded as required. This has the potential to effect 3 of 3 CAH patients.

Findings include:

1. The CAH policy and procedure titled, "Serving Temps of Hot Foods," last revised 1/27/00, was reviewed on 12/6/11. It indicated under, "POLICY: To ensure that all hot food items are properly cooked and are at a proper serving temperature in accordance with Infection Control Policies....PROCEDURE: 1. Foods shall be held in a safe temperature zone after cooking - above 140 degrees F. 2. Foods not at the 140 degrees or above shall be reheated immediately to 165 degrees of 15 seconds at the most internal point. All temperature must reach stated temperature on the temperature log sheets for industry standards for serving....4. All temperatures shall be recorded by the cook on the daily temperature sheets, prior to meal service."

2. The food temperature logs for 30 days during the months of Nov/Dec 2011 were reviewed on 12/6/11. It was documented 9 times that the egg temperatures did not reach the required 140F and no corrective actions taken. Of the 90 serving times between Nov/Dec 2011 there were 25 serving times that no food temperatures were recorded.

3. During an interview with the Dietary Manager, conducted on 12/6/11 at 10:45 AM, it was verbalized that the food is prepared for patients, staff, and the county jail.

4. During an interview with the Dietary Manager, conducted on 12/6/11 at 10:45 AM, the above findings were confirmed.

B. Based on a review of the dietary Quality Assurance Calendar, the dietary dishwasher temperature logs, and staff interview it was determined that the CAH failed to ensure all dishwasher temperatures were recorded and the minimum temperatures were always achieved to ensure dishes/utensils were thoroughly cleaned and sanitized. This has the potential to effect 3 of 3 CAH patients.

Findings include:

1. The dietary departmenets Quality Assurance Calendar that is completed by the dietary department and submitted to Quality Assurance (QA) was reviewed. It indicated under "Dishwasher temp" and "Dishwasher rinse temp" that the temperatures were to be taken in the "AM, Noon, & PM" (at least 3 times a day). The recordings on the Dietary Quality Assurance Calendar for the months of Aug, Sep and Oct, 2011 indicated all were "OK". The dietary dishwasher temperature logs for the months of Aug, Sept, Oct and Nov were reviewed and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. The log indicated that the dishwasher was utilized 3 times a day and temperatures were to be checked during the wash, 1st rinse and final rinse cycles. Of the temperatures (temps) that were recorded, the following were observed: The wash temps were not reached 9 times in Aug, 3 times in Sept, 2 times in Oct and 5 times in Nov. The 1st rinse temps were not reached 43 times in Aug, 34 times in Sept, 25 in Oct and 19 times in Nov. The final rinse temps were not reached 12 times in Aug and 4 times in Sept. There was no documentation that indicated corrective actions were taken.

2. During an interview with the Dietary Manager, conducted on 12/6/11 at 10:45 AM, the above findings were confirmed.

C. Based on a review of policy and procedure, the dietary department's Quality Assurance Calendar, the cooler/freezer temperature logs, and staff interview, it was determined that the CAH failed to ensure all temperatures were recorded as required to ensure safe food storage. This has the potential to effect 3 of 3 CAH patients.

Findings include:

1. The CAH policy and procedure titled, "Temperature Checks/Cold," last revised 1/27/00, was reviewed. The policy indicated under "Procedure: 1. Refrigeration temperatures shall be below 40 degrees F and freezers shall be below 0 degrees F. 2. Cooks shall check the temperatures routinely, and report any that are outside acceptable range. 3. Cooks will record temperature readings three times daily at regular intervals and recorded on the temperature control sheets logs."

2. The dietary department's Quality Assurance Calendar, that is completed by the dietary department and submitted to Quality Assurance (QA), were reviewed for the months of Aug, Sept, and Oct and all indicated "OK" for the 7AM and 7PM walk-in refrigerator temperatures. The "temperature checks" logs for the walk in-refrigerator for the months of Aug, Sept, Oct and Nov were reviewed and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. The walk-in refrigerator logs indicated there were 43 of 93 recorded temps in Aug, 33 of 90 recorded temps in Sept, 39 of 93 recorded temps in Oct, and 32 of 90 temps recorded in Nov. There was no documentation that indicated corrective actions were taken in for the 3 times the temperature was above 40 degrees F.

