HospitalInspections.org

Based on interview and document review, the critical access hospital (CAH) failed to ensure patients were provided the Important Message from Medicare About Patient Rights (IM), and failed to ensure patients were provided an opportunity and/or encouraged to develop advance directives. This affected 3 of 20 inpatient whose records were reviewed (P4, P5 and P20) whose medical records were reviewed.

Findings inlcude:

P20 was admitted to the CAH on 1/11/18, and was discharged on 1/13/18. P20's medical record lacked a signed IM message.

P5 was admitted to the CAH on 12/31/17, and was discharged on 1/1/18. P5's record revealed the IM Message was not provided to P5 at the time of hospitalization, but was provided 28 days post discharge. In addition, P5's record did not indicate the patient had been made aware of the right to formulate an advance directive.

P4 was admitted to the CAH on 10/28/18, and discharged on 10/30/18. P4's paper record identified a code status of Do Not Resuscitate/Do Not Incubate (DNR/DNI). However, the electric medical record indicated P4 should be Full Code.

On 7/31/18, at 1:16 p.m. registered nurse (RN)-B confirmed the IM message was required to be given to all inpatients who are Medicare eligible.

On 8/1/18, at 1:37 p.m. EE-DD verified advance directive information had not been documented for P5, and indicated the code status documentation was conflicting for P4.

On 7/31/18, at 3:00 p.m. social services (SS) staff-A stated the hospital did not provide mandatory training for staff on advanced directives.

On 7/31/18, at 3:38 p.m. employee (EE)-G stated she would expect advance directive training for staff to be offered per the regulation.

Based on interview and document review, the critical access hospital (CAH) governing body failed to ensure safe and effective surgical practices, and infection control competencies were implemented. This had the potential to affect any surgical patients whose procedures were performed at the CAH.

Findings include:

Refer to findings identified at the Surgical Services Condition at C320.
Refer to findings identified at the Patient Care Policies standard at C278.

During interview on 7/30/18 at 2:25 p.m., with the surgical services director (SSD-A) and the director of patient care services and quality (DPCSQ-B) regarding the CAH's use of flash sterilization, SSD-A and DPCSQ-B verified based on review of Flash Sterilization Record documents, it appeared staff had been using flash sterilization for non-emergent situations.

During interview with surgical technician (ST)-D on 8/1/18 at 8:45 a.m., ST-D stated they had utilized flash sterilization as recorded on the Flash Sterilization Record. ST-D verified instruments most often flash sterilized were orthopedic packs, "Because the doctor [surgeon-C] likes to stay busy." ST-D also confirmed they had enough time between patients that they should have used the autoclave for full sterilization instead of using the flash sterilization method. ST-D verified the Flash Sterilization Records indicated flash sterilization may have been used for convenience, even though the CAH's policies and procedures indicated flash sterilization should be reserved for emergency needs.

During interview with the CAH's infection control preventionist (ICP)-E on 8/1/18, at 10:40 a.m., ICP-E stated she
had not been auditing the surgical department for infection control measures. She stated, "[SSD (surgical services director)-A] handles all that." ICP-E stated although she is in charge of surveillance and monitoring of surgical patients, she relied on patients coming back to office visits with their surgeons and reporting whether there had been any surgical complications, including infections. ICP-E state at that time, it would be up to the surgeon to report any findings to her, otherwise ICP-E had no way of tracking patients seen by outside providers. ICP-E stated she would monitor in-house lab reports routed to her to see whether any infections were from surgical patients, but could not produce record of any patients she'd had to actively monitored. ICP-E stated she utilized standards set forth by the National Healthcare Safety Network (NHSN) and the Centers for Disease Control (CDC). ICP-E agreed the current system in place to monitor for surgical infections was not as thorough as it could be, and stated she could have missed potential infections. ICP-E agreed she should develop proactive surveillance and monitoring.

The facility's Medical Staff Bylaws dated May 2015, indicated the medical staff was responsible to ensure facility policies were implemented for medical care, to ensure competent clinical performance, to supervise the infection control program in all phases, to provide effective mechanisms to monitor and to evaluate the quality and appropriateness of patient care and clinical performance of all individuals.

Based on interview and record review, the critical access hospital (CAH) failed to ensure a program for prevention, control and investigation of infections and communicable diseases was implemented in accordance with nationally recognized infection control practices or guidelines, as well as applicable regulations of other federal or state agencies. In addition, the CAH failed to ensure 3 of 5 employees (E-AA, E-BB, ECC) were appropriately screened for tuberculosis (TB). These deficient practices had the potential to affect any patients who would receive services from the CAH.

