HospitalInspections.org

Based on observation the hospital failed to implement cross connection controls to maintain the hospital's drinking water supply in safe condition.

Failure to maintain cross connection controls on chemical dispensers places the patients at risk for possible exposure to chemical and biological contaminates.

Findings:

On 3/14/2012 the surveyor observed two chemical dispensers in the kitchen above the sinks and in the janitorial closets (across from patient rooms #2 and #103 ) that did not have an approved air gap between the water supply and the chemical supply. The chemical dispensers in both cases employed E-Gap Eductors which are not recognized as providing safe and effective cross connection control.

Ventilation in ED procedure room ok

Based on observation the hospital failed to ensure proper ventilation is maintained in patient care areas. Failure to maintain correct ventilation and air flow patterns in patient areas places the patients at risk for the spread of infections.

Findings:

1. On 3/14/2012 the surveyor found ventilation pressures in the shared clean and dirty utility space to be incorrect to prevent the possible spread of infections. The surveyor used a strip of tissue paper to measure the direction of air flow in the clean utility room and found the air pressure in the clean utility room was negative to the corridor. This allowed for the mixing of air between the shared clean utility room and soiled utility room. The clean utility room needed positive air flow to prevent possible mixing with any contaminated air from the soiled utility space.

2. On 3/14/2012 the surveyor and hospital engineering staff observed air balance problems with the air monitor outside the endoscopy and procedure room. The air monitor was installed with a positive and negative control switch to change air pressures in the room. The pressure monitor outside the room always indicated negative pressure when the control switch was changed to the positive air position. The air monitoring equipment was not operating as designed.

3. On 3/14/2012 during the environmental tour with hospital engineering staff the surveyor observed the laboratory was directly across the corridor from the kitchen. The surveyor used a strip of tissue paper to observe the direction of air flow from the lab and found the tissue strip blew out from the lab into the corridor. The air pressure in the lab was positive to the corridor. The lab needed negative air pressure with the air from the corridor blowing into the lab and not out of the lab into the corridor across from the kitchen.

Based on observation the Critical Access Hospital (CAH) failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Refer to the Fire Life Safety report for deficiencies found during the survey on 3/13/2012.

Based on interview and review of personnel files, the facility failed to conduct periodic staff performance reviews per policy.

Failure to do so risks patient care by staff unprepared or unable to competently perform their duties according to standards of practice, resulting in the potential for poor patient outcomes.

Findings:

During review of human resource records by Surveyor #1 on 3/14/2012 the Human Resources/Staff Development administrator (Staff Member #6) stated that facility policy stipulated that performance reviews were to be conducted annually. Review of human resource records found that there were no annual performance reviews for 3 of 11 personnel files reviewed (Staff Member #1, #4, #7).

Based on interview and document review, the hospital failed to develop and implement a policy and procedure to guide staff in performing the Critical Access Hospital ' s (CAH) annual evaluation.

Failure to develop a process to perform a thorough program evaluation impairs the facility's ability to improve the quality of healthcare it provides to patients.

Findings:

Review of the hospital ' s CAH program evaluation for 2011 revealed that the hospital was collecting the appropriate information to perform the CAH evaluation but was not analyzing the data in order to determine whether the utilization of services was appropriate and/or to determine if changes were needed in the services provided by the hospital.

On 3/22/2012, Surveyor #1 requested the hospital ' s policy and procedure for performing the CAH annual evaluation. The Director of Nursing services stated that the hospital did not have a policy and procedure for performing the annual CAH evaluation.

Based on review of policy and procedures and administrative staff interview, the hospital failed to develop and implement written policy and procedure addressing patient visitation rights.

Failure to develop a policy and procedure for patient visitation rights risks denying a patient of the health and safety benefits of open visitation.

Findings:

Review of the hospital ' s policies and procedures on 3/13/2012 revealed that the hospital did not have a policy and procedure for patient visitation rights.

An interview with the Director of Nursing Services 3/15/2012 confirmed the above findings.

Based on review of policies and procedures and administrative staff interview, the hospital failed to develop and implement a written policy and procedure addressing patient visitation rights; and failed to develop a process for informing each patient, or support person, of his/her visitation rights including any restrictions or limitations on such rights and his/her right to receive visitors whom he or she designates.

Failure to develop and implement a policy and procedure for patient visitation rights risks denying a patient of the health and safety benefits of open visitation.

Findings:

Review of the hospital ' s brochure entitled " Patient Rights " (no publication date) revealed that the brochure did not include a section that informed patients of their visitation rights.

Review of the hospital ' s policies and procedures on 3/13/2012 revealed that the hospital did not have a policy and procedure for patient visitation rights.

An interview with the Director of Nursing Services 3/15/2012 confirmed the above findings.