HospitalInspections.org

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Item #1 - Crash Carts

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff maintained supplies and equipment to meet patient needs during an emergency for 1 of 3 emergency carts inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Crash Carts," Procedure Number: PR008-442, effective date 10/04/12, showed that crash carts will be checked daily by a licensed nurse.

2. Document review of the surgical department's Crash/Defibrillator Nightly Checklist showed the crash cart missing daily checks for the following dates: May 19-21, June 11-13, 31, July 9-11, 15, 16, 23-31, August 5-8.

3. On 08/12/21 at 8:40 AM, Surveyor #10 interviewed a Registered Nurse (Staff #1019) in the surgery department regarding the missing dates on the Crash/Defibrillator Nightly Checklist. Staff #1018 stated that the night charge nurse for the hospital was responsible for the checklist and that the nurses in the surgery department do not perform these checks.

Item #2 - Expired patient care supplies

Based on observation, document review, and interview, the Critical Access Hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer expiration date.

Failure to establish a systematic process for ensuring patient care supplies do not exceed their expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the Critical Access Hospital's procedure titled, "Outdated Supplies," Procedure Number: PR008-071, approved 06/21, showed that materials management personnel and nurses will be responsible for checking of outdates on all nursing supplies and that outdated items will be pulled from work areas.

2. On 08/10/21 at 11:30 AM, Surveyor #6 toured the patient care area with the Housekeeping Manager (Staff #603) and the Interim Infection Preventionist (Staff #604). The observation showed a bottle of Medichoice Ultrasound Gel with an expiration date of 06/11/21.

3. At the time of the observation the surveyor asked Staff #604 about the expired ultrasound gel. Staff #610 stated it should have been discarded and disposed of the bottle.

4. On 08/10/21 at 2:30 PM, Surveyor #6 toured the imaging department with the Diagnostic Imaging Manager (Staff #605) and the Interim Infection Preventionist (Staff #604). The observation showed 3 PDI Sani-Cloth® canisters with an expiration date of 04/21 in the Bone Density exam room #R-109.

5. At the time of the observation the surveyor asked an ultrasound technologist (Staff #606) about the expired canisters. Staff #606 stated that she didn't use the canisters in that room. She stated that she used the wipes on her cart to disinfect the surfaces in that exam room.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the Critical Access Hospital Medicare Life SAFETY CODE inspection report found at Shell NZG721.
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Based on interview and policy and procedure review, the Critical Access Hospital staff failed to have a medical doctor and mid-level provider involved in the facility's policy and procedure review process.

Failure to ensure a medical doctor and mid-level provider involved in the facility's policy and procedure review process may lead to sub-optimal patient care

Findings included:

1. Document review of the hospital's policy and procedure titled, "Policy on Policies, Bylaws and Medical Staff Rules and Regulations," Policy #PO 060-106 effective date 04/27/09, showed all patient care policies and procedures will be reviewed annually by patient care medical staff and by at least one-mid-level medical practitioner if mid-level medical practitioner is involved in the provision of the patient care services."

2. On 08/11/21 at 2:45 PM, during review of the facility's policies and procedures with the Quality Director (Staff #1010), Surveyor #10 verified evidence that the facility's policies and procedures were being reviewed annually. There was no evidence that a medical provider and a mid-level provider had reviewed patient care policies and procedures.

3. At the time of the review Surveyor #10 interviewed the Quality Director (Staff #1018) regarding involvement of a medical provider and a mid-level provider in reviewing policies and procedures. Staff #1018 verified that a medical practitioner and mid-level were not involved in policy and procedure review.
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Based on observation, medical record review, and interview, the Critical Access Hospital failed to ensure that medical healthcare providers properly executed Informed Consents for procedures by not signing, dating, and timing the forms for 4 of 4 medical records reviewed (Patients #1014, #1015, #1016, and #1017).

Failure to ensure that Informed Consents are properly executed creates a risk for lack of understanding to what and when a patient consented to a procedure.

