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Based on observation and review of the Rules for Critical Access Hospitals in Arkansas 2021 and National Fire Protection Association (NFPA) 99 2012 Edition, it was determined the facility failed to label the Medical Gas Central Supply Room, establish a threshold for empty medical gas cylinders, and mark empty medical gas cylinders in accordance with NFPA 99 standards. The failed practices had the likelihood to affect all patients relying on portable oxygen in that in the event of an emergency the staff would not be able to determine if an available cylinder was empty or not. Findings follow:

A. Review of the Rules for Critical Access Hospitals in Arkansas 2021 showed medical gas storage shall be provided in accordance with NFPA 99.
B. Review of NFPA 99 2012 Edition: 5.1.3.1.9 showed locations containing central medical gas supply systems shall have their door(s) labeled as follows:
Medical Gases
NO Smoking or Open Flame
C. Observation on 06/03/21 at 10:00 AM of the Medical Gas Central Supply Room showed the entry door did not display any signage as required by NFPA 99 standards. This finding was verified with the Director of Plant Operations at the time of observation.
D. Review of NFPA 99 2012 Edition: 11.6.5.3 showed empty medical gas cylinders shall be marked to avoid confusion if a full cylinder is needed in a rapid manner.
E. Observation of the Rehabilitation Center on 06/02/21 at 2:30 PM showed two of two medical gas cylinders stored in the Rehabilitation Center with integral pressure gauges with needles in the red portion reading "refill". One of the cylinders was stored on a loaded crash cart in the main therapy area, and another cylinder was stored on a wheeled cart in the Staff Break Room. Neither cylinder was marked to indicate whether it was empty, and in an interview with the Director of Rehabilitation on 06/02/21 at 2:40 PM he stated he did not know whether the two cylinders were empty.
F. Review of NFPA 99 2012 Edition: 11.6.5.2.1 showed when the facility employs medical gas cylinders with an integral pressure gauge it shall establish the threshold pressure at which a cylinder is considered empty.
G. In an interview with the Director of Rehabilitation on 06/02/21 at 2:40 PM he stated the facility had not established a threshold pressure at which medical gas cylinders would be considered empty.

Based on review of the facility's Temperature and Humidity Log and Rules for Critical Access Hospitals in Arkansas 2021, it was determined the facility failed to provide a surgical environment in accordance with the temperature and relative humidity ranges specified in the Rules for Critical Access Hospitals in Arkansas 2021. The failed practice had the likelihood to affect all patients in that a safe and sanitary environment could not be ensured for surgical procedures. Findings follow:

A. Review of the Rules for Critical Access Hospitals in Arkansas 2021 showed a relative humidity of 20% - 60% and a temperature of 68-73 degrees Fahrenheit shall be provided in Operating Rooms.
B. Review of the facility's Temperature and Humidity Log showed the relative humidity of Operating Room 1 was outside the required range for 36 of 265 days recorded in the 12 months prior to the survey (June 2020 -May 2021), the temperature of Operating Room 1 was outside the required range for 222 of 265 days in the 12 months prior to the survey (June 2020 -May 2021), the humidity of Operating Room 2 was outside the required range for 48 of 265 days recorded in the 12 months prior to the survey (June 2020 -May 2021), and the temperature of Operating Room 2 was outside the required range for 223 of 265 days recorded in the 12 months prior to the survey (June 2020 -May 2021).
C. The above finding was verified with the Director of Plant Operations on 06/03/21 at 10:40 AM.

Based on observation and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, the facility failed to maintain two of two (Administration Corridor, Kitchen Dry Storage) fire-rated door assemblies as required by NFPA 101 2012 Edition in that the fire-rated doors were not closed and latched. The failed practice 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 practice had the likelihood to affect all patients, staff and visitors. Findings were as follows:

A. 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. 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.
B. Observation on 06/01/21 at 3:05 PM showed the doorway connecting the Main Lobby to the Administration Corridor was constructed of a fire-rated door assembly consisting of a door leaf which did not latch when closed. This finding was verified on 06/03/21 at 10:40 AM with the Director of Plant Operations.
C. 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. Review of NFPA 80 2010 Edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited.
D. Observation of the Kitchen on 06/03/21 at 9:45 AM showed the doorway to the Kitchen Dry Storage was constructed of a fire-rated door assembly consisting of a door leaf which was held open by a metal shelf, preventing the door from closing. This finding was verified on 06/03/21 at 10:40 AM with the Director of Plant Operations.

