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The Critical Access Hospital (CAH) reported a census of three acute care patients and two swing bed patients. Based on document review, manufacturer's instructions for use and staff interview, the infection control officer failed to develop and implement a system for identifying, reporting, investigating and controlling infections for one of one household washer and dryer used for patient laundry.

Findings include:

- The CAH's policy titled "Infection Prevention All Departments", reviewed on 10/11/12 at 11:45am, revealed departments directly involved in patient care "3.a. Practice good aseptic technique".

- The CAH's job description for the "Infection Control Person", reviewed on 10/11/12 at 11:45am, directs "1. The infection prevention nurse is to ensure general supervision of the Infection Prevention Program", and "17. The infection prevention nurse through direct observation...evaluates the general state of cleanliness in hospital, the skills used in practicing asepsis...and other matters relating to infection prevention".

- Administrative staff B, interviewed on 11/20/12 at 11:20am acknowledged the CAH failed to change the CAH's procedures and practices since 10/11/12. The CAH continues to launder obstetric patient nursing gowns without disinfecting the gowns. Staff B confirmed the CAH failed develop and implement a process to disinfect the obstetric patient nursing gowns.

The CAH's continued non-compliance has the potential to affect all obstetric patients that wear the nursing gowns.





21996

- The manufacturer's product information sheet reviewed on 10/16/12 at 5:00pm stated, "Neutra-Zyme...Enzyme Laundry Detergent..."

- The CAH's ploicy titled "USING AUTOMATIC WASHER IN HOSPITAL AND LTC" reviewed on 10/11/12 at 11:30am directed "Washer in hospital...will use enzyme laundry detergent. Surflex series neutra-zyme contains sodium tripolyphosphate...Nuetra-zyme will sterilize the tub of the washer..."

- Observation on 10/9/12 at 12:50pm of the soiled utility room on the patient unit revealed a household type washer and dryer. Staff S, Registered Nurse (RN) explained the facility uses the washer and dryer for the Obstetric (OB) breast feeding patient gowns using "Neutra-Zyme laundry detergent. Staff B, Administrative Staff, explained the CAH uses the washer and dryer to wash some clothes using the "Nuetra-Zyme" laundry detergent.

Staff S, RN, and Staff B, Administrative Staff, and Staff M, Maintenance Staff, interviewed on 10/9/12 at 1:15pm acknowledged they were not aware the product they used in the wash machine to wash the gowns and patient's clothes did not contain a disinfectant.

Staff M, Maintenance Staff, interviewed on 10/11/12 at 11:35am verified they received conformation from the manufacturer of the "Neura-Zyme" laundry detergent that it is an enzymatic detergent and does not contain a disinfectant.

- Observation on 10/9/12 at 1:45pm of exam rooms #1, and #2, revealed a Yankauer suction tip (a rigid hollow tube made of disposable plastic with a curve at the distal end used to remove thick secretions during oral pharyngeal suctioning) not in the packaging it comes in connected to the suction tubing. Observation on 10/9/12 at 1:50pm in exam rooms #3 and #4 revealed a Yankauer suction tip in the open packaging connected to the suction tubing. The Yankauer package label states, "sterile unless opened or damaged."

The ER, observed on 10/10/12 at 8:30am, revealed one opened Yankauer suction tip package opened and connected to the suction tubing. Registered Nurse I, acknowledged the opened suction tip.

The CT scan room, observed on 10/11/12 at 10:50am, revealed on opened Yankauer suction tip package opened and connected to the suction tubing.

- The CAH's "Annual CAH Service Assessment, Departmental Assessment", for the Infection Prevention Department, reviewed on 10/16/12 at 11:30am, revealed the CAH failed to identify surveillance of the physical environment, cleaning procedures, use of chemical for disinfection and patient care equipment as "Areas of Noncompliance".

- Infection control nurse H, interviewed on 10/15/12 at 10:50am acknowledged the lack of infection prevention activities and confirmed the CAH failed to perform surveillance of the physical environment, cleaning procedures, the use of chemicals for disinfection, and patient care equipment.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview the CAH failed to ensure physicians date and/or time all authenticated (signed) entries in the clinical record for 15 of 34 patient clinical records reviewed (patient #2, 7, 8, 11, 12, 19, 21, 22, 23, 24, 25, 26, 28, 29, and 30).

- The CAH's policy titled "Verbal Orders" reviewed on 10/16/12 at 8:40am directed, "The ordering practitioner or covering physician must date and time the order at the time he or she signs..." The CAH failed to include in their policy all entries in the clinical record must be timed and dated when authenticated.

- Patient #21's closed clinical record reviewed on 10/11/12 at 10:20am revealed an admission date of 9/14/12 for a scheduled Cesarean Section (C-Section). Patient #21's clinical record revealed between 9/14/12 to 9/17/12, five standing orders/protocols lacked a time when signed and dated by the physician and six verbal/telephone orders lacked a time when signed and dated by the physician.

- Patient #29's closed clinical record reviewed on 10/10/12 at 1:10pm revealed an admission date of 10/6/12 with Diarrhea, Congestive Heart Failure, and Renal Failure. Patient #21's clinical record revealed between 8/6/12 to 8/9/12, four verbal/telephone orders lacked a time when signed and dated by the physician.

- Patient #30's closed clinical record reviewed on 10/10/11 at 1:30pm revealed an admission date of 8/21/12 with diagnoses of Anemia (low blood count) and Left Hip Pain. Patient #30's clinical record revealed between 8/21/12 to 9/6/12, eleven verbal/telephone orders lacked a time when signed and dated by the physician.

Administrative Staff C, interviewed on 10/16/12 at 12:15pm acknowledged the clinical records lacked the date and/or time when the physician signs entries in the clinical record.

This deficient practice also affected patient #'s 2, 7, 8, 11, 12, 19, 22, 23, 24, 25, 26, and 28.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview, the CAH failed to assure a qualified social worker provided medically related social services.

Findings include:

- The CAH's policy titled "Job Description: Social Service Consultant", reviewed on 11/20/12 at 1:20pm revealed the "Performance Requirement: Responsible for: Arrange for consultation with social services designee on a regular schedule (should be monthly)".

- Administrative staff A, interviewed on 11/20/12 at 11:35am, acknowledged the CAH employs a qualified social worker, who has not provided services to the CAH in more than 10 months.

- Administrative staff A, interviewed on 11/20/12 at 11:35am, acknowledged the CAH failed to implement their policies and procedures assuring a qualified social worker provides medically related social services at least monthly.

The continued non-compliance has the potential to affect all swing bed patients.