Findings included:

1. Document review of the hospital's policy titled, "Consent - Informed and Implied," policy #PR008-061, effective 12/30/15, showed the following:

a) The Anesthesia Provider and/or Provider obtaining the consent signs in the appropriate location.

b) The date and time of witnessing the signature completed.

2. Medical records review showed 4 of 4 patients (Patient #1014, #1015, #1016, and #1017) signed an Informed Consent for anesthesia services. There was no evidence the Certified Registered Nurse Anesthetist (CRNA) (Staff #1016) or a witness signed, dated or timed the form prior to the procedure.

3. On 08/11/21 at 1:15 PM, Surveyor #10 interviewed an Informatic Registered Nurse (Staff #1018) regarding CRNA and witness signatures dates and times on the consents for Anesthesia Services. Staff #1018 confirmed there was no documented signature, date, or time by the CRNA or a witness.

4. On 08/12/21 at 7:45 AM, Surveyor #10 interviewed the CRNA (Staff #1016) regarding signature time and date on the consent for Anesthesia services. The CRNA confirmed there was no place for a witness or CRNA to sign, date, or time the Informed Consent.
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Item #1 - Sterilization standards of practice

Based on observation, interview, and document review, the Critical Access Hospital failed to clean, disinfect, sterilize, and store patient care equipment according to acceptable standards of practice and/or manufacturer instructions for use.

Failure to properly clean, disinfect, sterilize, and store patient care equipment risks contamination with microorganisms and places patients at risk for infection.

Resource: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Update May 2019. Factors Affecting the Efficacy of Disinfection and Sterilization: Cleaning, " ... hinged instruments should be opened fully to allow adequate contact with the detergent solution; ... " Sterilizing Practices: Packaging. " ...hinged instruments should be opened; " Loading. " All items to be sterilized should be arranged so all surfaces will be directly exposed to the sterilizing agent. ... allow for free circulation of steam (or another sterilant) around each item. "

Findings included:

1. Document review of the Critical Access Hospital's procedure titled, "Sterilization and Disinfection-Infection Prevention," Procedure Number: PR-238-018, effective 02/02/16, showed that the procedure did not provide a reference to a national standard for sterilization and disinfection of surgical instruments. The procedure did not include information or instruction on proper reprocessing of hinged instruments.

2. On 08/12/21 at 8:32 AM, during a tour of the surgical department, Surveyor #10 observed the following:

a. Multiple peel packs of instrumentation with closed hinges.

b. Several peel packs containing multiple instruments, e.g. five Carmalt forceps stacked in one peel pack; two needle drivers overlapped in one peel pack.

3. On 08/12/21 at 8:15 AM, Surveyor #10 interviewed a sterile processing professional (Staff #1017) regarding the closed hinged instrumentation in the peel packs. Staff #1017 confirmed the hinged instrumentations were closed in the peel packs. Staff #1017 stated that she tries to keep them open. Surveyor #10 requested information regarding multiple hinged instrumentation processed in the same peel pack. Staff #1017 stated that it was the surgeon's preference to have multiple instruments in a single pack.

4. On 08/12/21 between 9:50 AM and 11:00 AM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) toured the Sterilization Department. The observation showed:

a. Numerous peel packs containing multiple instruments in a single package.

b. Many peel packs containing instruments with closed and locked hinges.

5. At the time of the observation, Surveyor #6 asked the Central Service Technician (Staff #607) about packing multiple instruments in a single peel pack and proper reprocessing of hinged instruments. Staff #607 stated that she had talked to the other surveyor about it.

Item #2 - Handwashing station

Based on observation and interview, the facility failed to provide a handwashing station in the Central Sterile decontamination room.

Failure to provide an appropriate hand-washing station in the decontamination room places staff at increased risk of exposure to infectious microorganisms during reprocessing of contaminated patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.8.1 Soiled workrooms shall contain (1) A clinical sink (or equivalent flushing-rim fixture) and a hand-washing station. Both fixtures shall have a hot and cold mixing faucet.

Findings included:

1. On 08/12/21 between 9:50 AM and 11:00 AM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) toured the Sterilization Department. The observation showed a 2-compartment utility sink in the decontamination room with neither side designated for handwashing. One compartment contained a small basin.

