HospitalInspections.org

Based on observation, staff interview, and record review, the critical access hospital (CAH) failed to provide a physical environment for the cleaning, decontamination, movement, and storage of endoscopes (illuminated tube inserted into the intestinal tract) and surgical instruments. Failure to provide an appropriate physical environment for scope and surgical instrument cleaning and storage can lead to cross contamination of infectious organisms including bacteria, viruses, and fungus through aerosolization (dispersing particles into the air) resulting in increased infections, increased morbidity, and possible death.

Findings include:

- Observation of the endoscope cleaning procedure with RN Staff EE on 6/28/2017 at 4:00PM revealed the current process for scope processing is to perform the initial rinse of the scope with distilled water in the procedure room using the wrapper in the cleaning kit. The scope is transported in the wrapper through the common hallway (hallway used to transport patients to and from surgery and for all staff passing between surgery rooms) to perform the cleaning process. The process room has sink one and two along one wall with a small counter top next to the sink. Above sink one is a wall mounted oxygen with tubing hanging from the connection. The opposite wall has sink three and four with a short counter top on each side of the sinks. The Olympus scope washing machine (equipment manufactured for the use of cleaning and processing scopes) sits on the third wall next to the entry door. The fourth wall has a door that enters the instrument wrapping and sterilization room. Sink one is used for the scope cleaning and sink two is used for rinsing the scopes. Sink three had dirty surgical instruments in it and sink four was empty. No separation is evident between the sinks and countertops on either side of the room. RN Staff EE was observed cleaning an endoscope in sink one and rinsing it in sink two then loading it into the Olympus machine. RN Staff EE then sprayed the countertop next to sink two with Virex Plus (disinfectant cleaner) and allowed a five minute dwell time. The countertop was then covered with a clean towel and the endoscope was lifted from the Olympus machine and placed on the towel. The tubing connected to the oxygen was pulled across sink one and sink two and the oxygen was blown through the scope. The scope was then carried through the exit door, through the instrument wrapping sterilization room to the scope storage closet.

Interview with Surgical RN Supervisor Staff X on 6/28/2017 at 5:00 PM acknowledged that processing room is not adequate.

CDC guidelines regarding health care physical facilities recommends "The central processing area(s) ideally should be divided into at least three areas: decontamination, packaging, and sterilization and storage. Physical barriers should separate the decontamination area from the other sections to contain contamination on used items. In the decontamination area reusable contaminated supplies (and possibly disposable items that are reused) are received, sorted, and decontaminated ....The sterile storage area should be a limited access area.

Based on observation and interview, the critical access hospital (CAH) failed to ensure the hospital provided proper isolation and ventilation for patients requiring airborne precautions in one of one former isolation rooms. This deficient practice has the potential to expose hospital patients to airborne illnesses, which could lead to a worsening of condition or death.

Findings include:

- Room #10 observed on 6/19/2017 at 3:30 PM revealed negative pressure on/off switches mounted to the wall.

Registered Nurse Staff J interviewed on 6/19/2017 at 3:45 PM indicated Room # 10 was the isolation room, but is now used for labor and delivery patients. Staff J reported they are not even sure the system works and indicated they had never used it.

Infection control officer Staff H interviewed on 6/27/2017 at 4:30 PM reported the no longer have a negative pressure room and verified the room did not function correctly. Staff H indicated if a patient requiring isolation/negative pressure precautions they would transfer the patient immediately to a higher level of care facility with an isolation/negative pressure room.

The facility failed to provide a policy requiring the maintenance of an isolation/negative pressure room.

Based on interview and record review, the critical access hospital (CAH) failed to ensure mid-level practitioners perform peer review of patients' medical records with a doctor. Failure to perform review puts all patients at risk of inappropriate care.

Findings include:

- Review of policies and Medical Staff Bylaws on 6/27/2017 at 11:00AM revealed medical staff peer review of patient medical records does not include mid-level practitioners.

CEO Staff A confirmed on 6/27/2017 that mid-level practitioners are new to the CAH and peer review has not been initiated with them at this time.

Based on observation, staff interview, and policy review, the critical access hospital (CAH) failed to ensure the outdated medications and medical supplies were unavailable for use in one of one nursing station crash carts, one of one cardiac rehabilitation crash carts, one of one wound care supply cart, and the respiratory therapy office. This deficient practice has the potential to expose patients to unsafe, ineffective medications and supplies resulting in inadequate results.

