HospitalInspections.org

Based on observations on facility tour and staff interviews, it was determined the Critical Access Hospital (CAH) failed to provide written notice of its policies regarding the implementation of Patient's Rights to make decisions concerning medical care, such as the right to formulate advanced directives. This deficient practice poses a risk to patient's health and safety if the facility does not inform the patient and/or patient's representative of their Patient Rights.

Findings include:

Observation on facility tour 12/19/16 revealed that a posting of the Patient Rights is not posted in the facility's main lobby or in the Emergency Department's registration/waiting room.

Observation on facility tour 12/22/16 revealed that a copy of Patient Rights is not given to the patient and/or patient's representative on admission or at the time of registration within the Emergency Department.

The CEO, CFO and Director of Finance & Revenue Cycle identified during tour on 12/22/16, that the TV monitor in the Emergency Department registration/waiting room is how Patient Rights information is communticated to patients and the broadcast acts as their means of posting Patient Rights; and that the TV broadcast was not on and that no Patient Rights were posted.

The CFO, CNO and Director of Finance & Revenue Cycle confirmed during interviews
conducted 12/22/16, that Patient Rights are broadcast on video screens located in the facility's main lobby and the Emergency Department's registration/ waiting room, and that the video screens were off 12/19/16, 12/20/16, /12/21/16, and 12/22/16, which is a potential risk for patients not knowing their rights concerning care in the facility.

Based on observation and staff interviews, it was determined that the facility failed to require that there was a system in place to ensure that supplies used in an emergency had not expired. This deficient practice poses a risk to patient's health and safety if the patients are provided treatment with expired supplies that may be potentially ineffective, and if the facility does not discard expired supplies.

Findings include:

Observation of the obstetrics nursing alcove area (IV & handwashing station), revealed 1 (one) black/gray supply box and 2 (two) "Neonatal" Drug Kits (maroon & gray) used for emergencies, contained the following expired supplies:

Neonatal Drug Kit #1:
24G 5/8 inch Acuvance angiocath x2 expired 4/2016, 22G 5/8 inch BD Nexia angiocath x1 expired 11/2016;

Neonatal Drug Kit #2:
24G 5/8 inch Acuvance angiocath x2 expired 4/2016;

Black/Gray Box:
Flexam glove size M x1 expired 4/2014, Triflex gloves size 8 x1 expired 3/2014, Triflex gloves size 7.5 x1 expired 1/2014, Ammonia Inhalant x1 expired 2/28/13, Aplicare Lubricant x2 expired 1/2015, BD Nexiva IV Catheter 19mm x1 expired 11/2016, Clave connector x1 expired 11/2015, green top test tube x1 expired 11/2015, purple top test tube expired 3/2016, red top test tube exp 12/2015, blue top test tube expired 6/2015.

Personnel #18 confirmed in an interview conducted 12/20/16 that "another nurse keep this up" and that the supplies were expired.

Based on observation, review of policies and procedures, facility documents, manufacturer recommendations, and staff interview it was determined that the facility failed to:

(C0278) 1. ensure policies and procedures related to sterilizing equipment and supplies, the use of personal protective equipment such as gowns, masks or face protection, disinfecting equipment in between patient use and the use of multi-dose vials according to CDC guidelines were maintained. This deficient practice poses a risk to a patient's health and safety if the facility cannot ensure that infection control standards are being enforced; and

2. require that expired supplies used for patient care were discarded. This deficient practice poses a risk to patient's health and safety when the facility does not discard expired supplies to avoid potential transmission of infection.

The cumulative effect of this system practice resulted in the Critical Access Hospital's inability to ensure compliance with Provision of Services.

Based on observation and staff interviews, it was determined that the facility failed to ensure that a cart used for an emergency is sealed until opened in an emergency; and that the emergency cart contents and sealing of the emergency cart are verified and documented according to policies and procedures. This deficient practice poses a risk to patient's health and safety if the facility cannot ensure the security of the cart used for emergencies.

Findings include:

An unlocked Code Cart/Emergency Cart was located within the Radiology Department in the "Tech Room". The cart had three drawers of medications and 1 drawer of supplies. The three drawers of medications were not secured or sealed.

The Manger of Radiology confirmed in an interview conducted 12/19/2016, that "pharmacy and nursing take care of this"and that she "did not know anything about the locks."

The Director of Nursing confirmed in an interview conducted 12/19/16 that the Code Cart/Emergency Cart was to be locked and that it was not locked and that the contents of the cart are to be verified and documented and that there was no verification or documentation available.

