HospitalInspections.org

Based on observation, record review, and staff interview, the facility failed to ensure proper ventilation control in patient care areas of the facility. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1.Observation during the facility tour on 11/13/17 at 1:05 p.m., revealed the corridor door at the Surgery Decontamination Room appeared to have positive airflow from the Decontamination Room towards the clean Surgery corridor.

2. Observation during the facility tour on 11/13/17 at 1:12 p.m., revealed the corridor door at the Surgery Soiled Holding Room appeared to have positive airflow from the Soiled Holding Room towards the clean Surgery corridor.

3. Record review and staff interview on 11/13/17 at 1:22 p.m., revealed no documentation to ensure airflow requirements were maintained in areas relative to the Surgery Suite.

4. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation, record review, and staff interview, the facility failed to meet the provisions applicable to Critical Access Hospitals (CAH) of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 10.

Findings include:

1. In reference to Federal Life Safety Code citation K211 the facility failed to ensure the means of egress is continuously maintained free of all obstructions to full use in case of emergency.

2. In reference to Federal Life Safety Code citation K300 the facility failed to ensure appropriate fire protection of Fire Barriers and Fire Doors within the facility.

3. In reference to Federal Life Safety Code citation K321 the facility failed to ensure that hazardous areas are separated from other spaces by appropriate barriers or partitions.

4. In reference to Federal Life Safety Code citation K345 the facility failed to ensure the fire alarm system is tested and maintained in accordance with National Fire Protection Association (NFPA) 72.

5. In reference to Federal Life Safety Code citation K353 the facility failed to ensure that the automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with National Fire Protection Association (NFPA) 25.

6. In reference to Federal Life Safety Code citation K712 the facility failed to ensure that fire drills were held at least quarterly on each shift and that staff were familiar with the fire drill procedures.

7. In reference to Federal Life Safety Code citation K914 the facility failed to ensure the appropriate maintenance and testing of electrical receptacles at patient bed locations.

8. In reference to Federal Life Safety Code citation K918 the facility failed to ensure that appropriate maintenance and testing of the emergency generator and associated equipment was performed in accordance with National Fire Protection Association (NFPA) 110.

9. In reference to Federal Life Safety Code citation K921 the facility failed to ensure appropriate testing and maintenance requirements for fixed and portable patient-care related electrical equipment (PCREE).

10. In reference to Federal Life Safety Code citation K926 the facility failed to ensure that personnel concerned with the application, maintenance, and handling of medical gases and cylinders are trained on the risk.

11. These findings were verified with the Facilities Services Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review and a staff interview it was determined the hospital failed to follow their own policy for venipuncture procedures. This failure has the potential to adversely affect the rights of all patients.

Findings include:

1. Review of the hospital policy titled " Venipuncture Procedure, revised 07/2017, revealed in part: Blood is drawn into either evacuated tubes ( Vacutainer tubes) or into disposable syringes. Verify tubes are not expired before drawing."

2. A tour of the north side Nurse Med Room conducted on 11/13/17 at 8:30 a.m. revealed six (6) blue top vacutainers and three (3) gray top vacutainers, expiration date 03/2017, and four (4) Bact/Alert Blood culture containers, expiration date 06/2017. All expired vacutainers and blood culture containers were located in the phlebotomy tray.

3. A tour of the west side Nurse Med Room conducted on 11/13/17 at 8:50 a.m. revealed ten (10) blue top vacutainers, expiration date 03/2017. All expired vacutainers were located in the phlebotomy tray.

4. An interview was conducted on 11/13/17 at 9:00 a.m. with the Director of Nursing. She verified the findings and stated these supplies should not be in the phelobotomy trays.

This STANDARD is not met as evidenced by:

Based on document review and staff interview it was determined the facility failed to monitor and document the daily temperatures of the refrigerator/freezer in the dietary area of the facility. This failure has the potential to adversely impact the condition of all patients and visitors receiving dietary services.

Findings include:

1. A review of the temperature log entitled 'Pop (Bottles) Cooler' revealed on 11/4/17, 11/5/17, 11/11/17, 11/12/17 and 11/13/17 there was no daily temperature documented.

2. A review of the temperature log entitled 'Pop (Cans) Cooler' revealed on 11/4/17, 11/5/17, 11/11/17, 11/12/17 and 11/13/17 there was no daily temperature documented.

3. A review of the temperature log entitled 'Cafeteria Dessert Cooler' revealed on 11/3/17, 11/4/17, 11/5/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17 there was no daily temperature documented.

4. A review of the temperature log entitled 'F 5 Workers Cooler' revealed on 11/1/17, 11/2/17, 11/3/17, 11/6/17, 11/7/17, 11/8/17, 11/9/17 and 11/10/17 there was no daily temperature documented.

5. A review of the temperature log entitled 'Ice Cream Cooler' revealed on 11/1/17, 11/2/17, 11/3/17, 11/6/17, 11/7/17, 11/8/17, 11/9/17 and 11/10/17 there was no daily temperature documented.

6. A review of the facility policy entitled 'Refrigerator/Freezer Temperature Monitoring' stated in part ' ...these units are to be checked and documented daily on a Temperature Log ...'.

7. In an interview with the Manager of Dietary on 11/13/17 at approximately 1:15 p.m. he agreed with the above findings.