Findings include:

- Nursing station crash cart observed on 6/26/2017 at 4:15 PM revealed following outdated medications and supplies:
-2 Epinephrine (medication used to treat cardiac arrest and anaphylaxis), 1:10,000 (1mg, 0.1mg/ml), outdated 1/6/2017
-2 Atropine (medication used to slow the heart rate) 0.1mg/ml (1mg), outdated 1/6/2017
-1 D5W (IV solution), 500ml, outdated 1/6/2017
- 3 alcohol single swabsticks, outdated 2/17/2017

Staff RN D confirmed the outdated supplies.


- Nursery observation on 6/26/2017 at 3:45PM revealed the following outdated supplies:
- 1 Infant feeding tube, outdated 4/2017
- 2 Pediatric colometric CO2 detectors (used to note expired CO2), outdated 10/2016
- 1 Vaseline gauze strip, outdated 4/2017

Staff RN D confirmed the outdated supplies.


Policy "Expiration Dating" directed " ...all outdated medications will be removed from all Omnicells and pharmacy stock upon expiration ...All drugs have an expiration date and it should be used as a guideline for removing drugs from stock ..."


- Cardiac Rehabilitation Room Code Cart observation on 6/26/2017 at 4:37 PM revealed the following expired supplies:
- One package of cardiac electrodes (sticky patches used when placing a patient on a heart monitor) with an expiration date of 8/2016
- One carbon dioxide detector (used to assess ventilation) with an expiration date of 12/2016
- Two packages of sterile gloves, size 8 ½ with an expiration date of 7/2016,
- One IV bag of normal saline 1000 ml with an expiration date of 4/2017
- Two IV flushes (used to flush an IV line before and after medications) with an expiration date of 12/2016, and one with an expiration date of 2/2017
- Two clear occlusive bandages (clear film dressings) with an expiration date of 2/2006,
- Two 22g IV catheters (used to insert IVs) with an expiration date of 8/2016

Cardiac Therapy RN Staff F interview on 6/26/2017 at 4:37 PM communicated the outdated supplies in the code cart are used for training purposes.


- Physical Therapy Wound Treatment Cart observation on 6/27/2017 at 8:56 AM revealed
- Three Medi-honey packages (medical grade honey dressings for wound care) with an expiration date of 1/2017
- Two bacterial swabs (used to take culture samples) with an expiration date with 3/5/2017 and one with an expiration date of 11/13/2016
- One bottle of liquid topical lidocaine (numbing medication) topical gel with an expiration date of 3/2016.

Therapy Director Staff E interview on 6/27/2017 at 8:56 AM acknowledged the items were expired, and disposed of them

- Physical Therapy Treatment Room observation on 6/27/2017 at 9:17 revealed one bottle of Biofreeze gel (cold therapy pain relief gel) with an expiration date of 6/2015.

Therapy Director Staff E interview on 6/27/2017 at 9:17 acknowledged the item was expired.


- Respiratory Therapy Office observation on 6/27/2017 at 3:10 PM revealed one bag of sterile water, 1,000 ML for inhalation with an expiration date of 10/2016.

Respiratory Therapist Staff G interview at 6/27/2017 at 3:10 PM acknowledged the item was expired and removed it from the supply storage area.

Policy "Outdates in Medical Supply" directed "...Items with expiration dates are monitored on a monthly basis..."

Based on observation, staff interview, and policy review, the critical access hospital (CAH) failed to dispose of expired food products in the kitchen pantry and on the nursing unit, failed to clean patient use equipment as directed by CAH policy, failed to dispose of open medical supplies labeled as single patient use or sterile until packaging compromised, failed to ensure all furniture and patient care items had cleanable surfaces, failed to wear surgical attire appropriately (Registered Nurse Staff X), failed to remove food from clean equipment room, failed to perform hand hygiene (Surgical Staff Nurse EE), and failed to remove contaminated equipment after use (Surgical Staff Nurse EE). Failure by the CAH to dispose of expired food, failure to dispose of open and expired supplies, failure to clean patient care equipment properly, failure to ensure all surfaces are washable, failure to wear surgical attire appropriately, failure to keep food products out of clean work rooms, failure to perform hand hygiene, and failure to remove contaminated equipment after use puts all patients at risk of foodborne illness and cross contamination of bacteria and viruses.

