HospitalInspections.org

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Based on interview and document review, the Critical Access Hospital failed to have a certified food protection manager on staff to oversee the dietary needs of the hospital as required by the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12).

Failure to have the required certified food protection employee to manage the dietary services puts patients, staff, and visitors at risk of harm from food borne illnesses.

Findings included:

1. On 07/24/24 at 9:00 AM, Surveyor #4 inspected the hospital's dietary kitchen with the kitchen manager (Staff #403). During the inspection, the surveyor asked Staff #403 about her Food Protection Certification. Staff #403 stated that she had not yet completed a certified Food Protection Management course but believed the Registered Dietician (RD) may have completed this.

2. On 07/24/24 at 3:30 PM, Surveyor #4 reviewed personnel files and training records with the Human Resources Coordinator (Staff #404). The review showed the hospital's Registered Dietician (Staff #405) has a state dietician license but is not a certified Food Protection Manager. The surveyor discussed the requirement with Staff #404. Staff #404 confirmed that currently no hospital staff are Certified Food Protection Management as required.

Reference: Washington State Retail Food Code WAC 246-215-02107 Certified food protection manager (FDA Food Code 2-102.12).
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Based on observation, interview, and document review, the hospital failed to implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturer's expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital's policy and procedure titled "Outdates," Reference ID # 4.1.017, last reviewed 02/19, showed the following:

a. The purpose of this policy is to ensure the safety and well-being of Ferry County Public Hospital District (FCPHD) staff and patients from items, equipment, and supplies that have outlived their usefulness and effectiveness due to reaching their expiration date.

b. All dated items sterilized by the manufacturer that have reached the "expiration date" must be removed from service and returned to the Materials Management Department for credit, exchange, and/or proper disposal.

2. On 07/24/24 between 10:00 AM and 10:30 AM, Surveyor #2 and the Manager of the Republic Medical Clinic (Staff #204), inspected the procedure room of the Medical Clinic. The inspection showed the following:

a. Three Premier Pro exofin dermabond high viscosity tissue adhesive 1 milliliter, with a manufacturer's expiration date of 04/23.

b. Six Premier Pro exofin dermabond high viscosity tissue adhesive 1 milliliter, with a manufacturer's expiration date of 03/24.

c. Two 5-0 Ethilon PS-2 suture, with a manufacturer's expiration date of 04/24.

3. At the time of the review, Staff #204 verified the outdated supplies and removed them from use.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy.

Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies.

Findings included:

1. Document review of the hospital's policy and procedure titled "Outdates," Reference ID # 4.1.017, last reviewed 02/19, showed the following:

a. The purpose of this policy is to ensure the safety and well-being of Ferry County Public Hospital District (FCPHD) staff and patients from items, equipment, and supplies that have outlived their usefulness and effectiveness due to reaching their expiration date.

b. All dated items sterilized by the manufacturer that have reached the "expiration date" must be removed from service and returned to the Materials Management Department for credit, exchange, and/or proper disposal.

c. Central Service shall be responsible for checking dated items distributed by Central Service in the following departments: Patient Care Units and the Emergency Department.

2. On 07/23/24 between 9:15 AM and 10:30 AM, Surveyor # 2 and the ER and Acute Care Manager (Staff #201) inspected the ER. The inspection showed:

In the Broselow cart

a. One Glidescope Spectrum Miller S1 laryngeal blade (used for intubation), with a manufacturer's expiration date of 06/24.

In the Trauma Cart

a. Two Glidescope Spectrum Miller S1 laryngeal blade (used for intubation), with a manufacturer's expiration date of 06/24.

3. Surveyor #2 asked Staff #201 who checks the rooms for outdated supplies, Staff #201 reported the nurses check the ER rooms for outdated supplies. At the time of the review, Staff #201 verified the outdated supplies and removed them from use.
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Based on observation, interview and document review, the hospital failed to implement policies and procedures to ensure compliance with the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12).