3. The dietary department's Quality Assurance Calendar, that is completed by the dietary department and submitted to Quality Assurance (QA) were reviewed. The months of Aug, Sept, and Oct all indicated "OK" for the 7AM and 7PM walk-in freezer temperatures. The "temperature checks" logs for the walk-in freezer were reviewed for the months of Aug, Sept, Oct and Nov and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. The walk-in freezer logs indicated there were 41 of 93 recorded temps in Aug, 33 of 90 recorded temps in Sept, 37 of 93 recorded temps in Oct and 35 of 90 recorded temps in Nov. There was no documentation that indicated corrective actions were taken for the 59 times the temperature was above the range of 0 degrees F.

4. The dietary department's Quality Assurance Calendar, that is completed by the dietary department and submitted to Quality Assurance (QA) were reviewed. The months of Aug, Sept, and Oct all indicated "OK" for the 7AM and 7PM milk cooler temperatures. The "temperature checks" logs for the milk cooler were reviewed for the months of Aug, Sept, Oct, and Nov and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. There were columns on the logs for a 7AM and 7PM temperature check. The milk cooler temperatures were recorded 26 times in Aug, 13 times (with 5 recordings of "No Temp" or "No temp gauge") in Sept, 9 in Oct and none in Nov (there were 7 recordings that were marked "No Thermometer"). There was no documentation that indicated corrective actions were taken.

5. The dietary department's Quality Assurance Calendar, that is completed by the dietary department and submitted to Quality Assurance (QA) were reviewed. The months of Aug, Sept, and Oct all indicated "OK" for the 7AM and 7PM ice cream freezer temperatures. The "temperature checks" logs for the ice cream freezer were reviewed for the months of Aug, Sept, Oct and Nov and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. The ice cream freezer logs indicated there were 23 recorded temps in Aug, 16 in Sept, 9 in Oct and 6 in Nov. There was no documentation that indicated corrective actions were taken.

6. The dietary department's Quality Assurance Calendar, that is completed by the dietary department and submitted to Quality Assurance (QA) were reviewed. The months of Aug, Sept, and Oct all indicated "OK" for the daily temperature check of the pass-through cooler. The "temperature checks" logs for the pass-through cooler were reviewed for the months of Aug, Sept, Oct and Nov and contraindicated the "OK" results for the months of Aug, Sep, and Oct 2011. The pass-through logs indicated there were 28 temps in Aug, 30 temps in Oct and 11 in Nov. There was no documentation that indicated corrective actions were taken.

7. During an interview with the Dietary Manager, conducted on 12/6/11 at 10:45 AM, the above findings were confirmed.

D. Based on a review of the directions for the dietary sanitizer (Quat) dilution, a review of the Quat strength tests, and staff interview, it was determined the CAH failed to ensure the Quat was diluted and tested properly for safe use as a sanitizer solution. This has the potential to effect 3 of 3 CAH patients.

Findings include:

1. The "Preparation and Monitoring of Sanitizing Solution" instructions were reviewed. They indicated, "1. Quat solution shall be used for all sanitizing solutions used within the dietary department. 2. Solutions shall be prepared in clean red buckets at a dilution rate of EXACTLY 200 ppm...." 3. New solutions shall be prepared at 6:00 am, 10:30 am, 3:00 pm or as needed. 5. Solutions shall be tested at intervals, with the person testing the solution initialing that the solution was tested and if dilution rate is not 200 ppm a new solution shall be made."

2. The Quat testing logs for the months of Aug, Sept, Oct and Nov 2011 were reviewed. They indicated the Quat strengths were to be checked at least 3 times a day. In Aug they were tested 10 times and 6 were out of compliance with the 200 ppm. In Sept they were tested 10 times and 5 were out of compliance, in Oct they were tested 8 times and 1 out of compliance, in Nov they were tested 8 times and 3 out of compliance. There is no documentation during the 4 months reviewed that new solutions were prepared at the 10:30 am or 3:00 pm intervals. There was no documentation that indicated new solution was made when the dilution rate was not at 200 ppm.

3. During an interview with the Dietary Manager, conducted on 12/6/11 at 10:45 AM, the above findings were confirmed.

A. Based on clinical record review and staff interview, it was determined in 1 (Pt. #3) of 5 clinical records reviewed with surgical services, it was determined that anesthesia failed to ensure all pre and post operative asssessments were conducted.

Findings include:

1. The clinical record of Pt. #3 was reviewed on survey date 12/07/11. Pt. #3 was admitted to the Hospital on 08/28/11 with focal peritonitis secondary to leakage from gastric band erosion. There was no documentation to indicate pre- baseline vital signs were taken prior to the initiation of anesthesia.

