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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Re-Certification Survey conducted on July 9, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure a safe and secure environment free of ligature risk. This has the potential to affect all staff, visitors, and patients who receive care and/or are present, in areas where ligature risk concerns are present.

Findings include:

1. On 6/25/19 at 1:00 PM, during an observational tour of the ED, an interview was conducted with the ED Manager (E#9). E#9 stated that Patients who are at risk for suicide are placed in the triage room, located directly across from the ED nurses station. Patients are not assigned 1:1 observation "because we can see them from the desk". Police, family, Social Workers, etc would be considered "ok" to sit with suicidal patients in lieu of ED staff.

2. On 6/25/19, the observation tour of the ED, included the triage room. The nurses station is encased in glass and a door. The triage room was observed to have a full wood door (no window) that led into the room. The counter top, sink, and upper and lower cabinets were all that could be visualized. The patient chair was located to the left side of the room, between the door and the wall, and was not visible from the nursing station. E#9 did not comment when asked how the patient could be visualized behind the door, out of the line of sight.

3. On 6/25/19, at approximately 2:45 PM, a tour of the Emergency Department (ED) was conducted with the Chief Executive Officer (E#24). The triage room, utilized for ED patients who are assessed to be at suicidal risk, was noted to have the following ligature risks identified: drop ceiling, hinges on door, door handle, wire basket secured to wall with screws, and a J- loop faucet. These findings were concurrently confirmed with E#24.

4. Policy Number: 03.12.01 Ligature Risk Management (implemented by the CAH 2/2018) was reviewed on 6/26/19 at approximately 9:10 AM. The policy indicated, "... anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulations... shower rails, coat hooks, pipes... ceiling fittings, handles, hinges and closures."

5. The Ligature Risk Assessment for the "Senior Life Solutions", (dated by the CAH, 4/15/19) was reviewed on 06/26/19 at approximately 9:30 AM. A concurrent interview was conducted with the Chief Nursing Officer (E#1). E#1 stated, "We didn't realize the ED needed to have one done (a ligature risk assessment). We thought it was only for our outpatient behavioral health clinic, but now I realize that we do see a lot of patients in the ED that have suicidal issues."

6. On 6/27/19 at approximately 12:30 PM, a tour of the Senior Life Solutions (outpatient behavior health clinic) was conducted with the Program Director (E #12). The following ligature risks were identified and confirmed by E #12:
a. Common area; a round approximately 4 inch steel tube which extended across the ceiling.
b. Group Room #223; hinges on door to room, looped door knob, and hand sanitizer on the wall.
c. Bathroom; J-loop faucet; hinges on bathroom door, round door knob on bathroom door; paper towel dispenser screwed to wall, and U-loop plumbing.
d. The above findings were not identified in the unit's ligature risk assessment.

A. Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure mechanical and electrical equipment, available for patient use, was inspected and had routine preventive maintenance. This has the potential to affect all patients receiving services at the CAH with an average daily census of 3.

Findings include:

1. On 6/25/19 at approximately 10:45 AM and on 6/26/19 at approximately 12:40 PM, tours were conducted of the following areas and electrical equipment was observed which lacked maintenance stickers indicating an inspection was conducted prior to patient use:
a) Medical surgical unit-1 plug in scale (tour conducted with Supervisor of Medical Surgical - E#8).
b) Rehabilitation- 3 Hi-Lo treatment tables (tour conducted with Director of Therapy - E#7).
c) Sleep lab- 1 plug in scale and 2 tower fans located in rooms 214 and 215 (tour conducted with Chief Nursing Officer - E#1).

2. The following policies and guidelines were reviewed:
a. The policy titled "Preventative Maintenance (reviewed by the CAH 11/2017)" was reviewed on 6/26/19 at approximately 10:25 AM. The policy required "Policy: Equipment included in the program shall meet one...of the following criteria: The equipment is essential for life support or is used in diagnosing or monitoring any physiologic condition of the patient."
b. The policy titled "Electrical Safety- Equipment Condition- Department of Rehabilitation Services (reviewed by the CAH 4/2017)" was reviewed on 6/26/19 at approximately 2:20 PM. The policy required "...Procedure: Electrical equipment and devices with electronic component shall be evaluated..."
c. The manufactures guideline for the "Hi- Lo treatment tables" was reviewed on 6/26/19 at approximately 2:45 PM. The manufactures guideline required "Maintenance ...moving parts of the table should have a drop of oil placed on them approximately every 6 months. Frequently check to make certain that all hardware...are properly adjusted."