Failure to follow the Washington State Retail Food Code and the U.S. Food and Drug Administration Food Code places patients, staff, and visitors at risk of foodborne illness.

Findings included:

1. Document review of the hospital's checklist titled, "Environment of Care (EOC) Checklist," no policy number or approval date, showed the environmental checklist of items to be inspected throughout the hospital during EOC rounding. The checklist includes inspecting the nourishment refrigerator for temperature and that staff are checking and logging this daily.

2. On 07/24/24 at 10:45 AM, Surveyor #4 toured the Acute Care Clean Utility Room with the Environmental and Maintenance Manager (Staff #401). Surveyor #4 used a thin stemmed thermometer to assess the temperature of a Danby mini refrigerator in the room. The surveyor placed the open thermometer on refrigerator shelf and closed the door for a minute before assessing, the air reading was 58 degrees Fahrenheit. The surveyor then tested the temperature of a grape jelly packet stored in the refrigerator, the jelly reading showed a temperature of 56 degrees Fahrenheit.

3. At the time of the observation, Staff #401 confirmed the temperatures.
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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

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

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell OCT721.
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Based on interview and document review, the Governing Body failed to ensure the medical staff periodically reviewed bylaws, rules, and regulations.

Failure to periodically review bylaws, rules, and regulations risks inappropriate oversight and outdated practice.

Findings included:

1. Document review of the hospital's document titled "Bylaws of the Medical Staff of Ferry County Public Hospital District #1," last approved 07/23, Article X111 which showed that that the Rules and Regulations of the Medical Staff of Ferry County Memorial Hospital shall conduct at least a yearly review of the Rules and Regulations.

2. On 07/25/24, Surveyor #2 interviewed the Chief Executive Officer (Staff #206) regarding the "Medical Staff Bylaws" and "Medical Staff Policies Rules and Regulations" which were both approved by the Medical Staff in December 2014 and approved by the Governing Body in January 2015. Staff #206 stated this document is the most current version.
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Based on document review and interview the Critical Access Hospital failed to ensure that policies and procedures were reviewed every two years to reflect current standards of practice.

Failure to review policies and procedures every two years places patients at risk for unsafe care or injury.

Findings included:

1. Document review of the hospital's policy and procedure titled "Policy and Procedure Development," Reference ID # 1.4.001, last reviewed 01/24 showed the following:

a. Policy and Procedures (P&P) via Forms computer drive must be reviewed at least bi-annually (facility intended to state biennially) and revised as necessary. Departments are able to review policies more frequently if indicated.

b. All existing P&P will be updated to the new format on their bi-annual review.

2. Between 07/23/24 and 07/25/24, Surveyor #2 reviewed requested hospital policies and procedures. The following policies reviewed did not have a review date within 2 years:

a. Outdates, Reference ID # 4.1.017, last reviewed 02/19.

b. Use of expired, past "use by date", uncovered, and unwrapped medical supplies, Reference ID # 22.01.128, last reviewed 05/22.

c. Multi-dose vials, Reference ID # 15.01.031, last reviewed 03/22.

d. Assessment of pain on admission, Reference ID # 14.1.036, last reviewed 03/22.

e. End of Life Care, Reference ID # 14.1.005, last reviewed 03/22.

f. Cleaning of patient care equipment, Reference ID # 14.1.063, last reviewed 03/22.

g. Unprofessional Conduct, Reference ID # 13.1.005/2.1.001/14.01, last reviewed 06/22

h. Disclosure - adverse events, errors, and unanticipated outcomes, Reference ID # 21.0.002, last reviewed 04/22.

i. Wound measurement protocol (would protocol staging/treatment), Reference ID # 14.1.055, last reviewed 03/22.

j. Infection risk assessment, Reference ID # 22.01.116, last reviewed 05/22.

k. Nutrition assessment policy, Reference ID # 14.1.001, last reviewed 03/22.

l. Patient care plan, Reference ID # 14.1.022, last reviewed 03/22.

m. High alert medications, Reference ID # 15.01.047, last reviewed 03/22.

n. Environment of care plan 2013, Reference ID # 12.11.001, last reviewed 06/22.

o. Intravenous procedural sedation, Reference ID # 14.1.025, last reviewed 03/22.

p. IV therapy, Reference ID # 14.1.031, last reviewed 03/22.

q. Documentation procedure for electronic charting by exception, Reference ID # 9.1.0004, last reviewed 06/22.

r. Comprehensive discharge planning policy, Reference ID # 14.1.020, last reviewed 03/22.

