HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.

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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure that staff followed policies and procedures for labeling multi-dose vials of medication in accordance with USP 797.
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Failure to date and discard multi-dose vials after 28 days of opening risks contamination of the contents of the vials and transmission of infectious diseases to patients during medication administration.

Reference: United States Pharmacopoeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised 04/16).
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Findings included:
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1. Document review of the the hospital's policy titled, "Use and Expiration of Multi-dose Vials," Policy #792.00, revised 06/17, showed that multi-dose vials should be discarded 28 days after first use and that vials are to be marked with beyond use date labels at the time of opening.
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2. On 07/10/18 at 3:00 PM, Surveyor #9 examined multi-dose vials of medication contained in the Pyxis (automated medication dispensing system) on the Mother-Baby Unit. One of two vials of Labetalol 5 mg. (a medication used to decrease blood pressure) were open, but did not have a label indicating beyond use dates.
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3. At the time of the observation, a registered nurse (Staff #901) stated that the vial should have been marked with "beyond use dates" at the time it was opened.

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Item #1- Infection Control Education
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Based on document review and interview, the critical access hospital failed to conduct annual infection control training for contracted staff members. Documentation of infection control training was missing for 1 of 9 files reviewed.

Failure to provide annual training in infection control for contracted employees puts patients, staff and visitors at risk from communicable diseases.

Findings included:

1. On 07/12/18 between 1:00 and 1:45 PM, Surveyor #4 reviewed the hospital's human resource files. Documentation of infection control training was missing for a contracted employee (Staff #401) who worked as a patient access representative.

2. At the time of the review, the hospital's Market Human Resources Director (Staff #402) stated that the provider for the contracted staff had not provided evidence of infection control training for incoming staff, and that the hospital had not included contracted staff in hospital-wide infection control education.


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Item #2- Hand Hygiene

Based on observation, interview and review of policy and procedure, the critical access hospital failed to ensure that staff adhered to hand hygiene (HH) standards during preparation for a surgical procedure.
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Failure to follow HH standards creates a risk for transmission of infection to patients, visitors and facility personnel.
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Findings included:
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1. Document review of the hospital's policy and procedure titled, "Hand Hygiene," Policy #9.31.00, reviewed 01/18 showed that HH should be performed after picking up items that have fallen on the floor.
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2. On 07/11/18 at 10:20 AM, Surveyor #9 observed preparation for a surgical procedure on Patient #901. The observation showed that during the set up for the surgical procedure, the outer cover of a sterile item fell to the floor. The Radiology Technician (Staff #902), retrieved the cover from the floor and placed it in a trash receptacle. She did not perform HH after disposing of the trash.
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3. At the time of the observation, the Peri-Operative Director (Staff #903) stated that the employee should have performed HH as directed by policy.

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