3. Interviews were conducted during the tours with E #1, E#7, and E#8. Each verbally confirmed that the respective electrical equipment lacked inspections, prior to patient use.


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B. Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure patient use equipment was cleaned and maintained, in accordance with the manufacturer's guidelines. This has the potential to affect all outpatients who underwent hydrocollator therapy services by the CAH offsite therapy.

Findings include:

1. On 06/25/19 at approximately 3:00 PM, a tour of the off-site therapy unit was conducted with the Director of Therapy (E#7), along with a concurrent interview. A hydrocollator (machine used for heating water to warm pads used in physical therapy) was observed in the patient treatment area. The Hospital lacked documentation of the hydrocollator cleaning. E#7 stated that the Hydrocollator was used daily and that the water was drained and the machine cleaned every three months.

2. The following CAH policy and manufacturer's guidelines were reviewed:
a. On 06/26/19 at approximately 9:00 AM, the policy "Cleaning Hydrocollator" (revised by the CAH 06/2018) was reviewed. The policy stated "The hydrocollator will be cleaned (typed) Q (every) 3 months...." The "Q 3" and the "m" and "s" on the policy were hand written in with no indication as to who made the changes or when.
b. On 06/27/19 at approximately 11:00 AM the Hydrocollator manufacturer's instructions were reviewed. The manufacturer's guidelines state, "The tank should also be drained, cleaned, and inspected at minimum intervals of every two weeks."

3. On 06/28/19 at approximately 9:00 AM, an interview with the Chief Nursing Officer (E#1) was conducted. E#1 stated, "I don't think we (E#7 and the CAH) realized there was a discrepancy (between the CAH's policy and the manufacturer's guidelines). We will clean the hydrocollator according to the manufacturer's guidelines."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on July 9, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review and interview, it was determined the Governing Body failed to ensure its' Medical Staff Bylaws were followed to assure the provision of safe care and services by competent, privileged staff. Therefore the Condition of Participation 42 CFR 485.627, Organizational Structure, was not met. This has the potential to affect all inpatients and outpatients serviced by the Critical Access Hospital, with an average daily census of 63 and 3, respectively.

Findings include:

1. The Governing Body failed to ensure care and services were provided by Medical Staff who were competent and privileged in all services provided, in accordance with its' Medical Staff Bylaws. See C-241.

2. See C-294

Based on document review and interview, it was determined for 1 of 2 (Medical Doctor -MD#8) Physicians, granted Temporary Privileges within the last 6 months, the Governing Body failed to ensure care and services were provided by Medical Staff, whom were competent and privileged in all services provided, in accordance with its' Medical Staff Bylaws. This has the potential to affect all inpatients and outpatients serviced by the Critical Access Hospital, with an average daily census of 63 and 3, respectively.

Findings include:

1. The "Bylaws of The Medical Staff" (undated) was reviewed on 6/25/19 at approximately 12:55 PM. On page 30, the Bylaws indicated, "Section 2. Temporary Privileges... Upon receipt of an application for Medical Staff membership and/or privileges from the licensed practitioner, the CEO (Chief Executive Officer) may, upon the basis of information then available which may be reasonably be relied upon... and with the written concurrence of the Chief of Staff grant temporary admitting and clinical privileges to the applicant. Prior to granting temporary privileges, there must be verification of ... query and evaluation of National Practitioner Data Bank report... If the application raises no concerns, temporary privileges may be granted..."

2. The credential file of MD#8 was reviewed on 6/26/19 at approximately 12:00 PM and on 6/27/19 at 8:40 AM with the Administrative Assistant (E#23). MD#8's file indicated the following:
a. Initial Medical Staff application was dated 3/4/19.
b. Temporary Privileges in Emergency Medicine were granted by the CEO and Chief of Staff on 3/15/19.
c. Internal documentation, dated 6/19/19, indicated, "The QI (Quality Improvement) Committee tabled (MD#8). The following information is stuff we need to get from (MD#8)... 2. (MD#8) filled out priv (privilege) lists for a lot of things, but didn't do one for Medicine. (MD#8) will need to do that. 3. Can you find out from (MD#8) about the 2000 case that was settled for the 61 year old man - it was never reported to the NPDB (National Practitioner Data Bank) and we don't know why..."
d. Internal documentation, dated 5/17/19, indicated "As part of our Focused Professional Practice Review/Peer Review process... The Review came back with a score of 4 for Inappropriate Care of Disposition. What this means is that the review indicates significant misdiagnosis or problems with care..." Internal documentation, dated 3/15/19, related to the QI meeting, indicated, "Concerns: 1) Decompensated heart failure, met admission criteria 2) Did not follow normal heart failure protocol with cardiac rule out 3) Missed fracture".

