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Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide a visual mechanism for monitoring the air pressure of the room at one of one (Patient Room 206) airborne infectious isolation room. The failed practice had the likelihood to affect all patients and staff in that an incorrect air pressure of the isolation room would not be detected, allowing an infectious disease to be transmitted through the air going out of the room. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 44:C.7 showed each airborne infection isolation room shall have a permanently installed visual mechanism for monitoring the pressure status of the room when occupied by patients with an airborne infectious disease.
B. Observation of Patient Room 206 on 10/18/22 at 2:10 PM showed the room was an airborne infection isolation room and was not provided with any mechanism for monitoring the pressure of the room while occupied. This finding was verified with the Director of Maintenance at the time of observation.

Based on review of Rules for Critical Access Hospitals in Arkansas, Arkansas Department of Health - Health Facility Services (Revision Date February 5, 2021), observation and interview, it was determined the facility failed to have an emergency call system in one of one Outpatient Rehabilitation Toilet Room. By not having an emergency call system in place, an incapacitated patient would not have a way to communicate to nursing personnel they needed help. The failed practice had the likelihood to affect all patients that received outpatient rehabilitation services: Findings follow:

A. Review of Rules for Critical Access Hospitals in Arkansas, Arkansas Department of Health - Health Facility Services (Revision Date February 5, 2021) Section 72.F.2. Physical Environment, Electrical Standards showed an emergency call system shall be provided at each inpatient/outpatient toilet, bath, and shower room. An emergency call shall be accessible to a collapsed patient on the floor. Inclusion of a pull cord within four to six inches from the floor will satisfy this standard. The emergency call shall be designed so that a signal activated at a patient's calling station will initiate a visible and audible signal distinct from the regular nurse/patient communication station that can be turned off only at the patient calling station. The signal shall activate an annunciator panel at the nurse station, a visible signal in the corridor at the patient's door, and at other areas defined by the narrative program.
B. During a tour of Outpatient Rehabilitation Services on 10/18/22 at 12:40 PM, observation revealed one of one Outpatient Toilet Room did not have an emergency call system.
C. On 10/18/22 at 12:50 PM, the Manager of Rehabilitation Services verified there was no emergency call system in the Outpatient Toilet Room.

Based on policy, review of refrigerator temperature logs, and interview it was determined the facility failed to ensure that employees followed its policy regarding safe patient nourishment refrigerator temperatures for four (Breast Milk, Obstetrics, Emergency and Critical Care) of five (Medical/Surgical, Breast Milk, Obstetrics, Emergency and Critical Care) Units. Failure to ensure refrigerator temperatures were within acceptable ranges did not ensure that patient food and beverages were kept at safe temperatures to prevent contaminants or ruined product. Findings follow:

A. Review of a sign hanging on patient nourishment refrigerators showed the temperature was to be below 40 degrees F (Fahrenheit). It also showed the temperatures were to be recorded daily.
B. During a tour of the facility on 10/18/22 from 2:00 PM to 3:15 PM, observation revealed the following:
1) Obstetrics - patient nourishment refrigerator temperatures were not being logged. There was no observable thermometer in the refrigerator.
2) Breast milk refrigerator - The log for the refrigerator showed the temperature range was to be between 36-46 degrees F (which is incorrect, should be below 40 degrees F but above freezing which occurs at 32 degrees F). Observation showed the temperature was 30 degrees F, but the log was marked 39 degrees F at 7:00 AM 10/18/22. There was a large accumulation of ice in the freezer compartment hanging from the freezer bottom.
3) Emergency Department - The log for the refrigerator showed the temperature range was to be between 36-46 degrees F (which is incorrect, should be below 40 degrees F but above freezing which occurs at 32 degrees F). The temperature log for 10/01/2022- 10/18/2022 showed 13/18 of the days the temperature was 7 degrees C (Celsius) which is 44.6 degrees F. The temperature for the remaining 5 days was 6 degrees C which is 42.8 degrees F. All these noted temperatures were above the recommended "below 40 degrees F".
4) Critical Care Unit - The log for the refrigerator showed the temperature range was to be between 36-46 degrees F (which is incorrect, should be below 40 degrees F but above freezing which occurs at 32 degrees F). The temperature log for 10/01/2022- 10/18/2022 showed all 18 days were between 26 and 32 degrees F. All these noted temperatures were below the recommended freezing range which occurs at 32 degrees F.
C. The findings were verified at the time of observation with the Chief Nursing Officer and the Compliance Officer.

Based on review of policy, Occupational Therapist Assistant's Job Description, review of Occupational Therapist Assistant's (OTA) personnel file and interview, it was determined one (OTA #1) of two (OTA #1 & #2) did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per policy and Occupational Therapist Assistant' Job Description. By not having evidence of these qualifications, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Record review of facility policy titled "Credentials," revised October 2022, showed all occupational therapy personnel shall maintain competency in CPR.
B. Record review of Occupational Therapist Assistant' Job Description, showed that one of the minimum qualifications is to be CPR certified.
C. Review of OTA #1's personnel file showed OTA #1's CPR certification expired 12/20/20.
D. On 10/18/22 at 12:40 PM, the Manager of Rehabilitation Services verified OTA #1 has seen patients on 10/10/22, 10/11/22 and 10/17/22 while having an expired CPR certification.