3. At the time of the review, Staff #205 verified the policies have not been updated.
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Item #1 - Expired medications

Based on observation, document review, and interview the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date/use date.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, or efficacy.

Findings included:

1. Document review of the hospital's policy and procedure titled "Crash Cart," Reference ID # 6.1.006, last reviewed 03/23 showed the following:

a. Certain medications used during emergency situations will be stored in locked crash carts. One crash cart will be stored across the hallway from the team center, and the other crash cart will be stored in the Emergency Room (ER).

b. Charge nurses will check the cart monthly (between the 25th and 31st) for any items that outdate; all items on and in the cart will be checked. The check will include all drawers, supplies in drawers on top of the cart, and in the bags on the side of the cart. The charge nurse may also delegate the task to another licensed nurse.

c. The crash cart check sheet will be turned in each month to the Chief Nursing Officer who will monitor compliance.

d. The Charge nurse will remove and replace all outdated items on the last day of the previous month, i.e. August 31st all items outdating in September will be removed and replaced.

e. If items cannot be replaced, the Charge Nurse will notify the appropriate department of the needed items and replace them when available.

2. On 07/23/24 between 9:15 AM and 10:30 AM, Surveyor # 2 and the ER and Acute Care Manager (Staff #201) inspected the ER. An inspection of the crash cart showed the following:

a. Three vials of naloxone hydrochloride (a medication that rapidly reverses the effects of opioid medication) 0.4 milligram/milliliter with a manufacturer's expiration date of 06/24.

b. One vial of diphenhydramine hydrochloride (a medication used to treat life-threatening allergic reactions) 50 milligrams/milliliter with a manufacturer's expiration date of 06/24.

3. Interview of Staff #201 indicated they thought the medications were on back order with the Pharmacy. Staff #201 asked the Pharmacist (Staff #202) if the medications had been received, Staff #202 reported the medications were in stock but had not been replaced in the crash cart. At the time of the inspection, Staff #201 verified the outdated medications and removed them from use.

4. On 07/23/24 between 10:30 AM and 11:30 AM, Surveyor # 2 and the ER and Acute Care Manager (Staff #201) inspected the Acute Care Unit. An inspection of the crash cart showed the following:

a. One vial of naloxone hydrochloride (a medication that rapidly reverses the effects of opioid medication) 0.4 milligrams/milliliter with a manufacturer's expiration date of 06/24.

b. Five boxes of epinephrine (a medication used to increase a patient's mean arterial blood pressure) 1 milligram/10 milliliters with a manufacturer's expiration date of 07/01/24.

c. One box of sodium bicarbonate (a medication used to treat metabolic acidosis) 50 milliequivalents/50 milliliters with a manufacturer's expiration date of 07/01/24.

5. At the time of the inspection, Staff #201 verified the outdated medications and removed them from use.

Item #2 - Multi-dose vials

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure hospital staff members followed the pharmacy's policy for administration of multi-dose medications.

Failure to follow safe medication administration practices risks contamination and transmission of infectious diseases to patients during medication administration.

Findings included:

1. Document review of the hospital's policy and procedure titled "Multi-Dose Vials," Reference ID # 15.01.031, last reviewed 03/22, showed all multi-dose vials of medications shall be dated with a beyond use date and initialed upon initial use and discarded after 28 days.