Based on review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and observation of the Emergency Department Waiting Room, it was determined the facility failed to install one of one alcohol-based hand-rub (ABHR) dispenser in a location to ensure the safety of patients and staff to prevent electrical shock or fire. The failed practice had the potential to affect all patients admitted into the Emergency Department. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6(8) showed alcohol-based hand-rub dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source.
B. Observation on 06/01/21 at 2:53 PM of the entrance to the Emergency Department Waiting Room showed one ABHR dispenser installed directly above an electrical outlet on the right-side wall of the entrance vestibule.
C. The above finding was verified with the Director of Plant Operations on 06/03/21 at 10:40 AM.

Based on observation AORN (Association of Perioperative Registered Nurses) Position Statement and interview, it was determined the facility failed to assure a Registered Nurse was only functioning as a circulating nurse in one of one procedure observed. The failed practice did not assure the circulator could perform the duties required of a Registered Nurse (i.e. patient assessment) during the procedure and had the potential to affect all patients undergoing procedures in the facility. Findings follow:

A. During observation on 06/03/21 at 10:35 AM in Procedure Room #1, one of one RN (Registered Nurse) who was functioning in the role of the Circulator Nurse assisted physician with obtaining biopsies.
B. Review of AORN position 2019 showed:
1) At a minimum, one perioperative RN Circulator should be dedicated to each patient undergoing operative or other invasive procedures and should be present during the patient's entire intraoperative experience.
2) The perioperative RN Circulator supervises and evaluates the activities of other team members while simultaneously executing immediate directives and interventions in urgent or emergent situations.
C. During interview with the Director of Surgical Services on 06/04/21 at 1:50 PM the above findings were verified.

Based on review of policy, Medication Error Report, review of clinical record and interview, it was determined the facility failed to have policies and procedures to ensure the incorrect administration of medications were documented in one of one (#16) incident of medications given to a wrong patient. By not documenting the medications the patients received, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Review of the facility's policy titled, "Medication Errors", dated 5/11/2017, showed the error was only to be documented in the Variance Reporting System. There was no mention that the medication error should be documented in the patient's medical record.
B. Review of Medication Error Report showed Patient #16 received Carbidopa/Levodopa 25-1100 mg (milligram), Isosorbide 30 mg, Gabapentin 100 mg and Allopurinol 100 mg in error on 5/22/21.
C. Review of the clinical record for Patient #16 showed no evidence of the medication they received in error.
D. During an interview on 06/03/2021 at 3:10 PM, the Quality Officer verified there was no evidence in Patient #16's clinical record indicating they received the medication that was not prescribed for them.

Based on observation, policy review, and interview it was determined the facility failed to implement practices and policies in the surgical area including prevention and surveillance to control transmission of infectious diseases. By not wearing proper surgical attire when moving from the restricted to non-restricted area, no training or observation of the terminal cleaning procedure, and performing IUSS (Immediate Use Sterilization) without documentation and proper storage. The failed practice had the potential to affect all patients having surgery in the facility. Findings Follow: See C1208

Based on policy and procedure review, observation, and interview it was determined that the Infection Control Nurse did not have a system for identifying, controlling, and preventing the transmission of infections in that four of four (Director of Surgical Services, Scrub Tech #1 and #2, and Circulating Nurse) surgical staff members moved to and from the non-restricted area to the restricted area of the Surgical Suite wearing the same scrub attire. The failed practice did not ensure the sterile Surgical Suite was maintained free of contaminants and had the potential to affect all surgical patients in the facility. Findings follow.

A. Review of policy and procedure titled "Surgical Attire "dated March 6th 2019 showed the following: "All persons entering the semi -restricted and restricted area within the Surgical Suite will wear appropriate scrub attire to facilitate the maintance of the optimal environment"
B. During tour of the Surgical Suite on 06/01/21 at 2:15 PM the Director of Surgical Services came from the wound clinic located in the pre and post area into the Surgery Suite entering OR #1 and #2 wearing the same scrub suit, shoe covers, and hat with no additional new clean cover over her scrub suit. During tour she stated both OR #1 and #2 were cleaned and ready for surgery.
C. After the observation of an Endoscopy procedure on 06/03/21 at 10:45 AM the Surveyor observed Scrub Tech #1 and #2 and the Circulating Nurse leave the Procedure Room and go into the Surgical Suite wearing the same scrubs, hats, and shoe covers that were worn for the Endoscopy Procedure.
D. During interview with Director of Surgery on 06/03/21 at 11:45 AM the above findings were verified.