3. An interview was conducted with E#23 during the credential file review. E#23 stated information is reviewed by E#23 and then the CEO (E#24) is notified that everything is ok and grants the temporary privileges. "We didn't realize that (MD#8's) information (NPDB and application) didn't match until the QI meeting (6/15/19). That's when we reviewed (MD#8's) cases and identified concerns with some of the care and sent (MD#8) a letter." When asked if MD#8 continued to be scheduled, despite Medicine privileges not being granted, E#23 stated, "Yes, I believe so. I think (MD#8) was here yesterday. Yes, the ED physicians also perform as the Hospitalist and that's why they have to have Medicine privileges as well as Emergency privileges. I'm sure they (CEO and Chief of Staff) have told (MD#8) that (MD#8) has to fill out the request for those privileges too."

4. The CAH ED schedule for June 2019 was reviewed on 6/27/19 at approximately 10:30 AM with E#23. MD#8 had worked on 6/26/19. E#23 further presented a "Medicine" privilege list for MD#8, dated 3/4/19. When asked why the privilege list was dated 3/4/19, instead of when it was actually filled out, E#23 did not answer.

5. An interview was conducted with the CEO (E#24) on 6/27/19 at approximately 12:00 PM. E#24 verbally agreed with the above findings.

Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure safe patient care and services were provided. Therefore the Condition of Participation 42 CFR 485.635, Provision of Services, was not met. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. The CAH failed to ensure a safe, secure environment free of ligature risk. See C-221.

2. The CAH failed to ensure its' suicide screening tools and subsequent suicide precautions policy, were initiated and followed to assure patient safety and decrease ligature risk. See C-271 A.

3. The CAH failed to ensure staff were knowledgeable and competent in the use of restraint/seclusion, in accordance with its' policy. See C-271 B.

4 The CAH failed to ensure consents were signed in accordance with its policy. See C-271 C

5. The CAH failed to ensure expired medications and biologicals were not available for patient care and/or use. See C-276.

6. The CAH failed to ensure infection control training and surveillance included all personnel providing care to its patients, in accordance with its' policy See C-278 A

7. The CAH failed to ensure proper cleaning to prevent the potential for cross contamination and infection. See C-278 B.

8. The CAH failed to ensure items were properly stored, in order to prevent the potential for cross contamination and infection. See C-278 C

9. The CAH failed to develop and implement policies on expired supplies, which were available for patient care and/or use, to ensure patient safety from contamination. See C-278 D

10. The CAH failed to develop and implement a food storage policy, preventing the available use of outdated or unlabeled food products, which may be unsafe for human consumption. See C-279

11. The CAH failed to establish, implement, and maintain an effective, house-wide initial and ongoing personnel competency instruction and evaluation program to ensure the provision of safe patient care services, by qualified, competent personnel. See C-294

A. Based on observation, document review, and interview, it was determined for 3 of 3 (Pt #3, Pt #5, Pt #6) patients, presenting to the emergency room with a chief complaint and/or diagnosis of psychiatric problems requiring suicide precautions, the Critical Access Hospital (CAH) failed to ensure its' suicide screening tools and subsequent suicide precautions policy, were initiated and followed to assure patient safety and decrease ligature risk. This has the potential to affect all patients presenting to the emergency room requiring suicide precautions.

Findings include:

1. See C-221.

2. On 6/25/19, during the observational tour of the ED, an interview was conducted with the ED Manager (E#9). E#9 stated that patients who are at risk for suicide are placed in the triage room, located directly across from the ED nurses station. Patients are not assigned 1:1 observation "because we can see them from the desk". Police, family, Social Workers, etc would be considered "ok" to sit with suicidal patients in lieu of ED staff. "They (Chief Nursing Officer-E#1) just brought us (the ED staff) the suicide prevention education (CSSRS sheet listed below) and I just didn't get the correlation of the education and what we have in the computer and that they were to be used together."

3. On 6/25/19, the observation tour of the ED, included the triage room. The nurses station is encased in glass and a door. The triage room was observed to have a full wood door (no window) that led into the room. The counter top, sink, and upper and lower cabinets were all that could be visualized. The patient chair was located to the left side of the room, between the door and the wall, and was not visible from the nursing station. E#9 did not comment when asked how the patient could be visualized behind the door, out of the line of sight.