2. Document review of the hospital's policy and procedure titled "Pharmacy Drug Control - Includes Access to Pharmacy, Med Prep Room/Emergency Rooms," Reference ID # 15.01.004 last reviewed 03/23, showed medication not in the pyxis for acute care patients shall be taken in 24 hour increments from the Pharmacy by the Charge nurse upon admission and returned to the Pharmacy when the patient is discharged.

3. On 07/23/24 between 9:15 AM and 10:30 AM, Surveyor # 2 and the ER and Acute Care Manager (Staff #201) inspected the Emergency Room (ER). The inspection showed the following:

In the shared medication room

a. One bottle of Geri-lanta (a medication used to treat heartburn) 12 ounces, with a dated open date of 06/06/24, being used as a multi-dose medication, and not discarded after 28 days from opening.

b. Two vials of Enoxaparin sodium injection (a medication used to prevent blood clots) 300 milligrams/3 milliliters with an open date of 07/19/24.

In the supply closet for the ER suture cart

a. One vial of lidocaine hydrochloride (a medication used to prevent pain/numb the skin) 1% 200 milligrams/20 milliliters, opened and no date of when opened.

4. At the time of the review, the Charge nurse (Staff #203) verified the Geri-lanta was being used as a multi-patient use and that the Enoxaparin sodium should be a single patient use and should have been discarded when no longer needed. Staff #201 and #203 removed the Geri-lanta, Enoxaparin sodium, and Lidocaine hydrochloride from use.
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Based on interview, document review, and review of the hospital's quality and performance improvement program, the hospital failed to ensure that performance measures for patient care services furnished under arrangement or agreements (contracted services) were developed and evaluated through the hospital's quality program as directed by 3 of 3 contracts reviewed.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings:

1. Document review of the hospital's policy and procedure titled "Contracted Services," Reference ID # 2.0.002, last reviewed 04/24, showed the following:

a. All contracts are to be reviewed at the initial contract, at the time of renewal, or bi-annually (clarified with the Chief Executive Officer (Staff #206) this was meant to be biennially, every two years) in the case of an extended contract.

b. Every contract and agreement is required to have a Ferry County Health System Contract Review Worksheet.

c. The criteria for evaluation and re-evaluation is that the contractor meets an acceptable level of performance with regard to selected indicators, the evaluation of services will occur at the time of renewal and/or bi-annually (again clarified with the Chief Executive Officer (Staff #206) this was meant to be biennially, every two years) in the case of an extended contract, and all contractual agreements related to direct patient care require medical staff input relative to the quality of care of and services provided. This does not include provider contracts.

d. Attachment B of the contracted services policy is a contract review and evaluation worksheet with quality indicators and ratings for contracted services provided that is expected to be filled out for all contracted services.

2. On 07/25/24 between 11:30 AM and 12:15 PM, Surveyor #2 and the Chief Executive Officer (Staff #206) and the Chief Nursing Officer (Staff #205) reviewed 4 contracted services agreements with the hospital. The review showed the following:

a. The contract for Omni Staffing Services had an original contract signed on 04/04/12. The contract review and evaluation worksheet for Omni Staffing Services had a due date of evaluation required listed as 03/24 and the date the evaluation was filled out was 07/24/24.

b. The contract for Vitalant Hospital Blood Service Agreement had an original contract signed on 08/23/21 to start providing services on 01/01/22. Surveyor #2 was unable to find evidence of a contract review and evaluation worksheet for Vitalant Hospital Blood Services.

c. The contract for Medication Review (tele-pharmacy services) had an original contract signed on 09/15/21. Surveyor #2 was unable to find evidence of a contract review and evaluation worksheet for Medication Review tele-pharmacy services.

3. At the time of the review, Staff #206 reported the facility was cited during the last state survey for not having a process for the contracted services review and thought now that there was a process in place they would be performing the contract review and evaluation worksheet for contract renewals. Staff #206 verified the first contract review was filled out at the time of survey and not when due in 03/24, and also verified the other 2 contracts did not have an up to date contract review and evaluation worksheet.
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Item #1 - Authenticating Provider Orders

Based on document review and interview, the hospital failed to ensure that provider orders were authenticated in accordance with policy for 1 of 3 Acute Care Unit charts reviewed (Patient #201).

