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Based on medical record review and interview, it was determined that the Critical Access Hospital failed to have a clinical reason to place patients in an observation status bed for 3 of 11 surgical patients in a survey sample of 46 patients. (Patient identifiers are #28, #29, and #30.)

Findings include:

Patient #28

Review on 1/24/19 at approximately 10:45 a.m. of Patient #28's surgical and post operation record dated 1/16/19 with Staff E (Registered Nurse) and Staff F (Registered Nurse) revealed "Post-OP Orthopaedic Orders" dated 1/16/19 indicating "Patient Status: ... (box checked) Ambulatory Surgery Extended Recovery". This record review revealed no documented evidence of a clinical reason for Patient #28's transfer to an observation status bed following surgery and post-op recovery on 1/16/19.

Resident #29

Review on 1/24/19 at approximately 10:45 a.m. of Patient #29's surgical and postoperation record dated 1/16/19 with Staff E and Staff F revealed "Post-Operative Neurosurgery Orders - MedSurg" dated 1/16/19 indicating "Patient Status ... (box checked) Extended Recovery". This record review revealed no documented evidence of a clinical reason for Patient #29's transfer to an observation status bed following surgery and post-op recovery on 1/16/19.

Resident #30

Review on 1/24/19 at approximately 10:45 a.m. of Patient #30's surgical and post operation record dated 1/16/19 with Staff E and Staff F revealed "Post-Operative Neurosurgery Orders - MedSurg" dated 1/16/19 indicating "Patient Status: ... (box checked) Extended Recovery". This record review revealed no documented evidence of a clinical reason for Patient #30's transfer to an observation status bed following surgery and post-op recovery on 1/16/19.

Interview on 1/24/19 at approximately 10:45 a.m. during the above listed medical record reviews with both Staff E and Staff F confirmed that there was no documented evidence of a clinical reason for the transfer to an observation bed status following surgery and post-op recovery for Patients' #28, #29 and ##30.

Based on observation and interview, it was determined that the Critical Access Hospital (CAH) failed to construct the procedure room for endoscopies and central sterile to ensure safety of patients.

Findings include:

Association of periOperative Registered Nurses (AORN). (2016). p 679-680
Sterilization and Disinfection, Flexible Endoscopes
I.c.: "The endoscopy processing room should be designed to facilitate a unidirectional workflow from the decontamination room to the clean workroom and then to clean storage in a separate location."
I.d.4.:"The airflow direction (ie, pressure relationship of one area to adjacent areas) for the endoscopy suite should be within the HVAC [heating, ventilation, and air conditioning] parameters. When endoscope processing activities will occur in two rooms, the pressure relationship should be: negative in the decontamination room and positive in the clean room."
I.e.3.: "Floor surfaces in endoscopy processing rooms, procedure rooms, and patient care areas should be monolithic. Junctions between floors and walls should have an integral coved [curved continuous surface between the floor and wall] wall base that is carried up the wall a minimum of 6 inches and tightly sealed to the wall."

Observation on 1/24/19 at 9:30 a.m. of a colonoscopy procedure in the procedure room revealed that after the endoscope was used in the procedure, it was placed on a table within the procedure room and pre-cleaned by wiping down. The endoscope was then placed in a plastic bag. It was carried in the plastic bag down an unrestricted hallway about twenty feet to the decontamination room at which time Staff G (Central Sterile Technologist) took the scope and decontaminated it. Staff G then placed the scope in a round white plastic container with cover and then walked this scope covered container across and down an unrestricted hallway about twenty feet to the clean workroom. Staff G hung the scope on a metal storage rack and performed bioburden testing. Staff G placed the scope in the processor. Staff G then removed a second scope from the processing unit and hung this scope on a wooden wall mounted peg. This scope hung over the hand soap dispenser and next to the handwashing sink. Staff G wiped the scope down and walked it across an unrestricted hallway adjacent to the procedure room and hung the scope in a drying cabinet.