4. The following two screening tools and one policy, utilized to determine suicidal risk, were reviewed:
a. The "Columbia-Suicide Severity Rating Scale (CSSRS)" (a 6 item tool used to identify and assess individuals at risk for suicide), which is incorporated into the initial patient safety screening assessment and is to be completed upon the initial nursing assessment in the emergency room, was reviewed on 6/26/19 at approximately 3:00 PM. The scale indicated interventions to be taken, if the patient answered yes to any of the items, such as Items 1 and 2 indicated, "Behavioral Health Referral at Discharge". Item 6 indicated, "3 months ago or less: Immediate Notification of Physician and/or Behavioral Health and Patient Safety Precautions".
b). A screenshot of the ED depression screening was reviewed concurrently with the ED records of Pt #3, Pt #5, and Pt #6). The depression screening indicated, "Do you have any suicidal/homicidal ideation?... Have you had any previous suicidal attempt?... If yes to above suicidal questions, complete the following: Sitter at the bedside. Belongings removed. Physician notified. Assess patient room for safety. Submit referral for Social..."
c). The "Suicide Precautions Policy" (reviewed by the CAH on 4/2019) was reviewed on 6/26/19 at approximately 3:00 PM. The policy required the following: "Suicide precautions shall be ordered by the physician, but nursing staff all implement suicide precautions while awaiting the order. All harmful objects shall be removed from the patient's possession. Clothing shall be removed and patient shall be given a gown. No electronic devices including cell phones, Ipads, laptops, etc. will be permitted during suicide precautions. "Suicide precautions shall be ordered for a maximum of 24 hours and reassessed each 24-hour period for renewal. The physician may discontinue them anytime... All patients placed on suicide precautions shall be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior." The policy does not refer to the CSSRS or the depression screening and the CSSRS and depression screening do not refer to the Suicide Precautions policy.

5. On 6/26/19 at approximately 11:00 AM, the medical record of Pt #3 was reviewed. Pt #3 was assigned to the Triage room for a chief complaint of Suicidal Ideations on 2/26/19. The CSSRS was completed and indicated yes to items 1 thru 5, which indicated Pt #3 was a suicide risk. The medical record lacked documentation that any required suicide precautions were initiated, in accordance with the CAH policy and suicidal screening tools

6. On 6/26/19 at approximately 12:00 PM the medical record of Pt #5 was reviewed. Pt #5 was assigned to the Triage room for a chief complaint of psychiatric problems on 3/26/19. Pt #5 presented with "complains of feeling suicidal, reports having thoughts of suicide". Pt #5 CSSRS was completed and indicated 2 - yes answers, which indicated Pt #5 was a suicide risk. The medical record lacked documentation that any required suicide precautions were initiated, in accordance with the CAH policy and suicidal screening tools.

7. On 6/26/19 at approximately 12:45 PM the medical record of Pt #6 was reviewed. Pt#6 was assigned to the Triage room for a chief complaint of psychiatric problems on 3/28/19. Pt #6 presented with "an injury that involved self harm.. complaint of suicidal ideation's". Pt #6 had been seen in the ER on 3/26/19 for Suicidal Ideations. The record lacked a CSSRS completed and lacked documentation that any required suicide precautions were initiated, in accordance with the CAH policy and suicidal screening tools.

8. On 6/26/19 at approximately 2:15 PM, an interview was conducted with the Emergency Room Nurse (E# 10). E #10 stated, "There is not a good understanding of how the suicidal screening prompts the suicidal precautions. I haven't had any training on their (the CAH) suicide precautions policy. They basically just handed us the tool (CSSRS) and told to review it."

9. On 6/27/19 at approximately 9:15 AM an interview was conducted with the Chief Nursing Officer (E #1). E#1 stated, "I thought they did a CBL (Computer Based Learning) on suicide precautions, but I'm not seeing that on their training record. The Columbia Suicide Rating Scale and the Suicide Precautions Policy are not connected, but they should be. They do not refer to each other for guidance in the assessment and interventions necessary to place a patient in suicide precautions."


B. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure staff were knowledgeable and competent in the use of restraint/seclusion, in accordance with its' policy. This has the potential to affect all inpatient and outpatients, who may require the use of restraint/seclusion at the CAH.

Findings include:

1. On 6/25/19 at approximately 2:45 PM, a tour of the Emergency Department (ED) with the Chief Executive Officer (E#24), was conducted. Both leather restraints and soft limb restraints were available for use in the ED.

2. On 6/25/19, during the tour, an interview was conducted with the ED Manager (E#9). E#9 stated that the CAH used to only use the soft limb restraints, but obtained the leather restraints for the ED in case needed with violent patients that present to the ED. E#9 stated their restraint training did not include hands-on demonstration in applying the restraints. E#9 was uncertain if the physicians had any training in restraints either. E#9 was unable to state how often and/or when the restraints had been used.

