HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure that a defibrillator was maintained in safe operating condition by monitoring the expiration dates for the adult and pediatric electrode pads for 1 of 5 emergency code carts observed.

Findings include:

Observation and record review on 3/15/22 at approximately 11:00 a.m. on the ICU (Intensive Care Unit) revealed an emergency code cart that had expired adult electrodes pads with an expiration date of 12-14-21 and two pediatric electrodes pads with an expiration date of 12-12-21.

Interview on 3/15/22 at approximately 11:05 a.m. with Staff E (Registered Nurse) confirmed the above observation.

Review on 3/17/22 at approximately 10:00 a.m. of the manufacturer's instructions [Name omitted] for Peadiatric Electrodes revealed, "Warnings ...Do not use if gel is dry. Dried out gel can lead to skin burning, Do not open pouch until ready to use. Do not use the electrodes past the expiration date printed on the pouch label."

Based on record review and interview, the Critical Access Hospital (CAH) failed to maintain proper humidity control in 1 out of 3 operating rooms reviewed and in 1 out of 1 operating central supply room reviewed.

Findings include:

Review on 3/16/2022 of the facility's operating rooms, Temperature and Humidity Log, documented by operating room staff from 6/18/2021 through 9/29/2021 revealed that the acceptable range for humidity in the operating and central supply storage rooms was 30-60%. Further review revealed operating room #1's humidity log levels were above 60% for 40 out of 66 days and the central supply room's humidity levels were above 60% for 39 out of 66 logged days.

Review on 3/16/2022 of the CAH facilities management electronic record of operating room #1's humidity levels from 6/30/2021 through 8/1/2021 revealed humidity levels above 60% for 10 out of 33 days. The CAH facilities management did not have a log for the central supply room.

Interview on 3/17/2022 at approximately 9:45 a.m. with Staff C (Operating Room Director) confirmed the above findings. Interview further revealed that Staff C was not notified that the humidity levels were outside of the acceptable standard ranges by either operating room staff or by facilities staff. Staff C confirmed there was no policy on what to do when humidity levels were out of range.

Based on record review and interview, the Critical Access Hospital (CAH) failed to check all staff regularly exposed to radiation for the level of radiation exposure in the operating room.

Findings include:

Review on 3/15/2022 and 3/16/2022 of the Radiation Dosimetry Report from 12/5/2021 to 1/4/2022 revealed that three orthopedic surgeons were not listed on the report with results for radiation exposure monitoring via dosimetry badges.

Interview on 3/16/2022 at approximately 3:10 p.m. with Staff B (Director of Imaging and Cardiopulmonary Services) confirmed the above finding that not all surgeons are monitored with an assigned dosimetry badges. Some operating rooms are monitored with a control badge instead of monitoring each staff member individually.

Based on interview and policy review, it was determined that the Critical Access Hospital (CAH) failed to have written policies and procedures that set reasonable restriction of limitation of visitation.

Review of the CAH's Visitor Guideline Policy, dated March 15, 2021, revealed the following:
Outpatient appointments: Adult patients who do no require a caregiver should attend their appointments alone.
Outpatient procedures: No visitors will be allowed with independent adult patients.
Adult Inpatients Patient are permitted one visitor.
Obstetrics: One caregiver or partner may be present through labor, delivery and post-partum care. Siblings, grandparents, and other visitors are not permitted.
Inpatients receiving End-of-Life Care: If the patient is not COVID-19 positive or under investigation for COVID-19, two family members/friends may visit at a time, subject to change based on the patient's clinical condition.

Interview on 3/15/22 at 11:25 a.m. with Staff A (Registered Nurse, Director of Emergency Department) revealed that the CAH allowed no patient visitation in the emergency department due to COVID-19. Staff A stated that there were some exceptions and that certain visitors were allowed in with patients, such as a parent with a child. Staff A stated the CAH was in development to change the visitation policy to allow visitors.

Interview on 3/17/22 at 8:45 a.m. with Patient #3 revealed that Patient #3 has had no visitors since Patient #3's admission on 3/14/22. Patient #3 was told that no visitors were allowed in the hospital due to COVID-19.

Interview on 3/17/22 at 8:50 a.m. with Staff G (Registered Nurse) revealed that the CAH did not allow visitors in the hospital due to COVID-19.

Based on record review and interview, it was determined that the Critical Access Hospital (CAH) failed to employ methods for cleaning and disinfecting equipment to prevent and control the transmission of infections within the CAH in 2 of 2 departments serving outpatients that disinfected equipment.

Findings include:

Observation on 3/16/22 at 3:10 p.m. revealed a trophon EPR used to high level disinfect validated ultrasounds probes.

Review on 3/16/22 of the trophon EPR User Manual, dated March 2014, revealed, "Chemical Indicator use is required with every disinfection cycle." and "A chemical indicator must be used for each disinfection cycyle and can only be used once. After correctly loading the prove into the chamber, a chemical indicator shall be placed into the holder."

Review on 3/16/22 of the trophon EPR Log book from 6/10/21 to 3/14/22 revealed the CAH failed to document the results of chemical indicators to validate high level disinfection when using the trophon EPR.

During interview on 03/16/2022 at 3:10 p.m. with Staff D (Radiology Technician) confirmed the findings above and revealed they do not use a chemical indicator when they use the trophon EPR to disinfect ultrasound probes.

Observation on 3/16/22 in the CAH outpatient department revealed a room designated for disinfecting Transesophageal (TEE) Probes.

Interview on 3/16/22 at approximately 12:30 p.m. with Staff F (Medical Assistant) confirmed the outpatient deparment disinfected their probes in the office and revealed that probes are disinfected for 8 minutes.

Review on 3/16/22 of the Disinfection Soak Solution Log Sheet for TEE Probe for 9/30/21 to 2/24/22 (13 TEE probe disinfections) revealed on 1/20/22, the TEE probe was soaked for 4 minutes.

Review on 3/17/22 of manufacturer's instructions on the bottle for use as a high level disinfection of the Revital-Ox Resert High Level Disinfectant solution revealed the following: "Once the instrument has been immersed and all surfaces in contact with the disinfection solution, soak the instrument for 8 minutes".