2. The above finding was confirmed with the CNO on 12/08/11 at 2:30 pm.

A. Based on a request for the annual, periodic evaluation of the CAH's program and review of Quality Assurance/Performance Improvement documentation, it was determined the Hospital failed to ensure an annual total program evaluation was conducted.

The cumulative effect of these systemic practices resulted in the CAH's inability to ensure its periodic evaluation was conducted to determine if services were utilized appropriately, identified areas for improvement, and evaluated the compliance with health care policies, determined any needed changes and/or corrective action on, at least, an annual basis. This has the potential to effect all patients who receive services at the CAH.

Findings include:

1. The CAH failed to ensure it carried out or arranged for an annual/ periodic evaluation of its total program. Please see deficiency at C331.

2. The CAH failed to ensure it evaluated the utilization of CAH services, including at least the number of patients served and the volume of services. Please see deficiency at C332.

3. The CAH failed to ensure its responsibility to evaluate and review at least 10% of both active and closed clinical records. Please see deficiency at C333.

4. The CAH failed to ensure there was evidence to demonstrate health care policies had been evaluated, reviewed, or revised as needed, annually. Please see deficiency at C334.

5. The CAH failed to ensure it conducted an annual evaluation to determine whether the utilization of services was appropriate, the established policies were followed and if any neccessary changes were needed. Please see deficiency at C335.

A. Based on a request for the annual total program evaluation and staff interview it was determined the Hospital failed to ensure the CAH arranged for a periodic evaluation of the program.

Findings include:

1. A request for the Hospital's evaluation of its total program was made on survey date 12/06/11. There was no documented evidence or information obtained to be included in the program since 2008.

2. The Quality Assurance/Risk Manager (QA) was interviewed on 12/07/11 and indicated she"no longer keeps an annual evaluation, as before, per request of the past interim Chief Executive Officer (CEO)."

3. The above finding was confirmed with the Chief Nursing Officer( CNO), CEO/Administrator and QA Manager on 12/07/11 at 10:00 am.

A. Based on a request to review the total annual program evaluation and staff interview, it was determined the Hospital failed to ensure the utilization of services,the number of patients served and the volume of Hospital services had been monitored.

Findings include:

1. A request for the Hospital's evaluation of its total program was made on survey date 12/06/11. There was no documented evidence or information obtained by the Hospital since 2008.

2. On survey date 12/07/11 at 2:30 pm the CEO, QA Manager and CNO confirmed there had not been an evaluation completed in 2009, 2010 or 2011.

A. Based on a request to review the annual program evaluation and staff interview, it was determined the Hospital failed to ensure a representative sample of both active and closed records had been reviewed.

Findings include:

1. A request to review the program evaluation, to ensure open and closed records had been reviewed, was made on 12/07/11 at 10:00 am. There was no documentation to indicate the Hospital had reviewed open and closed records for the annual evaluation.

2. The above findings were confirmed with QA Manager on 12/07/11 at 11:00 am.

A. Based on a request to review the annual program evaluation and staff interview, it was determined the CAH failed to ensure policies were reviewed or revised as needed annually.

Findings include:

1. A request to review the annual program evaluation was made on survey date 12/06/11 and 12/07/11. There was no documented evidence to demonstrate an annual total program evaluation was conducted to ensure policies were reviewed or revised as needed.

2. The above findings were confirmed with the QA Manager, the CEO and the CNO on 12/08/11 at 2:45 pm.

A. Based on a request to review the annual program evaluation and staff interview, it was determined the Hospital failed to ensure a total review of the program to determine if utilization of services was appropriate, policies were followed, and any necessary changes.

Findings include:

1. There was no evidence to indicate an annual evaluation of the Hospital's total program evaluation had been conducted since 2008. There was no documented findings to determine whether the utilization of services was appropriate, the established policies were followed and if any revisions were needed.

2. The above findings were confirmed with the Hospital staff (CEO, CNO) at the exit conference conducted on 12/08/11.

A. Based on a review of the contractual services agreements and list of contractual services, it was determined the Hospital staff/QA Manager evaluated all contractual services affecting patient care.

Findings include:

1. A list of contractual services agreements was presented on 12/07/11. The CAH failed to ensure all services were effectively monitored and evaluated that could affect patient care services. There was no documentation to indicate the ultrasound provider or pharamacy services were annually monitored and evaluated.

2. The above findings were confirmed with the QA Manager, CEO and CNO on 12/07/11 at 10:00 am.