3. Policy "Reference #10208A Restraints" (revised by the CAH 2/22/02) was reviewed on 6/26/19 at approximately 3:00 PM. The policy required the following:
- "All staff that has direct contact must have ongoing education and training in the proper and safe use of restraints. End of Conditions of Participation requirements for acute medical and surgical care."
- "All staff that has direct patient contact must have ongoing education and training in proper and safe use of seclusion and restraint application and technique and alternative methods for handling behavior, symptoms and situations that traditionally have been treated through the use of restraints or seclusion."

4. On 6/25/19 at approximately 3:40 PM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 verbally agreed that staff were not required to do a demonstration in the use of restraints. E#1 further stated uncertainty as to whether or not physicians, who could order restraint and/or seclusion, had any training in the CAH policy/procedure for restraint/seclusion. On 6/26/19 at approximately 9:00 AM, E#1 stated, "No, we don't require any type of training for our physicians (who could order restraint/seclusion) We are going to have to look into that."


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C. Based on document review and interview, it was determined in 1 of 2 (Pt #17) patients' records reviewed, for outpatient treatments, the Critical Assess Hospital (CAH) failed to ensure consents were signed in accordance with its policy. This has the potential to affect all out patients serviced by the CAH, with an average monthly outpatient census of 25 patients.

Findings include:

1. Pt #17 Date of outpatient service: 4/18/19. Diagnosis: Deficiency of Testosterone.
Pt #17's medical record was reviewed on 6/26/19 at approximately 2:30 PM. The record stated that Pt #17 received Testosterone 200 mg (milligrams) IM (intramuscular) on 4/18/19. The record lacked a signed informed consent by the patient for the 4/18/19 treatment.

2. The policy titled "Hospital Informed Consent" was reviewed on 6/27/19 at approximately 10:30 AM. The policy required "...Policy: A written informed consent form shall be completed and entered into the medical record when the patient seeks care from the hospital system..."

3. An interview was conducted with the Manager of Clinical Informatics (E#6) on 6/26/19 at approximately 3:00 PM. E#6 verbally confirmed the lack of the informed consent.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired medications and biologicals were not available for patient care and/or use. This has the potential to affect all inpatients and outpatients serviced by the CAH.

Findings include:

1. On 6/25/19 at approximately 10:45 AM, a tour was conducted of the Medical Surgical Unit, with the Supervisor of Medical Surgical (E#8). The following expired medication and biological was observed:
a.) In the patient refrigerator, located in the kitchen, a 1 gallon jug of CT (computed tomography) oral contrast, expired 6/24/19.
b.) In the medication room: 1 bottle of TB (tuberculocide) Cide, expired 8/6/14.

2. An interview was conducted with E#8 during the tour. E#8 verbally confirmed the outdated items were available for patient use and further stated, "They (the CAH) don't have a policy for expired biologicals." E#1 verbally confirmed the expired biologicals should have been disposed of.

3. On 06/25/19 at approximately 11:00 AM, a tour of the Radiology Department was conducted with the Infection Preventionist (E #2) and the Imaging Director (E #4). The following expired medications were available for use in the patient care areas:

a.) Fluoroscopy -- Two 10 ML (milliliter) prefilled Normal Saline syringes, expiration date 11/2018.
b.) Echocardiogram -- Fifteen Bacteriostatic 0.9% Normal Saline 30 ML vials, expiration date 05/01/2019.

4. On 06/26/19 at 2:00 PM, the Critical Access Hospital policy "Beyond Use Dating" [revised 03/2013] was reviewed. The policy stated, "Expired medications will be removed from patient supply and disposed of per protocol for expired medications.


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A. Based on document review and interview, it was determined for 3 of 3 (Medical Doctor- MD#1, MD#6, and Certified Registered Nurse Anesthetist- CRNA #1), staff members reviewed for infection control training and infection surveillance, the Critical Access Hospital (CAH) failed to ensure infection control training and surveillance included all personnel providing care to its patients, in accordance with its' policy. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. Policy "Reference #1001 Infection Prevention and Control Program" (reviewed by the CAH 6/2016) was reviewed on 6/25/19 at approximately 10:50 AM. On page 2, the policy indicated the CAH's infection control program would follow "evidence-based guidelines and recommendations from the following organizations: Centers for Disease Control and Prevention (CDC)..." On page 5, the policy indicated, "Implement a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and staff... Assist with staff infection prevention and control education... "

2. The CDC "Guideline for infection control in health care personnel, 1998" was reviewed on 6/25/19 at approximately 3:00 PM. On pages 293 to 296, the guideline indicated "D... Certain elements are necessary to attain the infection control goals of a personnel health service:... (b) medical evaluations... (d) immunization programs... 2. Medical evaluations.... a health inventory... physical examination... 4. Immunization programs... Ensuring that personnel are immune to vaccine-preventable diseases is an essential part of successful personnel health programs..."

