HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of 10 patients. Based on observation, policy review and interview the hospital failed to develop a system to monitor for outdated emergency supplies in one of one emergency room.

Findings include:

- The CAH's policy for "Outdates in Medical Supply" reviewed on 4/26/12 at 8:30am directed "...To insure that no outdated materials are used ...Items with expiration dates are monitored on a monthly basis ...Items are removed from the shelf on the expiration date..."

- Observation in the Emergency Room on 4/25/12 between 8:30am to 9:10am revealed a Broselow Pediatric Emergency Kit with the following outdated supplies:

1. One endotracheal tube (a tube used to provide an emergency airway) size 6.5 with an
expiration date of 10/2011.
2. One endotracheal tube size 6.0 with an expiration date of 10/2011.
3. Five endotracheal stylets (used to support an endotracheal tube) with an expiration
date of 3/2010.
4. One endotracheal stylet with an expiration date of 2/2010.
5. One endotracheal stylet with an expiration date of 12/2009.

The emergency room ambulance kit (used by medical personnel when riding the ambulance) contained the following outdated supplies:

1. One endotracheal tube size 6.5 with an expiration date of 10/2011.
2. One endotracheal tube size 8.5 with an expiration date of 10/2011.

Administrative staff A interviewed on 4/25/12 between 8:30am and 9:10am acknowledged the outdated supplies.

The Critical Access Hospital (CAH) reported a census of ten patients. Based on observation and staff interview, the CAH failed to assure all food preparation and handling surfaces are clean and orderly.

Findings include:

- The dietary kitchen, observed on 4/24/12 at 3:10pm, revealed a stacking dish rack with large chips of paint missing and many areas of loose paint. Staff M, interviewed on 4/24/12 at 3:25pm acknowledged the chipped and missing paint of the dish rack rendering the surface non-cleanable.

- The stand mixer, observed on 4/24/12 at 3:30pm revealed worn and missing paint on the support arms that hold the bowl during mixing. Staff M interviewed on 4/24/12 at 3:30pm acknowledged the missing paint and non-cleanable surface.

The CAH failed to assure surfaces in the food preparation area are maintained and cleanable.

Based on observation, staff interview, review of policies and procedures and infection control documentation, the Critical Access Hospital (CAH) failed to ensure the provision of service for infection control were met due to the failure to develop, implement and maintain an Infection Control program for the prevention, control and investigation of infections and communicable diseases for patients, staff, and visitors. The CAH failed to implement contact isolation precautions for two of two sampled inpatients with open wounds identified with MRSA(methicillin-resistant Staphylococcus) and VRE ((Vancomycin-Resistant Enterococci), infections resistant to antibiotics and spread quite easily from person to person through contact (patient #'s14 and 23). The effect of these problems resulted in the hospital's inability to provide an effective infection control program and the CAH failed to protect ten of ten inpatients from potential infection.

Findings include:

The hospital failed to develop an active system to identify, monitor, and implement infection control precautions for two of two patients with open wounds identified with a group of bacteria spread quite easily from person to person (patient #'s 14 and 23). See further evidence at CFR 485.635(a)(3)(vi), C-0278.

The Critical Access Hospital (CAH) reported a census of ten patients. Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for two of two sampled patients with open wounds (patient's #14 and 23) and for all other patients, staff and visitors of the CAH.

Findings include:

- The CAH's policy "Infection Control Protocol" reviewed on 4/26/12 at 9:00am directed "...hospitals have not only the responsibility of protecting their personnel against acquiring infection form patients, but also the responsibility of protecting patients from acquiring infection from hospital personnel...The purpose of the Infection Control Committee is to monitor all infections...All employees should adhere to Infection Control policies and procedures for their department...It is the responsibility of the Infection Control Committee to obtain cultures and review them when necessary to protect patients and or employees..."

- The CAH's policy "Bloodborne Pathogens Compliance Program" reviewed on 4/26/12 at 8:00am directed "...The Exposure Control Officer will be responsible for the overall management and support of our facility's Bloodborne Pathogen Compliance Program ...Department managers and supervisors are responsible for exposure control in their respective areas. They work directly with the Exposure Control Officer, the Infection Control Department and our employees to ensure that proper exposure control procedures are followed..."

- The CAH's policy "Work Practice Controls" reviewed on 4/26/12 at 9:00am directed "...The person in our facility who is responsible for overseeing the implementation of these Work Practice Controls is the hospital Director of Nursing or the Infection Control Committee...Compliance Monitoring 1. Surveillance of the workplace will be done to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used..."