2. At the time of the observation, the surveyor asked the Central Service Technician (Staff #607) where staff cleaned their hands. Staff #607 stated they used one of the compartments of the 2-compartment sink but that neither side was for handwashing only.

Item #3 - Hand Hygiene supplies

Based on observation, document review, and interview, the Critical Access Hospital failed to ensure that handwashing supplies were available for hand hygiene (HH) according to hospital procedure and accepted standards of practice.

Failure to provide handwashing supplies risks transmission of communicable diseases between staff and patients.

Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), October 25, 2002 / Vol. 51 / No. RR-16, Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Perceived barriers to adherence with HH practice recommendations include inaccessible HH supplies. Easy access to HH supplies is essential for optimal adherence to HH recommendations.

Findings included:

1. On 08/12/21 between 9:50 AM and 11:00 AM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) toured the Sterilization Department. The observation showed there was no soap or hand sanitizer available in the clean area.

2. At the time of the observation, Surveyor #6 asked the Central Service Technician (Staff #607) where staff cleaned their hands. Staff #607 stated there was sanitizer on the decontamination side.

Item #4 - High-level disinfection of reusable medical equipment

Based on observation, document review, and interview, the Critical Access Hospital staff failed to use high-level disinfectants according to manufacturer's instructions for use to reprocess endoscopes.

Failure to use high-level disinfectants according to manufacturer's specifications risks inadequate disinfection of patient care equipment that increases risk of patient infection.

Reference: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), updated May 2019. Enzyme solutions should be used in accordance with manufacturer's instructions, which include proper dilution of the enzymatic detergent.

Findings included:

1. Document review of the manufacturer's instructions for use for MediChoice® Enzymatic Presoak and Cleaner, showed that for presoak use 1 oz (30 mL) of enzymatic liquid to 1 gallon (3.79 L) water.

Document review of the Critical Access Hospital's Procedure titled, "Sterilization and Disinfection - Infection Prevention," Procedure Number PR 238-018, approved 11/27/19, showed that manufacturer's recommendations for dilution, temperature, water hardness, and use should be followed.

2. On 08/11/21 at 12:05 PM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) observed the reprocessing of an Olympus colonoscope by a Certified Registered Central Service Technician (Staff #607). The enzymatic cleaner had been prepared prior to the surveyor's observation of the colonoscope reprocessing.

3. At the time of the observation, Surveyor #6 interviewed Staff #607 about the preparation of the enzymatic cleaner. Staff #607 stated she "puts about 2.5 pumps of enzymatic detergent into the bin and adds water to where I think it's 3 gallons."

Item #5 - Disinfection of non-medical equipment

Based on observation and interview, the Critical Access Hospital staff failed to appropriately disinfect equipment used to transport contaminated instruments.

Failure to disinfect equipment used in instrument transportation places staff at increased risk of exposure to infectious microorganisms.

Reference: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), updated May 2019. Enzymatic cleaners are not disinfectants, and proteinaceous enzymes can be inactivated by germicides.

Findings included:

1. On 08/12/21 between 9:50 AM and 11:00 AM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) toured the Sterilization Department. The observation showed a rolling cart stored in a walkway between the decontamination area and the clean area of the instrument reprocessing room.

2. At the time of the observation, the surveyor asked the Central Service Technician (Staff #607) about the use and sanitation of the cart. Staff #607 stated that the cart is used to transport used instruments from surgery to the decontamination area. She indicated that the cart was wiped with the same enzymatic presoak and cleaner that is used for surgical instruments. Surveyor #6 asked whether the cart was disinfected. Staff #607 stated that she thought the enzymatic cleaner was a disinfectant.

Item #6 - Surgical suite terminal clean

Based on observation, interview, and document review, the Critical Access Hospital staff failed to follow standards of practice for cleaning the surgical suite.

Failure to follow standard infection control practices for cleaning surgical suites puts patients at risk of harm from infections.