3. On 6/27/19 at approximately 8:40 AM, two random Physician (MD#1 and MD#6) files and one random CRNA (CRNA#1) file were reviewed for infection control training and surveillance with the Administrative Assistant (E#23). The files lacked any infection control training and lacked any infection control surveillance (such as tuberculosis, hepatitis, and physical examination).
a.) MD#1: initial appointment- 7/18/19
b.) MD#6: initial appointment- 4/6/16
c.) CRNA#1: initial appointment- 10/1/73

4. An interview was conducted with E#23 during the review. E#23 stated, "We do that (infection control training, immunization status, and physical examination) on all of our other staff, but I don't think we do that for them (Physicians and CRNAs). I'm not sure why."

5. An interview was conducted with the Chief Nursing Officer (E#1) on 6/27/19 at approximately 9:30 AM. E#1 concurred with E#23's interview and stated, "We will have to revise our process to include the Physicians and CRNAs. I'm not sure why they haven't been included either."


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B. Based on observation, document review, staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure proper cleaning to prevent the potential for cross contamination and infection. This has the potential to affect all patients receiving services at the CAH with an average daily census of 3.

Findings include:

1. On 6/25/19 at approximately 10:45 AM, a tour was conducted of the Medical Surgical Unit with Supervisor of Nursing (E#8). During the tour, the ice scoop cleaning log was requested. The ice scoop cleaning logs for 1/1/19 to 6/25/19 were reviewed on 6/25/19 at approximately 1:00 PM. The log for June 2019 lacked documentation of cleaning for 19 days out of 24 days. The log also included date, time and initial of the ice scoop being cleaned on June 27th 2019 (2 days ahead of the current date of June 25, 2019).

2. The policy titled "Cleaning of Ice Machines (reviewed 1/25/19 by the CAH)" was reviewed on 6/25/19 at approximately 1:00 PM. The policy required "Policy: Dietary staff is to clean...ice scoop daily and record..."

3. An interview was conducted with the Chief Operating Officer (E#1), on 6/25/19 at approximately 1:15 PM, it was verbally confirmed ice scoop cleaning was to be completed daily and the date of June 27, 2019 was inaccurate.


C. Based on observation, document review, and staff interview it was determined the Critical Access Hospital (CAH) failed to ensure items were properly stored, in order to prevent the potential for cross contamination and infection. This has the potential to affect all patients receiving services at the CAH with an average daily census of 3.

Findings include:

1. On 6/25/19 at approximately 10:45 AM to 11:20 AM, the Medical Surgical Unit was toured with the Supervisor of Medical Surgical Services (E#8):
a.) The area under the medication room's sink contained: multiple glass vases, plastic storage bins, 1 opened TB (tuberculocide) Cide Cleanser (no open date) and 1 unopened container of Vinegar.
b.) The soiled utility room under sink cabinet area contained: 1 container of cream cleanser (no open date), 5 vases, and 1 opened container of bleach (no open date)
c.) The kitchen refrigerator (used for patient nourishments) contained: two, 1 gallon jugs of CT (computed tomography) oral contrast. E#8 stated, "Radiology mixes up the contrast and puts it in the refrigerator."

2. An interview was conducted with the Chief Nursing Officer (E#1) and the Infection Preventionist (E#2) on 6/25/19 at approximately 3:00 PM. Both stated that the CAH did not have a policy for storage under the sinks and both stated that it was the expectation of the CAH that no items be stored under the sinks.

3. During an interview conducted with Chief Nursing Officer (E#1) on 6/25/19 at approximately 3 PM, it was stated "the CAH didn't have a policy for storing the contrast in the patient refrigerator, but it should not be stored there."


D Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to develop and implement policies on expired supplies, which were available for patient care and/or use, to ensure patient safety from contamination. This has the potential to affect all inpatients and outpatients serviced by the CAH.

Findings include:

1. On 06/25/19 at approximately 11:00 AM, a tour of the Radiology Department was conducted with the Infection Preventionist (E #2) and the Imaging Director (E #4). The following expired supplies were available for patient use:
a. Nuclear Medicine -- Nineteen 3 ML Patient Safe Syringes, expiration date 02/2017.
b. Echocardiogram -- one Insyte Autoguard Angiocath 20 gauge, expiration date 05/2018.
c.) Ultrasound -- Cidex Solution Test Strips, expiration date 08/28/18.