Findings include:

- Observation of the Nursing Station Patient Food Cabinet on 6/26/2017 at 9:00AM revealed the following outdated food:
- 1Vegetable soup, 7oz, outdated 12/9/2016
- 1 Cream of Chicken soup, 7oz, outdated 1/6/2017
- 1 Cream of Chicken soup, 7 oz., outdated 4/28/2017


- Observation of the Nursing Station Patient Refrigerator on 6/26/2017 at 9:00AM revealed the following outdated and open food:
- 3 Individual serving puddings, outdated 2/23/2017
- 3 Individual serving puddings, outdated 4/2017
- 1 can Ensure, undated and uncovered and undated

Unidentified Staff removed the expired and open food from the nursing station area.


- Observation of the kitchen pantry on 6/27/2017 at 10:15AM revealed the following outdated food:
- 19 cans, 15oz Apricots outdated 3/1/2015
- 8 cans, 7oz Cream of Mushroom Soup outdated 1/8/2015
- 17 cans, 7oz Cream of Mushroom Soup outdated 6/17/2017
- 7 bottles, 2.5oz Mrs. Dash Shaker Blend

Dietary Manager Staff O confirmed and removed the outdated food.


Policy "Food Storage Safety" directed " ...Place new stock behind items of the same food so that older stock will be used first ... ...store all opened packages of food in covered containers or zip lock bags. Date when opened ... ...Do not keep leftovers past the three day time limit ... ...Mark the date and use by date on all containers that are placed in the refrigerator ..."

The Kansas Food Handlers Code 3-202.15 Package Integrity directs "FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants."


- Observation of Labor Room #11 on 6/26.2017 at 3:45 PM revealed the following open medical supplies:
-1 Neopuff (device used to aid newborn resuscitation)
- 1 oxygen (O2) monitor connected to bassinet

Staff RN D confirmed the open items and stated the room was clean and the items should have been removed at the time the room was cleaned.


- Observation of the Nursery on 6/26/2017 at 4:15PM revealed the following open medical supplies:
-1 package neonatal electrodes (device used for cardiac monitoring)

Staff RN D confirmed and removed the open items.


- Observation of the Nursing Station Crash Cart on 6/6/2017 at 4:20PM revealed the following open medical supplies:
- 1 disposable MAC 3 laryngoscope blade (used to guide the insertion of a breathing tube)

Staff RN J acknowledged and removed the open supplies.


- Observation of the Physical Therapy Wound Treatment Cart on 6/27/2017 at 8:56 AM revealed the following open single use items:
- 1 Kerlix (gauze wrap)
- 1 Xeroform (Vaseline gauze)
- 2 Aquacel AG (silver impregnated wound dressing) size 4 X 5 in.
- Non adhesive dressing
- 1 Dermagran (zinc impregnated dressing) size 4 X 5 in.
- 1 Medihoney (medical grade honey dressing) size 4 X 5 in.


- Medihoney packaging label reviewed on 6/27/2017 at 8:56 AM directed " ... sterility guaranteed in unopen, undamaged pouch."


- Kerlix gauze wrap packaging label reviewed on 6/27/2017 at 8:56 AM directed " ...do not use if package is opened or damaged."


Physical Therapy Director Staff E interview on 6/27/2017 at 8:56 AM stated, "I'm sure the Kerlix is opened because someone changed their mind" and indicated they thought if the supplies were in a zip-locked baggie, they could remain open in the cart.

The CAH failed to provide a policy regarding single use items.


- Cardiac Therapy RN Staff F interview on 6/26/2017 at 4:45 PM described their process of cleansing the patient glucometer (used to check blood sugar) involved wiping the glucometer with alcohol swabs between patients and occasionally using the Cavicide (hospital strength cleanser) wipes when soiled.

- Policy titled, 'Accucheck Inform II: Blood Glucose System' reviewed on 6/28/2017 directed " ...acceptable products for cleaning and disinfecting are: CaviWipes disinfecting novelettes (3 minutes) ..." and " ... meter must be cleaned and disinfected after each use ..."


- Observation of the Physical Therapy Gym on 6/27/2017 at 9:13AM revealed the CAH failed to ensure there was a cleanable surface for the wooden armrests for four patient chairs and for one stair training device with wooden railings.

- Observation of the Physical Therapy Pool on 6/27/2017 at 9:35 AM revealed the facility failed to ensure there was a cleanable surface for the wooden armrests for the patient chair in the pool bathroom.

