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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 (Medical-Surgical Room 314) 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 44-5 showed each airborne infection isolation room shall have a permanently installed visual mechanism for monitoring the pressure status of the room when occupied by infectious patients.
B. Observation of Medical-Surgical Room 314 on 2/8/22 at 1:30 PM showed the airborne infection isolation room 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 observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards in three of three patient care areas (Operating Room 1, Endoscopy Room, Emergency Department Room 1) in that there was no measure in place to prevent additional devices from being plugged in to the power cords, there was no measure in place to ensure the devices powered by the cords did not exceed 75% of each cord's rated ampacity, the electrical and mechanical integrity of the cords were not regularly verified and documented, and the power cords were not permanently attached to the equipment they were powering. The failed practices had the likelihood to affect all patients receiving care in the vicinity of the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, the electrical and mechanical integrity of the cord are regularly verified and documented, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
B. Observation on 2/8/22 at 9:30 AM of Emergency Department Room 1 showed a portable monitor was being powered by a multiple-receptacle power cord with 7 receptacles which was plugged into the wall. There was no measure in place to prevent additional devices from being plugged in to the power cord and the cord was not attached to the equipment it was powering.
C. Observation on 2/8/22 at 1:15 PM of the Endoscopy Room showed a portable monitor was being powered by a multiple-receptacle power cord with 6 receptacles which was plugged in to the wall and was lying loose on the floor. There was no measure in place to prevent additional devices from being plugged in to the power cord.
D. Observation on 2/8/22 at 1:25 PM of Operating Room 1 showed a portable monitor was being powered by a multiple-receptacle power cord with 6 receptacles which was plugged in to the wall. There was no measure in place to prevent additional devices from being plugged in to the power cord.
E. In an interview with the Director of Maintenance on 2/9/22 at 1:50 PM the above findings in B, C, and D were verified. It was also verified in this interview that the facility had no process in place for ensuring that the sum of the ampacity of all appliances connected to a multiple-receptacle power cord does not exceed 75% of the power cord's ampacity, and that there was no process in place for regularly verifying the electrical and mechanical integrity of the power cords used.

Based on interview and review of the facility's Temperature and Humidity Log and the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide the required temperature in two of two (Operating Room (OR) 1, Endoscopy Room) surgical areas. The failed practice had the likelihood to affect all patients undergoing procedures in these spaces in that a sterile environment was not ensured and an elevated risk of infection was present. Findings follow:
A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 showed operating rooms and endoscopy rooms shall be provided with a dry bulb temperature of 68-73 degrees Fahrenheit.
B. Review of the facility's Temperature and Humidity Log for the 13 months prior to the survey (February 2021 - February 2022) showed OR 1 was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 211 days of the 360 days recorded.
C. Review of the facility's Temperature and Humidity Log for the 12 months prior to the survey (February 2021 - February 2022) showed the Endoscopy Room was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 204 days of the 360 days recorded.
D. The above findings were verified with the Director of Plant Maintenance on 2/9/22 at 1:50 PM.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 13 Standard for Installation of Sprinkler Systems 2010 Edition, it was determined supplies in one of one Clean Supply Room were not stored 18 inches below the sprinkler deflector as required by NFPA 13 2010 edition: 8.8.6 and were in the path of the sprinkler spray pattern. The failed practice had the likelihood to affect all patients and staff in that a potential fire in the Clean Supply Room would not be immediately extinguished and could spread to other nearby areas due to the spray pattern of the activated sprinkler being obstructed. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.7.1.1 showed automatic sprinkler systems shall be in accordance with NFPA 13.
B. Review of NFPA 13 2010 Edition: 8.8.6 showed the top of storage must be at least 18 inches below the deflector of the sprinkler.
C. Observation on 2/9/22 at 2:25 PM of the Clean Supply Room showed a shelving unit in the center of the room which had a top shelf 10 inches directly below a sprinkler deflector. This finding was verified by the Director of Maintenance at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition, the facility failed to maintain three of three (Conference Room Hallway, Generator Room, Maintenance Room) fire-rated door assemblies as required by NFPA 101 2012 Edition in that all three of the fire-rated door assemblies were not arranged for automatically closing and latching when released and were not part of annual inspection. The failed practices had the likelihood for the fire-rated doors to be left open in the event of a fire, allowing smoke and fire to rapidly transfer into the adjacent spaces. The failed practices had the likelihood to affect all patients, staff, and visitors in the facility. Findings were as follows:

A. Review of NFPA 101 2012 Edition: 7.2.1.8.2 showed any door leaf required to be kept closed shall only be held open by a device which automatically releases the door leaf upon operation of a smoke detector and upon loss of power to the device. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80.
B. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing. Review of NFPA 80 2010 Edition: 6.1.4.2.1 showed self-closing doors shall be equipped with a closing device to cause the door to close and latch each time the door is opened. Review of NFPA 80 2010 edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited.

C. Observation of the Conference Room Hallway on 2/8/22 at 2:45 PM showed the doorway connecting to the adjacent shipping and receiving area consisted of a fire-rated door assembly which did not have latching hardware installed and was held open by a black cart which blocked it from closing.
D. Observation of the Generator Room on 2/10/22 at 9:00 AM showed the entry doorway consisted of a fire-rated door assembly. Further observation showed the door assembly did not have latching hardware installed and had a kickstand installed at the bottom of the door leaf to be used to block it from closing.
E. Observation of the Maintenance Room on 2/10/22 at 9:30 AM showed the entry doorway consisted of a fire-rated door assembly which had a kickstand installed at the bottom of the door leaf to be used to block it from closing.
F. The above findings in C, D, and E were verified with the Director of Maintenance at the times of observation.