Observation on 1/22/19 and again on 1/23/19 revealed that the procedure room failed to have a monitor device to measure the air pressure within the procedure room with respect to the adjacent hallway. Observation also revealed there was no pressurization gages on the decontamination room or the clean workroom.

Interview on 1/22/19 during the above observation with Staff E (Operating Room Manager) confirmed the above finding and revealed they were not aware that the procedure room would need to be monitored as part of the surgical suite.


13504

Observation on 1/24/19 at 9:30 a.m. of the central processing area and the clean work room for the endoscopy suite revealed that the floors failed to be monolithic with a coved 6 inch covered wall base that tightly sealed to the wall.

Based on observation and medical record review, it was determined that the facility failed to maintain a clean environment in central sterile, and failed to follow the infection control risk assessment for ongoing construction and failed to follow procedures for transmission based precautions for 1 of 15 inpatients. (Patient identifier is #8.)

Findings include:

The Facilities Guidelines Institute. Guidelines for Design and Construction of Hospitals. (2018)
1.2 Planning, Design, Construction, and Commissioning, 1.2-4.2 Infection Control Risk Assessment (ICRA),
1.2-4.2.2 ICRA Considerations: " Design Elements: At minimum, the ICRA shall address the following: (1) The number, location, and type of airborne infection isolation (AII) and protective environment (PE) rooms shall be determined by the ICRA where these rooms are required in the facility type chapters in the Guidelines."
1.2-4 Safety Risk Assessment, 1.2-4.2.3 Infection control risk mitigation recommendations (ICRMRs). 1.2-4.2.3.3 "ICRMRs shall, at (2) ventilation of the construction zone. d. Hospital construction barriers for projects in high-risk areas should be maintained at a pressure differential of at least 0.03-inch water gauge (7.0 Pascals), with airflow from hospital clean areas to construction dirty areas. Construction barriers in high-risk areas should have visual display of airflow direction."

Review on 1/23/19 of The Pre-Construction ICRA Checklist, dated 8/2/18, revealed the anticipated start date for the Magnetic Resonance Imaging (MRI) project, The assessment identified air quality/pressure management as a risk factor. The assessment identified there would be an anteroom that personnel will pass though as they enter and leave the work area and the work area will have a negative pressure to the non-construction, adjacent areas.

Observation on 1/23/19 at 11:15 a.m. revealed that the construction area for the MRI project did not have an anteroom and when the radiology hallway door was opened it immediately accessed to the work area. Observation also revealed there was no monitoring of the air pressure in respect to the adjacent areas.

Observation on 1/24/19 at 9:15 a.m. revealed an air pressure monitor had been installed at the MRI project site and the air pressure was reading "0".

Interview on 1/24/19 at approximately 9:15 a.m. with Staff H (Director of Facilities) confirmed the above finding and revealed that they were using a negative pressure unit in the MRI project area but they realized now with the new gauge that it was not large enough to maintain the negative pressure needed and they were going to bring in a second unit.

Interview on 1/24/19 at approximately 11:30 a.m. with Staff D (Infection Preventionist) confirmed there was no anteroom. Interview also revealed that at the project initiation there was an anteroom and when the project expanded they deconstructed the anteroom and they did not construct a new anteroom. Interview with Staff D also confirmed that the air pressure at the MRI project site should be negative.


13504

Observation on 1/22/19 at 10:30 a.m. of the central sterile repossessing area of the hospital revealed that the back side of the mobile Sterrad NX machine had a large amount of dust built up on the fan, which was blowing toward the central sterile wrapping area.

Interview on 1/22/19 at approximately 10:45 a.m. with Staff E (Central Sterile Repossessing), Staff E stated that the unit was just serviced on 1/10/19 and further stated that they must not have cleaned the fan. Staff E also stated that the unit is placed that way because there is not enough space to turn it the correct way so the back of the equipment with the fan is toward the wall and not blowing directly into the sterile wrapping area.