Reference: 2020 Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice: Environmental Cleaning. Recommendations: 2 Cleaning Procedures 2.5.1 When cleaning with the same cleaning material (e.g. cloth, wipe, mop head), progress from clean to dirty areas; 2.5.2 When cleaning and damp dusting, progress from top to bottom; 2.8.1 Consider items that contact the floor for any amount of time to be contaminated; 4 OR and Procedure Rooms 4.4.1 Clean and disinfect the exposed surfaces, including wheels and casters, of all items including OR beds; patient transfer devices (e.g. Roll boards).

Findings included:

1. Document review of the hospital's procedure titled, "Environmental Cleaning in the Surgery Department," Procedure Number: PR005-257, reviewed 07/21/21, showed a reference to AORN Standards and Recommended Practices 2014. Under Terminal Cleaning, review showed that lights should be cleaned first and then cleaning from top to bottom; cleaning the OR bed included elevating and extending it to a position where all surfaces can be sanitized; the OR bed is to be made prior to mopping the floor as the staff member leaves the room.

2. On 08/12/21 between 2:15 PM and 3:30 PM, Surveyor #6 and the Interim Infection Preventionist (Staff #604) observed an RN Circulator (Staff #608) as she performed terminal cleaning in the surgical suite. The observation showed:

a. Staff #608 used a pre-soaked cloth to disinfect the surfaces of a stainless steel rolling table. While wiping the bottom shelf, Staff #608 slid a canister of disinfectant wipes from one side to the other without disinfecting the bottom of the canister.

b. While wiping the legs of a rolling table, Staff #608 allowed the disinfectant wiping cloth to contact the floor. Staff #608 used the same cloth to wipe several other surfaces: 2 patient pillows, a stainless steel table, a Mayo stand (small portable stand with instrument tray), and 4 suction canisters.

c. Staff #608 failed to fully elevate and extend the support column of the surgical table to thoroughly disinfect all surfaces of the table.

d. Staff #608 failed to make the bed prior to mopping the floor.

e. At 3:20 PM Staff #608 stated that she had completed the terminal cleaning. At that time, the fire suppression waterlines hanging from the ceiling had not been high dusted; 3 step stools, 2 rubber floor mats, and wall mounted equipment (a patient transfer roll board, a sharps disposal container, a hand-sanitizer dispenser, and a glove box holder) had not been disinfected; and the OR bed was not made up.

3. At 3:20 PM Surveyor #6 interviewed Staff #608 about the terminal cleaning procedure. Staff #608 stated that she didn't know she should raise the OR bed and usually waited for all surfaces to dry before making it up. She stated that she didn't know when the waterlines hanging from the ceiling were dusted and that she didn't think about the wall mounted equipment or floor mats and step stools.
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Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures for the hospital's emergency preparedness plan to include provisions for food, water, and pharmaceutical supplies for staff and patients whether they evacuate or shelter in place.

Failure to provide provisions for subsistence needs places patients and staff at risk of harm during an emergency event.

Reference: 42 CFR 485.625(b)(1) The CAH must develop and maintain a comprehensive emergency preparedness plan to include policies and procedures that address the provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, to include, but not limited to food, water, medical, and pharmaceutical supplies.

Findings included:

1. Document review of the hospital's document titled, "Emergency Operations Plan (EOP) 2019," no document number, no approval date, showed that no policies attached to the plan included provisions for potable water supplies.

2. On 08/10/21 between 10:15 AM and 10:30 AM, Surveyor #6 interviewed and reviewed the hospital's emergency preparedness plan with the former Environment of Care (EOC) Coordinator (Staff #601). Staff #601 stated she did not know of a Memorandum of Understanding (MOU) or any other provision to provide potable water during an emergency.

3. On 08/11/21 between 9:45 AM and 10:30 AM, Surveyor #6 interviewed and reviewed the hospital's emergency preparedness plan with the Safety Officer (Staff #602). Staff #601 did not provide a plan to provide provisions for potable water supplies as required by federal regulations for CAHs. Staff #601 stated that the city water tank provides gravity delivery but there is no back up water supply.
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