HospitalInspections.org

Based on review of policies/procedures, tour of the emergency department (ED), personnel record review and interviews with staff, it was determined the hospital failed:

1) to identify improper sterilization procedures for sterile instruments used in the ED; and

2) to designate an Infection Control individual, qualified through training, education, experience or certification;

3) require the hospital have an active surveillance program to include specific measures for prevention, early detection, control, education, and investigation of infections and communicable diseases.

Findings include:

1. The hospital policy titled Sterile Instruments, required: "...The Emergency Department has switched to disposable instruments wherever available. Those instruments for which there is no disposable counterpart will be cleaned...Place instruments in open position on a towel to air dry...Packaging instruments for sterilization...Place instruments in package in open position with handle towards sealed end...Place biological indicator strip in package...."

A tour of the ED was conducted on 11/19/13 at 1400 hours. Used / dirty surgical instruments were observed in a basin in the sink and six surgical instruments were on a towel next to the sink, in the dirty utility room. Instruments drying included scissors and they were not in the open position. According to the RN on duty these instruments were being cleaned, dried and prepped for sterilization. She confirmed instruments needed to be in the open position to dry.

In the storage room surgical instruments in peel packs were observed for use in the ED. None of the surgical instruments contained a biological indicator strip to verify the sterilization process, and one large hemostat was not in the opened position, as required by policy.

An interview with the ED Charge Nurse on 11/20/13, confirmed the hospital did not have the biological indicator strips to place in the peel packs and that the instruments needed to be in the open position for drying and while in the peel pack for the sterilization process.
Based on record review and staff interviews, it was determined the facility failed to designate in writing an individual qualified through education, training, experience, and certification or licensure an infection control officer.

2. Review of RN #3's personnel file revealed annual Infection Control (IC)- non clinical training on 06/10/10; and the personnel file did not contain an Infection Control (IC) nurse signed job description.

The Director of Human Resources (HR) confirmed during an interview conducted on 11/20/13, that the HR department did not have a hospital policy or a job description with required qualifications for an Infection Control Nurse.

RN #3 confirmed during a telephone interview conducted 11/21/13 at 1130 hours, that the Director of Nursing designated her the IC Nurse. RN #3 confirmed during the same interview that she had training in April 2012 from the Association for Professionals in Infection Control and Epidemiology (APIC) titled EPI 101, however, RN #3's personnel file did not contain any documentation of the attendance of the class.

The HR Assistant confirmed during an interview conducted on 11/21/13 that RN #3's personnel file did not contain a job description nor APIC training documentation.

3. Hospital policy titled "Infection Control Plan" requires: "...develop, promote and evaluate preventable and corrective programs,,,Review and analyze...evaluate...and undertake control measures or recommend actions...."

Review of hospital infection control documents did not reveal trending, analyzing and evaluating of hospital acquired infections.

RN #3 confirmed during in an interview on 11/21/13, nosocomial infections are not a problem and we evaluate any occurrence of those infections in a meeting.

Based on review of governing body meeting minutes, medical staff meeting minutes, quality program meeting minutes, performance improvement plan 2012-2013 and staff interviews, it was determined the hospital failed to conduct a periodic evaluation and quality assurance review as evidenced by:

Tag C-0331 485.641(a) conduct an annual total program evaluation;

Tag C-0332 485.641(a)(1)(i) evaluate utilization of clinic services including the number of patients served and the volume of services;

Tag C-0333 485.641(a)(1)(ii) review a representative sample of both active and closed clinic records;

Tag C-0334 485.641(a)(1)(iii) evaluate the health care clinic policies;

Tag C-0335 485.641(a) (2) review utilization of services as appropriate;

Tag C-0337 485.641(b)(1) (c)(2) ensure patient care services are evaluated;

Tag C-341 485.641(b)(5)(i) ensure the staff considered the findings of an evaluation and take corrective action if needed.

Findings include:

During the onsite Compliance survey conducted on 11/19/13 through 11/21/13, the CEO, the Quality manager and employee #25 confirmed the facility did not conduct an annual program evaluation.

The cumulative effects of these cumulative practices nd findings under the condition of the Periodic Evaluation and Quality Assurance Review resulted in the failure of the hospital to be in compliance with 42 CFR Part 485, Subpart A and Subpart B, requirements for a Critical Access Hospital.

Based on staff interview, it was determined the hospital failed to evaluate the total program including how the evaluation is conducted and who is responsible for conducting the evaluation.

Findings include:

The Chief Executive Officer (CEO) confirmed during an interview conducted on 11/20/13 the facility did not conduct a program evaluation for 2013.

Based on staff interview, it was determined the hospital failed to evaluate the utilization of the facility services, including at least the number of patients served and the volume of services.

Findings include:

The CEO confirmed during an interview conducted on 11/20/13 the facility did not conduct a program evaluation for 2013.

Based on staff interview, it was determined the hospital failed to review a representative sample of both active and closed clinical records.

Findings include:

Employee # 25 confirmed during an interview conducted on 11/21/13 the facility did not conduct active and closed record reviews as part of the program evaluation for 2013.

Based on staff interview, it was determined the hospital failed to evaluate, review and/or revise health care policies as part of the annual program evaluation.

Findings include:

Employee #25 confirmed during an interview conducted on 11/21/13, the facility did not evaluate health care policies as part of the program evaluation 2013.

Based on staff interview, it was determined the hospital failed to evaluate if the utilization of services was appropriate, the established policies were followed, and any changes are needed.

Findings include:

The CEO confirmed during an interview conducted on 11/20/13 the facility did not evaluate utilization of services, established policies and determine if any changes are needed as part of the program evaluation for 2013.

Based on staff interview, it was determined the hosptial failed to evaluated all patient care services and other services affecting patient health and safety.

Findings include:

The Quality Manager confirmed during an interview conducted on 11/21/13, the facility did not perform an evaluation of patient care services as part of the program evaluation for 2013.