- The CAH's policy "Isolation Precautions" reviewed on 4/23/12 at 5:30pm directed "...It is the responsibility of the unit/shift charge nurse to...Ensure that any patient on that unit identified as having a clinical condition of physicians diagnosis requiring additional precautions is placed in the appropriate precautions...It is the responsibility of all personnel to adhere to isolation procedures as outline in this policy...Supplies that will be gathered are specific to the type of precautions ordered: Contact isolation: cart for storage of supplies, long sleeve moisture resistant gowns, non-sterile gloves, stethoscope, thermometers, contact precautions sign, and laundry stand and bags...Contact precautions in addition to standard precautions are used for MRSA (methicillin-resistant Staphylococcus, group of bacteria can be spread quite easily from person to person through contact.), VRE ((Vancomycin-Resistant Enterococci, a type of bacteria that have developed resistance to many antibiotics. VRE can be spread from one person to another through casual contact or through contaminated objects.), and others named by the Infection Control Committee..."

- The CAH's policy "Handwashing" reviewed on 4/23/12 at 5:30pm directed "...hands will be washed before and after patient contact, before putting on gloves and after removing gloves, after contact with inanimate objects including medical equipment in the immediate vicinity of the patient..." The CAH's policy "Waterless Hand Antiseptic" reviewed on 4/23/12 at 5:30pm directed "Hand antiseptic will be used in addition to hand washing when hands are not visibly soiled..."

- Nursing staff D, observed on 4/23/12 at 9:45am, provided patient #23 with an intravenous (IV) antibiotic medication. Staff D indicated patient #23's wound culture identified the patient with VRE Observation of the door to patient #23's room revealed a contact isolation precaution sign indicating staff must wear personal protective equipment of gloves and a gown to enter patient #23's room if anticipated contact with the patient or environment. Observation at the door of patient #23's room revealed no personal protective equipment available to staff. Staff D entered patient #23's room without gloves or a gown, placed the medication on the IV pole, flushed patient #23's IV site, connected the IV tubing, programmed the IV pump, and started the IV antibiotic. Staff D explained because patient #23's infection was contained within the patient's wound dressing staff need not wear a gown or gloves when entering the patient room.

- Patient #23's clinical record review on 4/23/12 at 10:10am revealed a admission date of 4/3/12 with a diagnosis of leg wound. The clinical record included a culture and sensitivity report on 4/23/12 at 7:22am indicating the wound on the left lower leg cultured VRE.

- Nursing staff E, observed on 4/23/12 at 11:07am, provided patient #14 with an IV antibiotic medication. Staff E entered patient #14's room without gloves or a gown, placed the medication on the IV pole, flushed patient #23's IV site, connected the IV tubing, programmed the IV pump, and started the IV antibiotic.

- Patient #14's clinical record review on 4/23/12 at 11:30am revealed an admission date of 4/13/12 with a diagnosis of MRSA wound of the right leg. The clinical record included a culture and sensitivity report on 4/13/12 indicating the wound on the right leg cultured MRSA. Ten days later observation of the room on 4/23/12 at 11:30am revealed patient #14 failed to be in contact isolation.

- Staff G, observed on 4/23/12 at 12:55pm provided patient #14 with wound debridement (the process of removing dead, contaminated or infected tissue, or any other foreign matter, from a wound intended to clean the site and promote healing) and a dressing change to a wound on the right leg. Staff G entered patient #14's room with a dressing cart, performed hand hygiene, and put on gloves (the only "protective" equipment). Staff G placed a terry cloth towel under patient #14's leg and a terry cloth towel on the top of the dressing cart. Staff G removed the old dressing exposing a wound approximately 1 and ? inches by 1 inch. The wound appeared dusky pink with dead tissue at the edges. Staff G removed their gloves and reapplied gloves, without performing hand hygiene, obtained 4X4 gauze, normal saline irrigation solution, instruments, and Dermagran (a dressing to promote healing) dressing from the drawer in the dressing cart and placed them on the towel draped dressing cart. Staff G cleaned the wound with normal saline irrigation solution and 4X4 gauze, debrided the wound with forceps, then cleaned the wound with normal saline solution. Staff G removed their gloves and reapplied gloves, without performing hand hygiene, then applied a wound dressing with the Dermagran and a covering.

- Staff F, observed during the dressing change on 4/23/12 at 1:10pm entered patient #14's room to flush the patient's IV site after infusion of the antibiotic. Staff F, identified as the nurse caring for the one obstetrical patient and one newborn baby, failed to wear any personal protective equipment to prevent the potential transmission of infectious microorganisms from one patient to another patient.