Failure to follow approved policies and procedures for orders risks inappropriate, incorrect, and inconsistently administered patient care and places patients at risk for harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Telephone, verbal and written orders for medication," Reference ID # 6002, last reviewed 10/22, showed the following:

a. Ferry County Memorial Hospital shall never allow verbal or telephone orders for the purposes of medical staff practitioners' convenience only. Whenever possible and practicable, all members of the medical staff with privileges and approval to prescribe medication shall do so by physically entering an order in the patient's medical record or on a Pharmacy prescription pad.

b. Telephone and verbal orders for administration of medications may be received and recorded by pharmacists and other licensed staff lawfully authorized to administer drugs. Such orders prescribed verbally or by telephone, shall be issued in the best interest of the patient and, therefore, shall be kept to a minimum. Telephone and verbal orders for medication may be prescribed when the prescribing practitioner has determined that the patient is in need of medication within a specified time period and he/she is unable to physically write the order in the medical record due to his/her physical location or when the practitioner has determined that the patient is in need of medication in an urgent or emergent situation, with verbal/telephone communication presenting the swiftest method of accomplishing the order.

c. The prescribing practitioner must date, time and authenticate the verbal order within the time designated by state law, or if no law exists, in the timeframe established by hospital policy.

2. Document review of the hospital's document titled, "Ferry County Public Hospital District #1 Rules and Regulations of the Medical Staff," last reviewed 11/14, showed all orders for treatment shall be in the electronic medical record (EMR). A verbal order given to a Registered Nurse or other authorized person and authenticated by the ordering provider within 48 hours shall be considered a written order.

3. On 07/24/24 between 1:05 PM and 3:35 PM, Surveyor #2 and the Chief Nursing Officer (Staff #205) reviewed the medical record of Patient #201. The review showed Patient #201 was a 64-year-old female admitted on 06/10/24 with a diagnosis of acute pancreatitis. Patient #201 had an order for Hydromorphone (a opioid medication used to treat pain) 1 milligram intravenously every 2 hours as needed for moderate pain (pain score of 5-7). Surveyor #2 was unable to find evidence that Patient #201's order for Hydromorphone was authenticated by a provider.

4. Surveyor #2 interviewed Staff #205 regarding the unauthenticated order for Hydromorphone. Staff #205 reported that the RN entered the order as a written order like a provider would do, not as a verbal order. Due to the order being entered in the EMR as a written versus verbal order, the order for Hydromorphone did not get routed to the provider's work que to authenticate. At the time of the review, Staff #205 verified the order for Hydromorphone was not authenticated by a provider.

Item #2 - Pain Medication Administration Parameters

Based on record review and review of hospital policies and procedures, the hospital failed to ensure that staff implemented provider orders for medication administration in accordance with acceptable practice for 2 of 3 Acute Care patients reviewed (Patient #201 and #202).

Failure to implement provider orders for medication administration risks patient harm from unsafe or inappropriate medication administration.

Findings included:

1. Document review of the hospital's policy and procedure titled "Medication Administration and Disposal," Reference ID # 14.1.082, last reviewed 10/23, showed the following:

a. Medication orders will be reviewed by the Resident Care Coordinator (RCC) or RN to assure the orders are properly entered into the computer/electronic health record (HER) system as entered by the provider.

b. The administering nurse will then ensure the Nursing Rights of Medication Administration are followed to ensure proper administration of medication.

c. The Nursing Rights of Medication Administration include the Right Patient, the Right Drug/Medication, the Right Route, the Right Time, the Right Dose, and the Right Documentation.

d. The Right Dose includes to ensure the right dose is given the Nurse must compare the dosage on the medication with the dosage on the order.

