HospitalInspections.org

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Based on observation and interview, the hospital failed to maintain a complete inventory of all patient care equipment and failed to identify critical equipment required for emergent events.

Failure to maintain a complete inventory of all patient care equipment puts patients at risk from inoperable or unmaintained equipment.

Findings included:

1. On 12/20/17 between 3:45 and 4:30 PM, Surveyor #1 reviewed the hospital's biomedical maintenance logs. The observation showed there was no listing for a Hill-Rom patient bed (Asset #250270).

2. At the time of the review, the surveyor asked the facility manager (Staff #1) if he maintained preventive maintenance logs for the Hill-Rom beds. He stated that the beds were maintained by a contractor, and that he did not retain copies of the work they performed.

3. At the time of the review, the surveyor asked Staff #1 if the inventory list of patient care equipment included a means to identify "critical equipment" (equipment which poses a higher risk to patient safety if it were to fail). Staff #1 stated that there was not currently a way to readily identify critical items within the inventory.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure documentation that hospital staff members who prepare intravenous medications have completed didactic competency requirements as directed by hospital policy and procedure and in accordance with sterile compounding standards.
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Failure to ensure compliance with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.
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Reference: United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016)
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Findings included:
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1. The hospital's policy titled, "USP <797> and the Compounding of Sterile Products" stated that all personnel would complete basic didactic competency requirements as determined by the Director of Pharmacy.
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2. On 12/21/17 at 8:30 AM Surveyor #2 interviewed the Pharmacy Director (Staff #2) and the Clinical Nurse Manager (Staff #3) regarding completion of the sterile compounding basic didactic competency for nursing staff. Staff #2 and Staff #3 stated that the competency confirmation process had not been implemented yet..

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Item #1- Water Management Plan

Based on document review and interview, the critical access hospital failed to implement a water management plan to identify and mitigate sources of pathogenic water-borne organisms.

Failure to develop and implement a facility-wide water management plan puts patients, staff and visitors at risk from water-borne diseases.

Findings included:

1. The hospital document titled "Environment of Care & Infection Prevention Committees Water System Inventory & Infection Risk Assessment" (Updated 12/11/17), stated that review for "dead legs" and inactive areas was pending and that policies and procedures for water storage tanks, flushing of eyewash stations, fire suppression systems, and maintenance of ice machines had not yet been developed or implemented.

2. On 12/20/17 at 4:30 PM, Surveyor #1 interviewed the facilities manager (Staff #1) about the implementation of the water management plan outlined in the document referenced in Finding #1. He stated that they had bought a filter (water sock) to address sediment issues in the incoming water, but that the items identified as action steps for identification and mitigation of hazards from opportunistic water-borne organisms had not been implemented at the time of the survey.

Item #2- Cross Contamination

Based on observation and interview, the critical access hospital failed to maintain clean endoscopes in a way that protected them from contamination.

Failure to maintain clean, disinfected patient care equipment in a way that protects them from contamination puts patients at risk of infection.

Findings included:

1. On 12/21/17, between 8:50 and 10:30 AM, Surveyor #1 toured the sterile processing department of the hospital. During an observation of re-processing of an endoscope, the surveyor observed an open, clean scope cabinet located directly across from the decontamination sink used for cleaning the scopes.

2. At the time of the observation, the surgical tech (Staff #4) stated that the cabinet is usually closed, and confirmed that the cabinet's location put it at risk from splash from the decontamination sink.
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Based on observation and policy review, the critical access hospital failed to ensure that staff followed hospital guidelines for surgical attire.
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Failure to follow hospital policy regarding surgical attire could lead to contamination of sterile fields that could lead to an infection of the surgical site.
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Findings included:
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1. The critical access hospital policy and procedure titled, "Surgical asepsis: Surgical Attire" revised 05/12/17 states that the surgical head cover should cover all hair and facial hair to prevent hair, dandruff and microorganisms from falling onto the sterile field.
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2. On 12/21/17 at 1230 PM, Surveyor #2 observed staff in OR suite #1 prepare for a procedure. Surveyor #2 noted that the circulating RN (registered nurse)(Staff #5) did not have her hair completely covered at the nape of the neck and the certified nurse anesthetist (CRNA) (Staff #6) did not have his beard hair covered by his mask.
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3.At the time of the observation, Surveyor #2 discussed this finding with the Chief Nursing Officer (CNO)(Staff #7) who agreed the hospital policy was to cover all hair.
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Based on document review and interview, the critical access hospital failed to address persons-at-risk in their patient population as part of their emergency preparedness program.

Failure to identify needs of the patient population in the event of an emergency, puts patients at risk of inadequate care during a natural or man-made disaster.

Findings included:

1. On 12/20/17 between 2:00 and 3:15 PM, Surveyor #1 reviewed the hospital's emergency preparedness program with the clinical educator (Staff #8) . The review revealed that the program failed to identify at-risk patient populations as part of its overall evaluation.

2. At the time of the review, Staff #8 stated that the hospital had only recently assigned her the oversight of the program, and that she was in the process of addressing identified gaps.