Staff G removed the charge stickers from the 4X4 gauze and the Dermagran dressing package and placed them on their uniform with the contaminated gloves. Staff G placed the contaminated instruments in a tray in the first drawer of the dressing cart and the used bottle of normal saline irrigation solution and the unused Dermagran in the second drawer of the dressing cart with the contaminated gloves. Staff G removed their gloves, reapplied gloves without performing hand hygiene, then readjusted patient #14's compression hose. Staff G removed the terry cloth towel from under patient #14's leg and from the top of the dressing cart, placed them in a plastic bag, left the room to take the soiled lines to the soiled utility room. Staff G, on 4/23/12 at 1:20pm returned to patient #14's room, removed their gloves, performed hand hygiene, removed the dressing cart from the room and wheeled the cart down the hall into the Physical Therapy room without cleaning the contaminated cart.

- Staff L, observed on 4/23/12 at 11:00am, entered patient #23's room to perform an accu check (a bedside blood sugar test). Patient #23's room door revealed a sign indicating the patient was in contact isolation. Staff L applied gloves, obtained a glucometer (a machine used to perform a bedside blood sugar test) reading, removed the gloves and exited the patient's room without performing hand hygiene. Staff L interviewed on 4/23/12 at 11:05am acknowledged the patient was in isolation.

- Staff K, observed on 4/23/12 at 1:20pm, enter patient #23's room to perform wound care. Staff K put on protective gloves and a gown then removed a gauze dressing. Staff K removed their gloves, reapplied gloves without performing hand hygiene and moved the wound care supply cart next to the patient's bed near the wound. Staff K cleaned the wound with gauze and water, removed their gloves without performing hand hygiene, and opened the drawer of the wound care supply cart to obtain another pair of gloves. Staff K applied gloves, prepared the wound care supplies, cut the dressing material and dressed the wound. Staff K removed their gloves, reapplied gloves without performing hand hygiene, and removed the contaminated linens and trash. Staff K moved the wound care supply cart from the patient's room, stored the scissors and other instruments in a bin on top of the cart, pushed the cart to the soiled utility room and wiped the top and sides of the cart with disinfectant wipes. Staff K wheeled the dressing cart to an outpatient care area with the contaminated instruments in the bin on the top of the cart for storage.

Staff B interviewed on 4/23/12 at 4:00pm verified they were responsible for the management of the infection control program. Staff B acknowledged they provide education to staff on hand hygiene and isolation precautions on hire and annually thereafter. Staff B acknowledged they do not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control practices. Staff B's infection control surveillance is based on patient assessment and antibiotic use, to track patient infections. The infection control officer compiles a report for Medical Staff and Governing Body on a monthly basis. Staff B acknowledged the CAH developed a hand hygiene surveillance project in March 2012 and had not developed and implemented a surveillance program for other infection control practices. Staff B revealed they were not aware patient #23 had a culture report of VRE and patient #14 had a culture report of MRSA. Staff B acknowledged both patients should be in contact isolation requiring those who enter the room wear at least gloves and a protective gown.

Administrative staff A and staff B interviewed on 4/23/12 at 4:35pm acknowledged Staff F cared for the one obstetrical patient and one newborn baby and did enter patient #14's room (a patient with MRSA) to flush the patient's IV site.

- The CAH failed to have a policy addressing the flow of staff between obstetric and newborn patients and other patient care areas.

Staff B, interviewed on 4/24/12 at 2:00pm, revealed the facility infection control monitoring only include antibiotic use. Staff B acknowledged the CAH failed to have a system to identify patients with a potentially infection. Staff B revealed they do not receive lab results such as cultures, elevated white count (a lab test used to assist in identifying an infection), or urine tests. Staff B revealed they do not check the patient's clinical record while they are in the hospital usually reviewed as a chart audit. Staff B acknowledged the CAH failed to have a reporting system in place.

Administrative staff A, interviewed on 4/24/12 at 2:00pm, revealed the CAH's reference lab failed to call the hospital with the results of patient #23's culture report over the week-end and the facility did not know patient #23 had VRE until 4/23/12. Staff A acknowledged they received outpatient and surgical reports but failed to send them to the Infection Control Officer. Staff A, acknowledged the CAH failed to have a reporting system in place.

Staff C, interviewed on 4/26/12 at 11:15am, provided the CAH's hand hygiene surveillance started on 3/22/12. Staff C indicated the facility conducted surveillance for hand hygiene but failed to conduct surveillance for staff practices. The facilities last staff education for hand hygiene documented 12/2009.