2. On 06/26/19 at 3:00 PM, an interview with the Director of Purchasing (E #5) was conducted. E#5 stated, "We do not have a policy that speaks directly to expired supplies such as needles and syringes."









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e

Based on observation and interview, it was determined that the Critical Access Hospital (CAH) failed to develop and implement a food storage policy, preventing the available use of outdated or unlabeled food products, which may be unsafe for human consumption. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. On 6/25/19 at approximately 11:45 AM, an observational tour was conducted in the Dietary Department with Dietary Manager (E #11). The following repackaged food items lacked labels identifying the item and the date of opening/expiration.
a)- one gallon plastic freezer bag of frozen cubed chicken (identified by E #11) in the walk-in freezer.
b)- one gallon plastic freezer bag of frozen fish (as identified by E #11) in the walk-in freezer.
c)- 6 plastic bags of frozen sub-buns (as identified by E #11) in the walk-in freezer.
d)- one gallon plastic bag of pecans (as identified by E #11) in a container in the main kitchen
e)- four 1 gallon plastic bags of sunflower seeds (as identified by E #11) in the main kitchen.
f)- three, 1 gallon plastic bags of raisins (as identified by E #11) in the main kitchen.

2. On 6/25/19 at approximately 1:15 PM, an interview with E #11 was conducted. E #11 stated "When we take food items from the original container, we lose the expiration date. We need to label and date every food item we store that's not in its' original container We do not have a policy to follow (for repackaging of food items)."

3. On 6/27/19 at approximately 12:00 PM, an interview was conducted with the Dietician (E#13). E#13 stated, "I mainly focus on the clinical side of things, like consults. I haven't been involved on the kitchen side of things. (E#1- Chief Nursing Officer) just told me they don't have some policies that they should have. Definitely, they should be labeling things (food items that are repackaged) so they can be sure they are ok to eat or use."

Based on document review and interview, it was determined in 7 of 7 (E#10, E#17, E#18, E#19, E#20, E#21, E#22) personnel files, the Critical Access Hospital (CAH) failed to establish, implement, and maintain an effective, housewide initial and ongoing personnel competency instruction and evaluation program to ensure the provision of safe patient care services, by qualified, competent personnel. This has the potential to affect all inpatients and outpatients serviced by the CAH.

Findings include:

1. The personnel files were reviewed throughout 6/26/19. Initial and/or ongoing competency evaluations over the last three years were reviewed. The following are examples of the lack of an initial and/or ongoing competency evaluations:
a. E#10 (Registered Nurse, Emergency Department) Date of Hire (DOH): 10/8/18. Lacked an initial competency evaluation.
b. E#17 (Licensed Practical Nurse, Medical Surgical Department) DOH: 5/15/17. Lacked an initial and/or ongoing evaluation.
c. E#18 (Laboratory) DOH: 12/1/09. Lacked ongoing competency evaluations.
d. E#19 (Occupational Therapist) DOH: 10/25/11. Lacked ongoing competency evaluations.
e. E#20 (Operating Room Technician) DOH: 11/10/17. Lacked ongoing competency evaluation.
f. E#21 (Radiology/Computed Tomography) DOH: 3/30/15. Lacked ongoing competency evaluations.
g. E#22 (Registered Nurse, Wound Clinic) DOH: 5/2/13. Lacked ongoing competency evaluations.

2. An interview was conducted with the Chief Nursing Officer (E#1) on 6/26/19 at approximately 10:55 AM. E#1 reviewed a sampling of the personnel files and stated, "I'll have to check on that (initial and ongoing competency evaluations). I don't know if we have a policy for that or not (initial orientation/competency evaluation and ongoing competency evaluation)."

3. A follow-up interview was conducted with E#1 on 6/27/19 at approximately 11:00 AM. E#1 stated, "It's my understanding that we give them (the new employee) a competency sheet with what they need to complete and have them signed off, but we don't keep any of them. That's the same for any of the others (ongoing competencies). I could not find a policy for it (initial and ongoing competency evaluations) and was told (no name given) that we don't have one for the clinical side on competencies at this time. On paper, we couldn't demonstrate the competency of the staff, in their respective positions (throughout the CAH) or know that they would be able to do what they do."

A. Based on document review and interview, it was determined for 3 of 3 (Medical Doctor- MD#1, MD#5, MD#8) Physicians, privileged to work in the Emergency Department (ED), the Critical Access Hospital (CAH) failed to ensure its ED physicians were privileged and qualified in the provision of moderate sedation, in accordance with its policy. This has the potential to affect all patients who present to the ED.