2. On 07/24/24 between 1:05 PM and 3:35 PM, Surveyor #2 and the Chief Nursing Officer (Staff #205) reviewed the medical records of 3 patients in the Acute Care Unit. The review showed the following:

a. Patient #201 was a 64-year-old female admitted on 06/10/24 with a diagnosis of acute pancreatitis. Patient #201 had an order for Hydromorphone (an opioid medication used to treat pain) 1 milligram intravenously every 2 hours as needed for moderate pain (pain score of 5-7). Patient #201 received hydromorphone 1 milligram on 06/12/24 at 6:46 AM for a reported pain score of 9. Patient #201 received hydromorphone 1 milligram on 06/13/24 at 8:35 AM for a reported pain score of 10.

b. Patient #202 was a 60-year-old male admitted on 07/16/24 for a urinary tract infection and sepsis (a serious condition where the body responds improperly to an infection). Patient #201 had a provider order for hydromorphone 1 milligram intravenously every 4 hours as needed for severe pain rated at 7-10. Patient #201 received hydromorphone 1 milligram on 07/20/24 at 4:04 PM for a reported pain score of 5.

3. At the time of the review, Staff #205 verified the pain medication administrations were given outside of the parameters of the provider's order.

Item #3 - Pain Assessment and Reassessment

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 3 of 5 patients reviewed (Patient #201, #202, and #203).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled "Assessment of Pain on Admission," Reference ID # 14.1.036, last reviewed 03/22, showed the following:

a. Each area of pain needs to be assessed and documented.

b. Following administration of pain medication: IV medications require a pain reassessment documented in the eMAR within 30 minutes of administration and PO (oral) medications require a pain reassessment documented in the eMAR within 60 minutes.

2. On 07/24/24 between 1:05 PM and 3:35 PM, Surveyor #2 and the Chief Nursing Officer (Staff #205) reviewed the medical records of 3 patients in the Acute Care Unit. The review showed the following:

a. Patient #201 was a 64-year-old female admitted on 06/10/24 with a diagnosis of acute pancreatitis. Patient #201 had an order for hydromorphone (an opioid medication used to treat pain) 1 milligram intravenously every 2 hours as needed for moderate pain (pain score of 5-7). Patient #201 received hydromorphone 1 milligram on 06/11/24 at 5:42 AM for a pain score of 7, Surveyor #2 was unable to find evidence of a pain reassessment in the medical record. Patient #201 received hydromorphone 1 milligram on 06/11/24 at 4:27 PM for a pain score of 7, Surveyor #2 was unable to find evidence of a pain reassessment in the medical record.

b. Patient #202 was a 60-year-old male admitted on 07/16/24 for a urinary tract infection and sepsis (a serious condition where the body responds improperly to an infection). Patient #201 had a provider order for morphine (an opioid medication used to treat pain) 4 milligrams intravenously every 4 hours as needed for severe pain rated at 7-10. Patient #202 received morphine 4 milligrams on 07/21/24 at 4:50 AM for a pain score of 10, Surveyor #2 was unable to find evidence of a pain reassessment in the medical record.

3. At the time of the review, Staff #205 verified the missing pain reassessments.

4. On 07/25/24 between 9:00 AM and 11:00 AM, Surveyor #2 and the Chief Nursing Officer (Staff #205) reviewed the medical records of 2 swing bed Patients. The review showed Patient #203 was a swing bed admitted for strengthening. Patient #203 had a provider order ibuprofen 400 milligrams orally every six hours as needed for mild pain (1-4). Patient #203 received ibuprofen 400 milligrams on 07/19/24 at 11:41 PM for a pain score of 7, Surveyor #2 was unable to find evidence of a pain reassessment in the medical record.