Based on observation, policy review, and interview it was determined the Infection Control Nurse failed to assure a clean and sanitary environment and avoid sources of transmission by not identifying, controlling, and performing surveillance of terminal cleaning of the Surgical Suite. The failed practice had the potential to affect all patients having surgery in the facility. Findings follow:

A. Observation of the Environmental Tech terminally cleaning Procedure Room #1 on 06/03/21 at 12:30 PM showed the following:
1) Removed trash then began to clean without changing gloves.
2) Sprayed the countertop, wiped the top surface wiped down to the bottom with cloth touching the floor. Using the same cloth, she cleaned the wall vent, wiped the floor, and then sprayed the top of the Endo Cart and wiped down to the bottom with the cloth touching the bottom of the floor.
B. Observation of Environmental Tech terminally cleaning Surgery Room #1 on 06/03/21 at 1:15 PM showed the following:
1) Environmental Tech used two cloths, one in her right hand to use after spraying and a dry cloth in her left hand to use to wipe dry. She sprayed an instrument table, wiped the top with the damp cloth, wiping to the bottom of the table, and both cloths touched the floor. She then used the dry cloth to wipe the top of the table wiping down to the bottom, and both cloths touched the floor.
2) Using the same cloths, she sprayed the next instrument table, wiped the top with the damp cloth, wiping to the bottom of the table, and both cloths touched the floor. She then used the dry cloth to wipe the top of the table wiping down to the bottom, and both cloths touched the floor.
C. Review of facility's policy titled "Environmental Cleaning for Surgical Services" dated 11/12/2017 showed the following:
1) 2.8 Perioperative and environmental services personnel should receive initial and ongoing education and competency verification on their understating of the principles and performance of the processes for environmental cleaning in perioperative area.
2) 2.6 All personnel should take precautionary measures to limit transmission of microorganisms when performing environmental cleaning and handling waste materials.
D. Review of facility's policy titled "Surveillance Methods" dated 10/2019 showed in Section 2.0
#8 Inspecting all departments of the hospital for cleanliness and compliance.
#10 Follow up inspections to inspect for corrections made.
#11 Staff trained for OR cleaning will be monitored according to policy.
E. On 06/02/21 at 1:45 PM during an interview with the Infection Control Nurse she stated the Environmental Services Tech performs terminal cleaning of the operating rooms and the procedure room at the end of the day. She stated there was no documentation of terminal cleaning training or any observations of terminal cleaning being performed.
F. On 06/03/21 at 11:00 AM during an interview with the Director of Surgical Services she stated she did not have any documentation of terminal cleaning training or any observations.
G. On 06/03/21 at 2:20 PM the findings above were verified with the Chief Executive Office.

Based on review of the Association of Operative Registered Nurses (AORN) guidelines for perioperative practice for 2020, Policy and Procedure, Sterilization log, and interview it was determined that the Infection Control Nurse failed to provide a plan of action for preventing, identifying and managing infections in that Immediate Use Steam Sterilization (IUSS) or FLASH was not used according to the AORN guidelines. The failure to use IUSS according to AORN guidelines did not assure the surgical instruments were being used immediately and surgical instruments were not documented or identified in each sterilization load on the sterilization log. The failed practice had the potential to affect any patient requiring surgery using instruments that were sterilized by IUSS. Findings follow:

A. Review of AORN guidelines for 2020 Sterilization Section 5.5.3 showed Items processed using IUSS should be immediately used and not stored.
B. Review of AORN guidelines for 2020 Sterilization Section 5.5.6 showed maintain documentation of IUSS cycle information and monitoring results.
C. Review of Facilities Policy and Procedure Titled Flash Sterilization of Contaminated Instruments showed the following " Instruments that are contaminated from infected procedures have been cleaned worth enzymatic solutions, rinsed and dried, As an extra layer of protection to ensure all contaminates ...Then the instruments are wrapped in the usual manner and sterilized.
D. Review of the Immediate Use Steam Sterilization log tickets dated 01/06/21 to 05/18/21 showed 30 of 30 tickets with FLASH (IUSS) or FLASH with 24 of 30 tickets with no documentation of the specific surgical instruments that were flashed.
E. During interview with the Director of Surgical Services on 06/03/21 at 2:45 she verified findings above.

Based on observation, policy review, review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines and interview, it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to screen four of four surveyors for a temperature or signs and symptoms of COVID-19 for two (06/01/21 and 06/02/21) of three (06/0121 - 06/03/21) days. 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 follow:

A. On 06/01/21 at 10:00 AM and on 06/02/21 at 9:30 AM when entering the facility, four of four surveyors (#1, #2, #3, and #4) were not screened appropriately according to the CDC recommendations. Staff Member #1 did not ask questions regarding a temperature or signs and symptoms of COVID-19.
B. 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 02/10/21 showed the following:
Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
C. Review of facilities policy dated March 31st 2021 titled "Visitation During Pandemic" provided by Infection Control Nurse on 06/03/21 at 1:30 PM showed the following: Screening positive to any of the screening questions -person may not be allowed to enter the facility.
D. On 06/02/21 at 1:00 PM the Infection Control Nurse verified above findings.