35095

Observation on 1/23/19 at 9:50 a.m. revealed Staff C (Licensed Nurses Aide) entered a patent room that had a notice outside the door that the patient inside the room was on droplet precautions. Staff C did not don a mask, gloves, or a gown prior to entering the patient's room. Personal Protective Equipment (PPE) was stored between the patients rooms and accessible to staff in the hallway. Posted at the room entrance was a notice that alerted all who entered the room that the patient was on droplet precautions. The notice included instructions for hand hygiene and use of PPE. Staff C exited the room at 9:55 a.m.

Interview on 1/23/19 following the above observation with Staff C outside of the patient's room, Staff C stated that Staff C was not aware of the notice since the patient was not on droplet precautions the day prior.

Interview on 1/23/19 at 9:57 a.m. with Staff B (Registered Nurse) revealed that the patient, in the room that Staff C had entered, had been on droplet precautions "For the last few days".

Interview on 1/23/19 at 10:40 a.m. with Staff A (Registered Nurse) revealed that Staff C had already informed Staff A with the information that Staff C did not follow droplet precautions when entering a room marked with the warning that the patient inside was on droplet precautions.

Based on medical record review and interview, it was determined that the Critical Access Hospital failed to ensure that the medical records for 5 patients in survey sample of 46 patients records were complete and accurate. (Patient identifiers are #6, #7, #19, #21 and #22.)

Findings include:

Patient #19

Review on 1/23/19 of Patient #19's surgical record with Staff E (Registered Nurse) revealed that Patient #19 had a surgical procedure done on 11/28/18. Review of the anesthesia consent dated "11/29/18" titled "Request for Anesthesia Services' for Patient #19 was .the incorrect date for the surgical procedure done on 11/28/18, the day after the surgical procedure. Further review of this "Request for Anesthesia Services" for Patient #19 showed that the anesthesia consent section for the "surgical procedure" was blank.

Review on 1/23/19 of Patient #19's surgical record with Staff E revealed that the "POST ANESTHESIA EVALUATION" for the surgical procedure done on 11/28/18 was not done for Patient #19.

Interview on 1/23/19 at approximately 1:30 p.m. with Staff E confirmed the above listed findings that there was no anesthesia consent and no post anesthesia evaluation completed for Patient #19.

Patient #21

Review on 1/23/19 of Patient #21's surgical record with Staff E revealed that Patient #21 had a surgical procedure done on 1/4/19. This medical record review revealed no documented evidence of a "Request for Anesthesia Services", anesthesia consent for the surgical procedure done on 1/4/19 for Patient #21.

Patient #22.

Review on 1/23/19 of Patient #22's surgical record with Staff E revealed that Patient #22 had a surgical procedure done on 1/21/19. Review of the anesthesia consent titled "Request for Anesthesia Services" dated 1/21/19 showed that the section for the "surgical procedure" was blank and not completed for Patient #22.

Review on 1/23/19 of Patient #22's surgical record with Staff E revealed that the "POST ANESTHESIA EVALUATION" for the surgical procedure done on 1/21/19 was not done for Patient #22.

Interview on 1/23/19 at approximately 1:30 p.m. with Staff E confirmed the above listed findings that the surgical records were not accurate and complete for: Patient #19 incorrect surgical date, no anesthesia consent for procedure and no post anesthesia evaluation, for Patient #21 no anesthesia consent indicating the surgical procedure and for Patient #22 no anesthesia consent for the surgical procedure and no post anesthesia evaluation.


35095

Review on 1/22/19 of Patient #6 and Patient #7's medical record revealed that the form titled General Patient Information (GPI) was not filled out with the patient name and medical record number. The date of admission was also absent. The form was unsigned. The form contained the sections 'Consent to Treat and Patient's Rights'.

Interview on 1/22/19 in the early afternoon with Staff A (Registered Nurse) confirmed that Patients #6 and Patient
#7's (GPI) forms had not been filled out with patient names or medical record numbers. There were no signatures by Patient #6 and Patient #7 or those parties acting on their behalf on the respective forms.