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Based on observation, interview, and policy and procedure review the Critical Access Hospital (CAH) failed to provide care and cleaning to the physical therapy Hydrocollator (water bath for moist heat packs) as directed by manufacturer's guidelines. Lack of sufficient cleaning and change of water can lead to damage of the Hydrocollator and result in delay of prescribed treatments to patients.

Findings included:

- According to the Hydrocollator Heating Units User Manual, item #6 stated, "Regularly clean and drain the tank (every two weeks). Failure to properly maintain the unit will cause premature wear and will void the warranty. "


Interview with physical therapy Staff # I and policy review revealed that the Hydrocullator water change and cleaning occurs quarterly and the water temperature is monitored weekly and documented on the water temperature log.

Interview with physical therapist Staff #P confirmed that the current practice of quarterly water changes and cleaning as well as weekly water temperature monitoring is the current practice of the physical therapy department of the CAH.

Failure to follow manufacturer's guidelines recommendation of cleaning every two weeks to avoid damage to the hydrocollator and cause potential inability of the CAH to provide prescribed physical therapy treatments.

Based on observation, interview, and policy review the CAH failed to have defined work counter space for contaminated medical equipment. There were posted signs for countertop space to place clean medical equipment and sterilized medical equipment directly next to the sink used for washing contaminated medical equipment.

Failure of the CAH to provide sufficient separation of work space between contaminated, clean, and sterilized items placed patients at risk of exposure to potentially contaminated medical equipment.


Findings included:


During interview with clinical staff member #S, s/he explained the procedure of bringing contaminated items into the sterilization room, washing in the designated sink, laying washed items on the counter next to the washing sink, drying, wrapping and placing them into autoclave. Following sterilization, items are removed from the autoclave and placed on counter top adjacent to the clean work top area.


- Designated counter work space for contaminated items was not defined. Separation of counter space between clean items and sink used for washing contaminated items as well as sufficient separation of counter space was not sufficient. Potential of splash contamination can occur.

Based on interview, record review and policy review, the facility failed to ensure their clinical and nursing policies and procedures were current. Policy Manuals had documented annual reviews of policies and procedures but the policies and procedures were not current with acceptable standards of practice.

Failure to have policy and procedure current with standards of clinical care created potential harm to the patients in the facility should the practices result in inadequate, unsafe care.


Findings included:

During interview with nursing staff # B, s/he stated written policies for all clinical departments are approved annually by review. Review of the policy manual showed policies were not current with standards of practice in all areas of clinical practice. Additionally, there are policies not included in the policy manual that directly relate to clinical practice. Evidence of a missing policy included the opening and dating on vial labels the appropriate date for disposal of multi-dose medication vials.

Based on observation and interview the Critical Access Hospital (CAH) failed to retain a summary list of destroyed medical records when written records were transferred to a storage device and subsequently destroyed.

Failure of the CAH to have a summary list of destroyed medical records could cause delay in review of pertinent medical information in time of need.


Findings include:

- According to Kansas State Regulations the CAH is obligated to keep essential information for destroyed original medical records including, patient name, identification, destroy date, and if transferred to permanent storage, location of the storage. A summary shall be maintained of medical records that are destroyed and shall be retained on file for at least 25 years.

Based on observation during a tour of the Critical Access Hospital (CAH) on 6/13/2016 at 10:10 AM revealed the CAH failed to provide Patient Rights information in a manner that was easily accessible during the admission process. There was no signage at entrances or written information at the registration desk or Emergency room entrance area. There was no written information provided to patients.

Failure by the CAH to post signage and/or provide written information of patient rights at public entrances or prior to admission failed to ensure that patients know their rights and responsibilities while a patient in the CAH.

Findings include:

- Review of the CAH policy and procedure revealed the patient right policy provided for each patient to receive a copy of the patient rights upon admission. No signage in view of the public at facility entrances or public hallways was provided and no written documentation was located at the registration area where patients were admitted.

Nursing staff # B, RN, was interviewed on 6/13/2016 at 10:10 AM and acknowledged the patient rights were not posted in the view for patients.