Based on observation and interview, it was determined the facility failed to have a policy and procedure to assure expired patient nourishments did not remain past their expiration date in the patient nourishment refrigerators in three (Obstetrics, Emergency and Critical Care) of three departments that patient nourishment refrigerators were observed. By not assuring patient nourishments were removed once expired, the facility could not assure the safety from bacterial growth. The failed practice had the likelihood to affect all patients who received nourishments from the refrigerators in these units at the facility. Findings follow:

A. During a tour of the facility on 10/18/22 from 2:07 PM until 3:10 PM, observation showed the following expired items in patient nourishment refrigerators:
1. Obstetrics
a) One Atkins Milk Chocolate Drink, 11 ounces, expired 10/11/22;
b) One Equate Protein Shake Carmel, 11 ounces, expired 7/05/22;
c) One Premier Protein Shake, 11 ounces, expired 07/16/22; and
d) Two Premier Protein Shake Strawberry, 11 ounces, expired 12/28/21 and 05/25/22.
2. Emergency
a) Two half pints of skim milk expired 10/16/22.
3. Critical Care
a) Two Glucerna Rich Chocolate, 11 ounces, expired 09/01/22; and
b) One Glucerna Homemade Vanilla, 11 ounces, expired 11/01/22.
B. On 10/18/22 at the times of observation, the Compliance Officer verified the findings at A.
C. A policy was requested regarding the process to assure patient nourishments were not available once expired on 10/20/22 at 10:55 AM. The facility stated they did not have one.



Based on review of policy, observation, and interview, it was determined the Infection Control Officer failed to identify the unsanitary condition of patient ice machines in four (Medical/Surgical, Obstetrics, Emergency and Critical Care Unit) of four areas toured. The failed practice had the likelihood for ice to become contaminated and could affect any patient receiving ice that had been dispensed from the ice machines. Findings follow:

A. Record review of the facility's policy titled, "Cleaning of Ice Machines," showed ice machines were to be cleaned quarterly by maintenance. Cleaning was to include the inside of the bin, inside of the spouts and outside of the machines. The outside of the machines showed the air filter was to be cleaned twice a month.

B. During a tour of the facility on 10/18/22 from 2:00 PM to 3:15 PM, the ice machines on Medical/Surgical, Obstetrics, Emergency and Critical Care Units showed splashes, stains and residue build up on the face of the machine where the cup was placed to receive the ice, and the chute that dispenses the ice had white residue buildup. The Ice machine in the Emergency department had dust buildup in the upper right corner in the ice dispensing area.

C. On 10/19/22 at 8:43 AM, the Compliance Officer verified the findings in B.




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Based on review of policy and procedure, review of Association of Perioperative Registered Nurses (AORN) guidelines, review of manufacturer's instructions for use, observation, and interview, it was determined the Facility failed to maintain a sanitary environment in that immediate use sterilization (IUSS) was commonly used on instrument sets and not for the purpose of immediate use. The failed practice did not ensure the time and temperature for sterilization was met and had the likelihood to affect all surgical patients requiring use of the instruments sterilized via IUSS. Findings follow.

A. Review of Facility's revised 2017 policy and procedure titled, "Immediate Use Steam Sterilization," showed that Immediate Use Steam Sterilization (IUSS) shall be kept at a minimum.

B. Review of AORN's 2018 sterilization guidelines titled, "The Guideline for Sterilization," showed the following:
1. 5.5.3. Used items processed by IUSS immediately and do not store them for future use or hold them from one procedure to the next.
2. Time constraints and lack of equipment and supplies may result in pressure on operating room (OR) personnel to eliminate or modify one or more steps in the cleaning and sterilization process.

C. Review of IUSS Logs from 10/04/22 through 10/13/22 showed IUSS performed on instruments for seven of seven patients (Patients #22-28), one unidentified eye tray and six unidentified "Battery (2)" for orthopedic procedures.

D. Interview with Scrub Technician #1 on 10/19/22 at 10:55AM, Scrub Technician #1 was asked about criteria requirements were for instruments that underwent IUSS. Scrub Technician #1 stated that IUSS was used for eye trays when three or more eye surgeries were scheduled for one day and stated that a preferred eye tray, used in the first eye case of the day, would be requested in following cases. When asked about IUSS for orthopedic Batteries, Scrub Technician #1 stated that IUSS was not utilized, and that documentation on the IUSS form was an error.

E. The findings in A, B and C were verified in an interview with the Director of Surgical Services on 10/19/22 at 2:50 PM.

Based on policy review, clinical record review, and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the POC for 6 of 6 (#1-#5 and #9) swing bed patients. The failed practice had the likelihood to effect continuity of care. The failed practice had the likelihood to affect all patients admitted to the Swing Bed unit. The findings follow:

A. Review of policy titled, " Discharge Planning," revised July 2015, showed:
1) During the admission assessment, patient planning was to be initiated to identify problems and make appropriate entries on the problem list or Plan of Care. Interaction with appropriate members of the healthcare team was to occur during the patient's hospitalization to enable a comprehensive plan for patient care to be developed.
2) All discharge planning were to include patient, family, or significant other teaching, were to be documented in the medical on the patient POC and Nurse's Notes as appropriate.
B. During an interview on 10/19/22 at 12:30 PM, Chief Nursing Officer (CNO) confirmed the findings in A.

C. Review of clinical record of Patient #1 on 10/19/22, admitted 10/12/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 10:45 AM, CNO confirmed the findings in C 1-3.

D. Review of clinical record of Patient #2 on 10/19/22, admitted 10/11/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 11:00 AM, CNO confirmed the findings in D 1-3.

E. Review of clinical record of Patient #3 on 10/19/22, admitted 10/04/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 11:15 AM, CNO confirmed the findings in E 1-3.

F. Review of clinical record of Patient #4 on 10/19/22, admitted 09/15/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 11:30 AM, CNO confirmed the findings in F 1-3.

G. Review of clinical record of Patient #5 on 10/19/22, admitted 10/06/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 11:45 AM, CNO confirmed the findings in G 1-3.

H. Review of clinical record of Patient #9 on 10/19/22, admitted 09/23/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 10/19/22 at 12:00 PM, CNO confirmed the findings in H 1-3.