Findings include:

1. The policy "Reference (blank) Conscious Sedation" (reviewed by the CAH 4/2019) was reviewed on 6/26/19 at approximately 8:40 AM. The policy stated, "The physician administering conscious sedation must have privileges for clinical administration of this category of drugs..."

The policy "Reference #10016... Moderate Sedation" (revised by the CAH 5/30/19, changes unrelated to the citation) was reviewed on 6/26/19 at approximately 2:20 PM. On pages 2 to 3, the policy indicated, "Only licensed independent practitioners (LIP- LP)(physician or CRNA- Certified Registered Nurse Anesthetist)... shall provide sedation... The LP administering moderate sedation must have privileges for clinical administration of this category of drugs... must be competent to manage an unstable cardiovascular system as well as a compromised airway and inadequate oxygenation and ventilation, including ACLS (advanced cardiac life support) certification." The policy lacked any indication of PALS (pediatric advanced life support) certification.

2. The Physician credential files were reviewed on 6/26/19 to 6/27/19. The following issues were noted:
a. MD#1 was reappointed to the Medical Staff on 3/4/19 with privileges in ED. There were no privileges for moderate sedation and MD#1 lacked ACLS and PALS (pediatric advanced life support) certifications.
b. MD#5 was reappointed to the Medical Staff on 3/4/19 with privileges in ED. There were no privileges for moderate sedation.
c. MD#8 was reappointed to the Medical Staff on 3/4/19 with privileges in ED. There were no privileges for moderate sedation.

3. An interview was conducted with CRNA#1 (Lead CRNA- no anesthesiologist on staff) on 6/26/19 at approximately 12:30 PM. CRNA#1 stated, "I didn't realize the physicians (ED) weren't credentialed for this (moderate sedation). I didn't realize it wasn't on the privileges (list as an option). All... the doctors (ED) are to be ACLS. We'll have to review that policy. It's not correct. We must have missed it. They (ED physicians) should probably be PALS (pediatric advanced life support certification) too, since they see kids, but that's not in our policy either."

4. An interview was conducted with the Administrative Assistant (E#23) on 6/27/19 at approximately 8:40 AM. E#23 reviewed the credential files of MD#1, MD#2, MD#5, and MD#8 and verbally agreed the ED privilege list lacked any request for moderate sedation. E#23 stated, "(MD#1) rarely, if ever, works there (in the ED) anymore. It's been a really long time. From what I understand, that's why (MD#1) doesn't have the ACLS and PALS like the other ones (other ED physicians) do. They (the ED physicians) have to have both (ACLS and PALS)."


B. Based on document review and interview, it was determined for 3 of 3 (E#9, E#10, and E#16) Emergency Department Registered Nurses (RN), whom can administer conscious/moderate sedation, the Critical Access Hospital (CAH) failed to ensure staff who could administer conscious/moderate sedation were trained to do so, in accordance with its' policy. This has the potential to affect all patients who receive conscious/moderate sedation.

Findings include:

1. During the survey, the personnel files for Emergency Department Registered Nurses (RN), whom may administer conscious/moderate sedation was reviewed. The files of E#9, E#10, and E#16 lacked documentation of the completion of conscious sedation medication education program.

1. The policy "Reference (blank) Conscious Sedation" (reviewed by the CAH 4/2019) was reviewed on 6/26/19 at approximately 8:40 AM. The policy stated, "Patients requiring conscious sedation... will be monitored by an RN trained in basic EKG (electrocardiogram)/arrhythmia's, with current BCLS (basic cardiac life support) certification, and have satisfactorily completed the conscious sedation medication education program..."

2. An interview was conducted with Certified Registered Nurse Anesthetist (CRNA#1) on 6/26/19 at approximately 12:30 PM. CRNA#1 stated "All nurses are to be ACLS (Advance Cardiac Life Support) certified (not BCLS). We'll have to review that policy. It's not correct. We must have missed it. I don't know about what their education was otherwise."

3. An interview was conducted with the Chief Nursing Officer (E#1) on 6/27/19 at approximately 2:45 PM. E#1 stated, "We don't have a list of how many ED patients have received conscious/moderate sedation. They (the ED Manager- E#9 and the ED staff) can't remember. They just know that they can do it. As far as the training (ED RN competency training for conscious/moderate sedation), our Pharmacist said they review information with the ED nurses, but they don't keep any documentation of it. They have a checklist and everything, but they don't fill it out or keep it."