The findings include:

During interview with the CAH's infection control preventionist (ICP)-E on 8/1/18, at 10:40 a.m., ICP-E stated she
had not been auditing the surgical department for infection control measures. She stated, "[SSD (surgical services director)-A] handles all that." ICP-E stated although she is in charge of surveillance and monitoring of surgical patients, she relied on patients coming back to office visits with their surgeons and reporting whether there had been any surgical complications, including infections. ICP-E state at that time, it would be up to the surgeon to report any findings to her, otherwise ICP-E had no way of tracking patients seen by outside providers. ICP-E stated she would monitor in-house lab reports routed to her to see whether any infections were from surgical patients, but could not produce record of any patients she'd had to actively monitored. ICP-E stated she utilized standards set forth by the National Healthcare Safety Network (NHSN) and the Centers for Disease Control (CDC). ICP-E agreed the current system in place to monitor for surgical infections was not as thorough as it could be, and stated she could have missed potential infections. ICP-E agreed she should develop proactive surveillance and monitoring.

Review of the January 2018, CDC guidelines for Surveillance Periods for surgical site infections (SSI) indicated the NHSN Operative Procedure Categories, used as the facility's professional standards, recommended 30 day surveillance to be performed for laparoscopic and other less invasive procedures; 90 day surgical surveillance was to be performed on orthopedic surgeries involving fracture repair, joint replacements, and other invasive surgeries.


37038

Employee (E)-AA personnel record revealed a hire date of 7/9/18. Documentation failed to indicate whether a tuberculin skin test had been completed for E-AA.

During interview with the operations director E-EE on 8/1/18 at 11 a.m., she confimred that there was no evidence a skin test for tuberculosis screening had been conducted for E-AA.

E-BB's personnel record revealed E-BB was a phlebotomist with a hire date of 10/7/17. TB skin test documentation revealed a first step mantoux had been administered on 9/21/17 at 4:25 p.m. however, no results were recorded. A second step mantoux had been administered on 10/16/17 at 10:13 a.m. However, it was read too soon. Results of the second step mantoux were recorded on 10/17/17 at 12:10 a.m. The Skin Test form indicated an RN or LPN should read and record results in millimeters of induration in 48-72 hours.

E-CC's personnel record revealed E-CC was a radiology technician with a hire date of 9/5/17. Although the provider had evidence two step TB skin testing had been conducted prior to hire, both TST steps had occurred greater than 90 days prior and none had been conducted since.

During an interview with the infection preventionist, registered nurse (RN)-A on 8/1/18, at 9:30 a.m., she confirmed that the TB Skin tests for E-BB and E-CC had not been completed in accordance with the facility's guidelines.

According to the MMWR (Morbidity Mortality Weekly Report) dated 2005, if a newly employed health care worker (HCW) had a negative TST in the recent 12 months, the second step could be administered at the time of hire.

The Regulations for Tuberculosis Control in Minnesota Health Care Settings dated July 2013, indicated baseline TB screening was required for all HCWs. In addition, the document indicated: An employee may begin working with patients after a negative TB symptom screen (i.e., no symptoms of active TB disease) and a negative IGRA or TST (i.e., fi rst step) dated within 90 days before hire. The second TST may be performed after the HCW starts working with patients.

Based on interview and document review, the facility failed to complete a timely medicare notification for 4 of 20 patients medical record (MR1, MR14, MR15) and 1 of 1 patient observation record (OR1) whose records were reviewed for timely notification of Medicare rights.

Findings include:

MR1 was admitted to the facility on 7/28/18, and was discharged on 7/30/18. The notification of his Medicare rights during his hospital stay was not given to him until 7/30/18.

MR14 was admitted to the facility on 5/18/18, and was discharged on 5/21/18. The notification of his Medicare rights during his hospital stay was not given to him until 5/21/18.

MR15 was admitted to the facility 5/27/18, and was discharged on 5/29/18. The notification of her Medicare rights during his hospital stay was not given to her until 5/29/18.

OR1 was admitted to the facility on 7/28/18,. The notification of his Medicare rights during his hospital stay was not given to her her family member until 7/30/18.