Based on observations on facility tour, review of policies and procedures, facility documents, manufacturer recommendations, and staff interviews, it was determined that the facility failed to:

1. Ensure that policies and procedures related to sterilizing equipment and supplies, the use of personal protective equipment such as gowns, masks or face protection, disinfecting equipment in between patient use and the use of multi-dose vials according to CDC guidelines were maintained. This deficient practice poses a risk to a patient's health and safety if the facility cannot ensure that infection control standards are being enforced; and

2. Require that expired supplies used for patient care were discarded. This deficient practice poses a risk to patient's health and safety when the facility does not discard expired supplies to avoid potential transmission of infection.

Findings include:

1. Observation of Cidex OPA Disinfecting Solution gallon container had date opened: 12-
19-16 and discard 3-4-17 which is a violation of the policy. No other policy was provided
to the Department when requesting policies specific for Cidex OPA.

Advanced Sterilization Products has issued a manufacturer recommendation document "How To Use Cidex OPA Solution" which revealed: "Personal protective equipment must always be worn when handling contaminated instruments and equipment...Personal protective equipment includes gloves, eye protection and fluid-repellent gown..."

The facility's Radiology Policy #58 titled "Cidex OPA Disinfecting Solution" and dated
revised: 8-13-14 revealed: "...Once opened the gallon solution is stable for 45 days..."

The Director of Nursing confirmed in an interview conducted 12/20/16, that the CDC and APIC are the professional standards used for the facility's Infection Control program.

Observation of the Respiratory Therapy/Stress Test/EKG Room revealed an Ultrasound
machine and treadmill machine. There were no disinfecting wipes in the room.
The

Employee #26 confirmed during an interview conducted on 12/22/16, stated they were
not aware of who stocks supplies for this room and could not verbalize that the ultrasound equipment or exam table required disinfecting between patient use.

Employee #26 confirmed during an interview conducted on 12/22/16, that there was no
knowledge of the expired supplies sitting on the Ultrasound Machine.

The CDC's "FAQ's regarding Safe Practices for Medication Injections: Multi-dose Vials"
reads: "...the United State Pharmacopeia General Chapter 797 recommends the
following for multi-dose vials...discarded within 28 days unless the manufacturer
specifies a different (shorter or longer date for that opened vial)..."

Personnel #7, 16, 18, 27 and 28 could not accurately state that a multi-dose must be discarded after 28 days.

2. Observation of OB Room #3 revealed a cabinet and storage container with the following expired supplies:

Triflex gloves size 6 x8 expired 11/16; Triflex gloves size 8.5 x5 expired 9/16; Biogel gloves size 8 x1 expired 7/16; BD Nexiva 22g x1 expired 10/16; NaCl Irrigation Solution 500ml x1 expired 11/1/16.

The Director of Nursing confirmed in an interview conducted 12/20/16 that the supplies were expired.

Observation of OB Room #4 revealed a cabinet and storage container with the following expired supplies:

Clave Connector x1 expired 11/15; Triflex gloves size 8.5 x3 expired 11/16; Bigel gloves size 8 x1 expired 7/16; Vicryl 4.0 x3 expired 6/16; sterilized purple top test tube x1 expired 9/15; sterilized red top test tube x1 expired 9/15; Transystem x1 expired 3/16; Aptima swab x4 expired 10/31/16.

The Director of Nursing confirmed in an interview conducted 12/20/16 that the supplies were expired.

Observation of OB Room #1 revealed a cabinet and storage container with the following expired supplies:

Triflex gloves size 8.5 x3 expired 11/16; Triflex gloves size 6 x1 expired 11/16; BD Nexiva 22G x1 expired 10/16; Clave Connector x1 expired 11/15; Latex Biogel Surgeons x3 expired 7/16; Urethral catheter tray x1 expired 11/16; sterilized red top tube x1 expired 8/16; sterilized purple top tube x1 expired 8/16.

The Director of Nursing confirmed in an interview conducted 12/20/16 that the supplies were expired.

Observation of OB Storage Supply closet revealed shelving with the following expired supplies:

Triflex gloves size 6 x8 expired 11/16.

The Director of Nursing confirmed in an interview conducted 12/20/16 that the supplies were expired.

Observation of the Respiratory/Stress Test/EKG Room revealed a cabinet and drawers with the following expired supplies:

Kendall Curity Gauze Sponges 12ply 4x4/10 count x1 expired 11/14; Kendall Curity Gauze Sponges 12 ply/10 count x1 expired 1/15; Kendall MediTrace 233 ECG Conductive Adhesive Electrodes x1 expired 7/12; Bioclusive Transparent Dressing 5.1cm x 7.6cm x11 expired 1/16; BD Nexiva 20G 1 inch IV start kit x2 expired 8/15; BD Nexiva 22G 1 inch IV start kit x1 expired 11/16; Clave Connector x1 expired 2/15; STR 1624 SEPP IV Start x8 expired 12/1/16; Medical Action Industries IV Prep Kit x1 expired 3/15.

The Director of Nursing confirmed in an interview conducted 12/22/16 that the supplies were expired.