Based on policy and procedure review, manufacturer's instructions for use, observation, and interview, it was determined the facility failed to ensure personal radiation dosimeters were stored properly in a radiation free environment. The failed practice did not ensure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected all employees required to wear a dosimeter. Findings included:
A. Review of Radiology Department's policy and procedure manual showed no policy regarding the proper storage of dosimeters.
B. Review of Landauer Dosimeters' Instructions for Use showed, "Not in use storage: The dosimeter must be stored together with the control dosimeter on the same badge board in a location where the background radiation is as low as possible and away from any source of heat and humidity."
C. On 2/9/22 at 1:15 PM, during a tour of the Radiology Department showed no designated storage area for employee dosimeters when not use.
D. Interview with Radiology Staff #1 on 2/9/22 at 1:20 PM, she stated employees sometimes put their dosimeters in their pockets or purse or they may take them home. She stated they have done it this way for 20 years.
E. The above findings in A, B, C, and D were verified by the DON (Director of Nursing) on 2/9/22 at 1:20 PM.

Based on policy and procedure review, observation, and interview, it was determined the hospital failed to provide or assign appropriate trained staff or nursing care when patients required Telemetry Monitoring. The failed practice had the potential to affect any patient requiring qualified telemetry care in the medical surgical unit of the facility.

A. Review of policy titled "Telemetry Discontinuation Protocol" dated 09/27/21 received on 02/09/22 from the DON dated showed the following: Protocal for telemetry ordering and discontinuing.

B. During a tour of the medical surgical unit on 02/08/22 at 1:30 PM, showed one of one telemetry monitor found in a staff utilization room, not within view of the nursing station or patient care areas.

C. During interview on 02/09/22 with the DON stated there is no dedicated staff member observing the telemetry monitors. The Registered Nurses do look at the monitors when they are in the room and the monitor does have an alarm.

D. During an interview with the DON on 02/10/22 she confirmed findings in A and B.

Based on policy review, review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, observation, and interview it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to follow policy and procedure and recommended CDC guidelines for COVID -19 screening. The failed practice did not allow for tracking of visitors for signs and symptoms of COVID-19 and had the likelihood to affect all patients, staff, and visitors. Findings included:

A. Review of Facility's Policy titled "Entrance Screening Policy for Staff, Patients and Visitor" dated 01/04/22 received on 02/16/21 showed the following:
Screenings are mandatory. The state health department mandates we have a process to screen persons who enter our buildings. Coworkers can self-screen from home and report symptoms. Visitors and patients should use designated building entrances and follow designated screening process. Screening actions: Patients and visitors will be screened by Mercy coworkers/Volunteers/contractors at designated entrances of buildings. If the patient or visitor or co-worker has a negative screening, they pass through with no restrictions and will be supplied a Mercy medical grade mask to wear for the duration of their visit. If the patient or visitor or co-worker has a Positive Screen. Patients who screen positive for fever {100+) or any of her symptom recommended by infection prevention such as +cough and/or exposure will be supplied a medical grade mask and informed they must wear the mask for the duration of their visit.

B. A. Review of Facility's policy titled "Education Infection Control Policy" showed the following:
The infection preventionist will act as recourse ...and the Centers for Disease Control will provide current educational resources.

C. Review of the CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance updated 02/02/22 showed the following:
Establish a process to identify anyone entering the facility regardless of their vaccination status, who has any of the following three so they can be properly managed: a positive viral test for SARS-CoV-2, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection. Options could include (but are not limited to): individual screening on arrival at the facility implementing an electronic monitoring system in which, individuals can self-report any of the above before entering the facility.

D. On 02/10/22 at 1:30 PM to 02/10/18/22 at 9:30 AM upon entering the facility and observation there was no screening for COVID -19 being performed.

D. On 02/11/22 at 10:30 AM the DON stated that the Facility performs passive screening.

Based on review of the facility's Emergency Preparedness Plan and interview, it was determined the facility failed to biennially review and update the Emergency Preparedness Plan. The failed practice did not assure the plan was still current and did not ensure all staff were knowledgeable of the plan. The failed practice had the potential to affect all patients and staff. Findings follow:

A. Review of the facility's Emergency Preparedness Plan showed there was no record of the Emergency Preparedness Plan being reviewed or updated.
B. The finding in "A" was verified during an interview with the Safety Officer at 1:50 PM on 2/9/22.

Based on interview and review of the facility's Emergency Preparedness Plan, it was determined there was no evidence the Emergency Preparedness Plan included provision of care and treatment at an alternate site and coordination efforts needed during a declared emergency when the 1135 Waiver is enacted by the Secretary. The failed practice had the likelihood to affect all patients and staff in that there was no procedure to ensure the staff would be knowledgeable on what to do during a declared 1135 waiver by the Secretary. The findings were:

A. Review of the Emergency Preparedness Plan showed there was no evidence the Emergency Preparedness Plan addressed the provision of care and treatment at an alternate site and coordination efforts needed during a declared emergency when the 1135 Waiver had been enacted by the Secretary.
B. The findings in A were verified during an interview with the Safety Officer on 2/9/22 at 1:50 PM.