5. At the time of the review, Staff #205 verified the missing pain reassessment.
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Item #1 - Cleanable and sanitary surfaces

Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Reference: AORN (Association of Perioperative Registered Nurses) Guidelines for Perioperative Practice: Design and Maintenance, (2020) - "Recommendation 12.2. Maintain the integrity of structural surfaces (e.g., doors, floors, walls, ceilings, cabinets) and have surfaces repaired with damaged." 12.2.1 "...Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

Findings included:

1. Document review of the hospital's checklist titled, "Environment of Care (EOC) Checklist," no policy number or approval date, showed the environmental checklist of items to be inspected throughout the hospital during EOC rounding. The checklist includes inspecting for damage to walls and surfaces, including painted surfaces and doors.

2. On 07/23/24 at 9:30 AM Surveyor #4 observed a terminal cleaning of the hospital's operating (procedure) room. During the observation, the surveyor noticed a section of laminate was missing from the door into the room, a small hole in the drywall had been patched on a wall but not yet repainted and 2 of the walls had a mounted (and raised approximately 3 inches from the wall) peg board that was not painted/sealed on the backside or inside the small peg holes.

3. During the observation, Surveyor #4 discussed the unsealed wood and non-painted areas as being a non-cleanable surface with the Environmental and Maintenance Manager (Staff #401).

4. On 07/23/24 at 10:30 AM, Surveyor #4 observed the hospital's IV Therapy/Outpatient room. During the observation, the surveyor noticed several small, patched holes on the walls of the room, the patched drywall had not yet been repainted. The surveyor discussed the patched areas as being non-cleanable surfaces with Staff #401. Staff #401 stated those needed to be painted.

Item #2 - Ice machine drain line

Based on observation, interview and document review, the hospital failed to fully implement their water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to implement and monitor a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings included:

1. Document review of the hospital's policy titled, "Water Management Program," Reference #12.12, last reviewed 06/03/23, showed a water management program for the hospital that identified ice machines as a risk point and included preventative maintenance cleaning to be scheduled quarterly.

2. On 07/23/24 at 10:45 AM, Surveyor #4 and the Environmental and Maintenance Manager (Staff #401) toured the Acute Care Unit Clean Utility Room. The surveyor observed a Follett Symphony Plus ice maker with an accumulation of black algae build up on the interior of the ice machine drain line before the air gap.

3. At the time of observation, the surveyor and Staff #401 discussed the growth from the drain line and the ice machine cleaning.

4. On 07/25/24 at 8:45 AM Surveyor #4 discussed the water management program and the ice machines with the Facilities Manager (Staff #402). Staff #402 stated the ice machine drain lines will be addressed during scheduled routine maintenance.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy regarding dental care and dentures for Long Term Care Services "Swing Bed" patients.

Failure to develop and implement a policy regarding dental care risks poor oral care, infection, and nutritional deficiencies.

Findings included:

1. On 07/25/24, Surveyor #2 reviewed the policies and procedures provided by the Critical Access Hospital. The Surveyor was unable to locate policies that addressed the dental care of the long term care services "swing bed" patient.

2. On 07/25/24 at 12:15 PM, Surveyor #2 interviewed Chief Nursing Officer (Staff #205) regarding the dental policy. Staff #205 stated that they were unable to locate a policy regarding dental care and dentures for long term care services "swing bed" patients however they do have a dentist who provides dental care for their patients.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to implement emergency preparedness policies and procedures based on a current community or facility risk assessment that fully addresses subsistence needs for staff and patients who evacuate or shelter in place.

Failure to fully develop policies and procedures for the subsistence needs of the CAH's staff and patients risks unsafe conditions during an emergency.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 07/25/24, showed there are procedures outlines for the provisions of water, sanitary supplies and fuel, but the policy did not fully include provisions for pharmaceutical supplies or food.

2. On 07/25/24 at 10:00 AM, Surveyor #4 interviewed the Facilities Manager (Staff #402) about the elements of the emergency preparedness program. Staff #402 confirmed the current policy did not delineate the procedures for pharmaceutical or specific dietary supplies for the subsistence needs of staff and patients who evacuate or shelter in place.
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