The Critical Access Hospital (CAH) reported a census of ten patients. Based on document review and staff interview, the CAH failed to obtain informed consent for the provision of care for two of six acute care patients (#'s 22 and 25). The CAH failed to assure the clinical record clearly identified one of six acute care patients (#27).

Findings include:

- Patient #22's clinical record, reviewed on 4/23/12 at 9:45am, revealed an admission date of 4/21/12 with diagnoses including gastroenteritis (inflammation of the stomach and intestinal tract) and dehydration (excessive loss of bodily fluids). The clinical record lacked evidence the patient and/or the patient's legal representative gave informed consent for the treatment of the patient.

- Patient #25's clinical record, reviewed on 4/23/12 at 12:50pm revealed an admission date of 4/22/12 with diagnoses including gastroenteritis. The clinical record lacked evidence the patient and/or the patient's legal representative gave informed consent for the treatment of the patient.

- Staff N, interviewed on 4/24/12/ at 1:30pm acknowledged the CAH must obtained consent to treat in most circumstances from the patient and/or their legal representative prior to treatment.

Administrative staff A, interviewed on 4/24/12 at 2:00pm acknowledged the CAH failed to obtain consent to treat upon admission for patient #22 and #25.

- Patient #27's clinical record, reviewed on 4/23/12 at 11:40am, revealed standing physician's orders on the clinical record with lack of evidence of the patient's identity. The clinical record contained three pages of post-partum orders, which lacked the name labels or other identification of who the physician intended to receive the care.

Administrative staff A, interviewed on 4/24/12 at 10:30am, acknowledged the physician's orders in patient #27's clinical record lacked the identity of the patient.

The Critical Access Hospital (CAH) reported a census of ten patients. Based on clinical record review, policy review and staff interview the CAH failed to assure medical staff date and/or time all authenticated (signed) entries in the medical record for 12 of 21 inpatient clinical records reviewed (patient #'s 11, 12, 13, 16, 17, 18, 19, 22, 23, 24, 27 and 29).

Findings include:

- The CAH's policy "Signature Authentication" reviewed on 4/25/12 at 11:45am directed "...all entries are legible, complete, authenticated date and timed promptly by the person who is responsible for ordering, providing or evaluating the service furnished..."

- Patient #11's clinical record reviewed on 4/23/12 at 9:25am revealed an admission date of 4/11/12 with a diagnosis of Bronchiolitis. Patient #11's clinical record revealed between 4/11/12 to 4/23/12, six telephone/verbal orders and six progress notes lacked a date and/or time when authenticated by the provider.

- Patient #12's clinical record reviewed on 4/23/12 at 10:30am revealed an admission date of 3/11/12 with a diagnosis of Congestive Heart Failure. Patient #12's clinical record revealed between 3/11/12 to 4/23/12, eleven telephone/verbal orders and one progress note lacked a date and/or time when authenticated by the provider.

- Patient #19's clinical record reviewed on 4/24/12 at 12:30am revealed an admission date of 10/22/11 and discharged on 10/28/11. Patient #19 received a surgical procedure during their hospital admission. Patient #19's clinical record revealed between 10/22/11 to 10/28/11, three telephone/verbal orders and three progress notes lacked a date and/or time when authenticated by the provider.

Staff O, interviewed on 4/25/12 at 11:20am acknowledged the CAH failed to assure medical staff dated and timed all entries in the medical record when authenticated.

This deficient practice also affected patient #'s 13, 16, 17, 18, 22, 23, 24, 27 and 29.

Based on Quality Assurance Committee meeting minutes review and staff interview the Critical Access Hospital (CAH) failed to identify and monitor staff and environmental infection control issues and/or problems and failed to include those in their Quality Assurance (QA) program and to ensure the Quality Assurance program included contracted services.

Findings include:

- Review of the Quality Assurance (QA) Committee meeting minutes on 4/25/12 at 10:10am lacked evidence of the identification or monitoring of infection control issues and/or problems. The Quality Assurance Committee meeting minutes lacked evidence of identification of monitoring of contracted services representing the CAH.

- Staff B interviewed on 4/23/12 at 4:00pm acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control.

- Administrative staff A, interviewed on 4/24/12 at 2:00pm, revealed the CAH's reference lab failed to call the hospital with the results of patient #23's culture report over the week-end and the facility did not know patient #23 had VRE until 4/23/12.

- Staff H, interviewed on 4/25/12 at 9:25am revealed the Laboratory department received QA information from their contracted services and failed to include contracted services in their QA program.

Staff P interviewed on 4/25/12 at 10:10am acknowledged the CAH failed to include infection control issues and/or problems in their QA program and failed to include contracted services in their QA program.