Physical Therapy Director Staff E interview on 6/27/2017 at 9:35 AM acknowledged the surfaces not being cleanable.

Infection Control Nurse Staff H interview on 6/27/2017 at 4:40 PM indicated surfaces that are not cleanable are usually caught on safety rounds, then passed on to maintenance.


- Emergency Department waiting area observed on 6/26/2017 at 4:15 PM revealed a three cushioned cloth covered piece of furniture.

Housekeeping Supervisor Staff BB interviewed on 6/26/2017 at 11:55 AM stated they clean the cloth furniture when it is visibly soiled, but not daily.

The CAH failed to provide a policy regarding cleanable surfaces.


- Registered Nurse Staff X and Certified Nurse Anesthetist observed on 6/28/2017 at 11:15 AM revealed them outside the surgical area hallway with masks hanging around their necks.

Registered Nurse Staff X interviewed on 6/28/2017 at 11:25 AM confirmed they had the mask around their neck and the facilities policy is for it to be either on or off but not hanging. Staff X indicated they were not sure what the AORN (Association of periOperative Registered Nurses) guidelines were.


Policy titled "Operating Room Attire" reviewed on 6/28/2017 at 12:00 PM directed " ...Masks must be "on" or "off". They must never hang around the neck ..."

AORN 2012 at VI.b. reads: "A fresh clean surgical mask should be worn for every procedure."
AORN 2012 at VI.b.1 reads: "Masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top."


- Observation of the clean instrument room on 6/28/2017 at 4:28 PM revealed food items as follows:
- One box of saltine crackers
- One bag of almonds
- Two bottles of water
- Four boxes of Craisens
- One can of soup

- Observation of the clean instrument room desk observation on 6/28/2017 at 4:54 PM revealed two water bottles and a bag of trail mix.

Surgical Staff Nurse EE interview on 6/28/2017 at 4:54 PM indicated they have no other place to put drinks or snacks.
Surgical Supervisor Staff X interview on 6/28/2017 at 5:10 PM acknowledged the presence of food items.

On 6/28/2017 the facility failed to provide a policy regarding food items in the clean instrument room.


- Observation of Surgical Staff Nurse EE on 6/28/2017 at 5:06 PM revealed staff removing gloves and protective gown, reaching down to grab a dirty scope wrap with bare hands, donning new gloves, and proceeding to work in the scope room without performing hand hygiene. The staff member then exited the scope room, failing to perform hand hygiene.

Interview with Surgical Staff Nurse EE acknowledged s/he did not perform hand washing and there is no hand hygiene facility available in the scope room.


- Observation in Scope Processing Room observation on 6/28/2017 at 4:48 PM revealed oxygen tubing hanging above dirty scope cleaning sink. The oxygen tubing is then stretched across the dirty field to the clean field to a clean scope for air drying.

Interview with Surgical Staff Nurse EE acknowledged s/he did not change the tubing prior to use.

Interview with Surgical Supervisor Staff Nurse X confirmed s/he usually changes the tubing before each use, but there is nothing in the facility policy about changing the tubing.

Based on medical record review and staff interview, the critical access hospital (CAH) failed to ensure that 5 of 30 medical records (Patient #12, #13, #14, #15, and #16) contained a complete individualized nursing care plan. Failure of the CAH to include comprehensive care plans can result in not meeting the medical, social, and physical needs of each patient and could result in inadequate care.

Findings include:

- Medical record review of Patient #12 on 6/27/2017 at 1PM revealed the patient was born at the CAH on 6/13/2017 and dismissed on 6/14/2017. The medical record revealed no documentation a comprehensive care plan was initiated.

- Medical record review of Patient #13 on 6/27/2017 at 1:15PM revealed the patient was admitted to the CAH obstetric department on 3/20/2017 and dismissed on 3/21/2017. The medical record revealed no documentation a comprehensive care plan was initiated.

- Medical record review of Patient #14 on 6/27/2017 at 1:30PM revealed the patient was born at the CAH on 3/20/2017 and dismissed on 3/21/2017. The medical record revealed no documentation a comprehensive care plan was initiated.

- Medical record review of Patient #15 on 6/27/2017 at 1:45PM revealed the patient was admitted to the CAH obstetric department on 1/2/2017 and dismissed on 1/6/2017. The medical record revealed no documentation a comprehensive care plan was initiated.