On 7/31/18, at 4:00 p.m., during a interview with the operations director (OD)-EE, she confirmed a notification of Medicare rights should be completed the day of admission. OD-EE confirmed that the admissions department works Monday through Friday, so that patients admitted on the weekend have a folder that is left for admissions to complete during the week. She confirmed the medicare notices were not issued on the day of admission.

Based on observation, interview and document review, the Critical Access Hospital (CAH) was found to be out of compliance with the Condition of Participation of Surgical Services 485.639. The CAH did not ensure proper sanitation of surgical instruments for patients when they implemented use of flash sterilization on a routine basis rather than reserving for emergency use. The cumulative effect of this systemic problem resulted in the CAH's inability to ensure the provision of quality health care in a safe environment.

Findings include:

The CAH failed to ensure proper sterilization of surgical equipment occurred for patients.

During environmental observations of the surgical suite area on 7/30/18 at 2:00 p.m., a sterilization room was observed to divide surgical suites 1 and 2. Within the sterilization room was an autoclave sterilizer (full sterilization processor) and a flash sterilizer (to be used for emergency purposes only). At the time of this observation, the surgical services director (SSD), stated surgical services staff were responsible to ensure sterilization of surgical equipment used in the hospital.

During a follow up interview on 7/30/18 at 2:15 p.m., SSD-A stated she was unaware of staff performing any flash sterilization stating, "It's been at least a year [since used]."

On 7/30/18 at 2:25 p.m., SSD-A and the director of patient care services and quality (DPCSQ)-B were interviewed regarding Flash Sterilization Record logs which indicated flash sterilization had not always been used for emergency procedures, but had been used for the following surgeries:
(1) 7/12/18: "Item- large powered, ortho (orthopedic) major/minor, knee jig. Reason: Have 2 sets, needed 3rd case."
(2) 4/19/18: "Item- ortho minor and Riley's knee jig. Reason: We used 1st case, needed 3rd."
(3) 2/22/18: "Item Arthroscopy Inst (instrument). Reason: Needed for 2nd case, we have 1 set."
(4) 2/22/18: "Item: TUR (transurethral resection) Inst. Reason: We have 1 set, needed both cases."
(5) 2/22/18: "Item: Cysto (cystoscopic) Inst & camera. Reason: We have 2 sets, needed for 3rd case to follow."
(6) 2/8/18: "Item: Tenotomy scissor (surgical scissors for delicate surgery)/skin hooks/ragnells (surgical retractor). Reason: Needed for 3rd case (we have 2 sets)."
(7) 2/8/18: "Item: Tenotomy scissor/skin hooks/ragnells. Reason: Needed 4th case (we have 2 sets)."
(8) 2/8/18: "Carpal tunnel/ganglion. Item: Skin hooks. Reason: Needed 4th case."

During the interview regarding flash sterilization 7/30/18 at 2:25 p.m., SSD-A and DPCSQ-B agreed it appeared staff had been using flash sterilization for non-emergent situations. They reiterated the CAH's surgical technicians were responsible for the sterilization of all surgical instruments in the hospital. DPCSQ-B stated staff were evaluated for competencies related to use of flash sterilization processes. SSD-A stated, "It takes 36 minutes to use full sterilization on instruments. The flash takes 3-5 minutes. We don't have enough instruments, so they [surgical technicians] probably needed them [surgical instruments] in a faster turn around time."

During interview with surgical technician (ST)-D on 8/1/18 at 8:45 a.m., ST-D stated they had utilized flash sterilization as recorded on the Flash Sterilization Record. ST-D verified instruments most often flash sterilized were orthopedic packs, "Because the doctor [surgeon-C] likes to stay busy." ST-D also confirmed they had enough time between patients that they should have used the autoclave for full sterilization instead of using the flash sterilization method. ST-D verified the Flash Sterilization Records indicated flash sterilization may have been used for convenience, even though the CAH's policies and procedures indicated flash sterilization should be reserved for emergency needs.

During interview with the CAH's infection control preventionist (ICP)-E on 8/1/18, at 10:40 a.m., ICP-E stated she was unaware the surgical technician's had been using flash sterilization as identified.

Although attempts to contact orthopedic surgeon-C were made twice, no return call was received.

The CAH's policy Operating Flash Sterilizer dated 2/7/17, indicated immediate use sterilizing was to be used to provide means of assuring appropriate sterilization of instruments for emergency need only.

The CAH's policy Cleaning, Disinfection, and Sterilization dated 2/7/17, indicated immediate use sterilization (flash) should not be used for implantable devices, and should be used only for emergency needs.