- Medical record review of Patient #16 on 6/27/2017 at 2:00PM revealed the patient was born at the CAH on 1/2/2017 and dismissed on 1/6/2017. The medical record revealed no documentation a comprehensive care plan was initiated.

Heath Information Manager Staff I confirmed the charts did not have documentation of nursing care plans.

The CAH did not provide a policy regarding developing and individualizing nursing care plans for all patients.

Based on record review, interview and policy review, the critical access hospital (CAH) failed to ensure patient records are complete. The facility failed to ensure an intraoperative report and a physician's progress note for 1 of 2 surgical patients (#20) was signed within 30 days. The facility also failed to ensure an anesthesia procedure note and a discharge summary for 1 of 2 surgical patients (#21) were signed within 30 days. The failure of the facility to ensure medical records are complete has the potential for incomplete patient record information necessary for continuity of care.

Findings include:

- Patient #20's medical record review on 6/28/2017 at 8:30 AM revealed the patient was admitted on 1/10/2017 with a diagnosis of pancreatitis and cholecystitis (inflammation of the pancreas due to gall-stones), underwent a surgical procedure, and was subsequently discharged on 1/16/2017 Medical record review revealed the intraoperative report was signed on 3/1/2017; 47 days after discharge, which exceeds the 30-day window. Medical record review also revealed a physician progress note was not signed until 2/23/2017; 41 days after discharge, which exceeds the 30-day window.

- Patient #21's medical record review on 6/28/2017 at 9:10 AM revealed the patient was admitted on 4/7/2017 for a scheduled C-Section (surgical delivery of a child), and was subsequently discharged on 4/9/2017. Medical record review revealed the anesthesia procedure note was signed on 5/22/2017; 43 days after discharge, which exceeds the 30-day window. Medical record review revealed the discharge summary was signed on 5/15/2017; 36 days after discharge, which exceeds the 30-day window.

- Medical Records Technician CC interview on 6/28/2017 at 10:30 AM acknowledged the records were not signed within the 30-day window.

Policy titled, 'Medical Record Content' reviewed on 6/28/2017 at 1:15 PM directed, " ... All records of [a] discharged patient must be completed within 30 days ..."

Based on medical record review, staff interview, policy review, and document review, the critical access hospital (CAH) failed to ensure one of thirty sampled medical records (Patient # 22) contained a pertinent medical history and physical (H & P) completed in a timely manner. The CAH's failure to ensure patients' medical history and physical are competed in a timely manner has the potential for poor patient outcomes.

Findings include:

- Patient #22's medical record reviewed on 6/27/2017 revealed an admission date of 6/24/2017 admitted with a diagnosis of Hypertension (high blood pressure) and dehydration. Patient #22's medical record revealed the history and physical was not completed as of the review date on 6/27/2107. The CAH failed to ensure History and physicals were completed within 48 hours of admission.

Registered Nurse Staff J interviewed on 6/27/2017 confirmed they were unable to find the H&P for Patient #22.

Medical Records Staff CC interviewed on 6/27/2017 provided Patient #22's H&P with a completion date of 6/28/2017 (4 days after admission).

Policy review on 6/28/2017 revealed the facility failed to provide a policy directing providers to complete History and Physicals within 48 hours of admission.

Based on document review and staff interview, the critical access hospital (CAH) failed to perform a periodic evaluation that included a review of their health care policies. This deficient practice had the potential to affect quality patient care.

Findings include:

- Review of the Health Care Policy review form on 6/27/2017 at 12:30 PM revealed the following information:

The 2014 form was not provided for review.

The 2015 form revealed the Department director, physician, mid-level provider, administrator, and Board of Trustees representative failed to sign the Policy review form confirming they had reviewed the facilities policies.

The 2016 form revealed the physician and mid-level provider and Board of Trustees representative failed to sign.

The 2017 form revealed the physician and mid-level provider failed to sign.


Health Information Manager Staff I interviewed on 6/27/2017 at 1:00 PM confirmed the appropriate personnel did not review the health care policies annually as required in 2015, 2016, and 2017 and did not have the 2014 form available for review. Staff I indicated the professional outside reviewer had completed the review each year, but facility staff had not.

Policy review on 6/27/2017 revealed the facility failed to provide a policy requiring health care policies to be reviewed at least annually by appropriate members of hospital staff.