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Based on observation, record review, policy review, and interviews, the facility failed to ensure wound care was provided in accordance with hospital policy. Specifically, the Registered Nurse (RN) failed to measure and document sacral wounds and photograph the wound at admission and every five days for one of two (Patients (P) 3) reviewed for wound care. This deficient practice had the potential to affect all patients admitted or who develop a wound in the facility.

Findings include:

Review of the hospital policy titled, "Wound Assessment and Documentation," effective 08/31/11, showed that wounds are to be measured for depth, width, and length at admission and every five days and as needed thereafter. A photograph of the site is to be taken and loaded onto the computer and a picture printed and placed on the wound documentation form at admission and every five days and as needed thereafter.

Review of P3's "Admission Order" located in the electronic medical record (EMR) showed that P3 was admitted on 08/31/20 with diagnoses of pneumonia, hyperglycemia, and hypertensive disorder. Further review of the section titled "Orders" showed a physician's order on 08/31/20 at 8:09 PM to clean the presacral decubitus with diluted normal saline solution and betadine and dress with Bactroban twice a day.

Review of "Shift Notes" located in the EMR under the "Notes" tab, showed a note documented by RN3 that he/she "Found skin breakdown at the buttock r/t [related to] to moisture." There was no documented evidence that an assessment of the wound, that included the depth, width, and length of the decubitus, and photograph in the EMR.

Review of "Shift Notes" located in the EMR under the "Notes" tab showed a note documented by RN4 that P3 "has pressure ulcer stage 2 on coccyx. Dressing applied." There was no documentation that an assessment of the wound, that included the depth, width, and length of the pressure ulcer was completed. A photograph of the wound dated 09/05/20 was noted in the EMR under the tab titled "Wounds."

Review of the entire EMR did not show documentation that P3's decubitus was measured to include the depth, width, and length from the time of admit on 08/31/20 through the time of review of the EMR on 09/21/20. There was no documented evidence the wound had been photographed every five days in accordance with hospital policy.

In an interview on 09/22/20 at 10:15 AM, Director of Nursing (DON) reviewed the P3's EMR and stated that the EMR did not contain documentation of wound measurements for the sacral decubitus. The DON stated that he/she did not think nursing measured a wound unless it was an open wound. When asked if a Stage 2 pressure ulcer was an open wound, DON stated "yes." The policy was reviewed, and DON stated if the policy states the decubitus is to be measured, then measurements should be done.

In an interview on 09/22/20 at 10:25 AM, RN4 stated that P3's wound measurement was not documented on 09/05/20 because he/she thought the wound measurements had been already documented.

In an interview on 09/22/20 at 4:20 PM, RN3 stated that the assessment of P3's decubitus was not documented on 09/02/20. RN3 stated that he/she should have taken pictures, documented the measurements, what the edges of the wound looked like, and the type of drainage noted.

Based on observation, record review, policy review, and interviews, the facility failed to ensure wound assessments were conducted and physician orders followed for wound care for (Patient (P) 3), and failed to obtain a stool specimen for testing for Clostridium difficile (C-diff) for P1 and P2. This deficient practice had the potential to affect the nine current inpatients and patients admitted to the hospital requiring wound care and controlling infectious diseases to prevent contamination.

Findings include:

Review of the hospital policy titled, "Wound Assessment and Documentation," effective 08/31/11, showed that wounds are to be measured for depth, width, and length at admission and every five days and as needed thereafter. A photograph of the site is to be taken and loaded onto the computer and a picture printed and placed on the wound documentation form at admission and every five days and as needed thereafter.

Review of the facility policy titled, "Physician Order Review," with an effective date of 04/01/00 and a revised date of 09/23/20 showed, "Policy: Every RN [Registered Nurse] and LPN [Licensed Practical Nurse] is responsible for ensuring that the physician's orders for each patient have been carried out as ordered ..."

1. Review of P3's electronic medical record (EMR) showed that P3 was admitted on 08/31/20 with diagnoses of pneumonia, hyperglycemia, and hypertensive disorder. Further review of the section titled "Orders" showed a physician's order on 08/31/20 at 8:09 PM to clean the presacral decubitus with diluted normal saline solution and betadine and dress with Bactroban twice a day.

Review of "Shift Notes" located in the EMR under the "Notes" tab showed a note documented by RN3 that he/she "Found skin breakdown at the buttock r/t [related to] to moisture." There was no documented evidence of an assessment of the wound that included the depth, width, and length of the decubitus, and no photograph was in the EMR.

Review of "Shift Notes" located in the EMR under the "Notes" tab showed a note documented by RN4 that P3 "has pressure ulcer stage 2 on coccyx. Dressing applied." There was no documented evidence of an assessment of the wound that included the depth, width, and length of the pressure ulcer. A photograph of the wound dated 09/05/20 was noted in the EMR under the tab titled "Wounds."

Review of "Flowsheet Wounds," located under the tab titled "Flowsheets" with a subtitle of "Wounds," showed that the first observed documentation of P3's wound was 09/08/20, 8 days after admission to the hospital and with admission orders for wound care.

Review of the entire EMR showed no documented evidence that P3's decubitus was measured to include the depth, width, and length from the time of admit on 08/31/20 through the time of review of the EMR on 09/21/20. There was no documented evidence the wound had been photographed every five days in accordance with hospital policy.

Review of P3's entire EMR showed no documented evidence P3's wound care was performed in accordance with the physician orders. Further review of the "Flowsheet Wounds" showed the wound was cleansed on 09/12/20 at 7:30 AM, 09/14/20 at 7:30 AM, 09/15/20 at 7:30 AM, and 09/17/20 at 7:30 AM with no documented evidence of what was used to clean the wound (order was to clean the presacral decubitus with diluted normal saline solution and betadine). Further review revealed no documented evidence the wound was dressed with Bactroban twice a day as ordered by the physician.

In an interview on 09/22/20 at 10:15 AM, Director of Nursing (DON) reviewed the EMR of P3. The DON stated that the EMR did not include documentation of wound measurements for P3's sacral decubitus. The DON stated that he/she didn't think the nurses measured the wound unless it was an open wound. When asked if a Stage II pressure ulcer was an open wound, the DON stated "yes." The policy was reviewed, and the DON stated if the policy states the decubitus is to be measured, then measurement should be done. He/she stated wound care should be done according to the physician's order, and if wound care needs to change, the nurse should get a new order. After reviewing the EMR of Patient 3, DON stated the physician's order for wound care was not done as ordered.

In an interview on 09/22/20 at 10:25 AM, Registered Nurse (RN)4 stated P3's wound measurements were not documented on 09/05/20, because he/she thought the decubitus measurements were already done.

In an interview on 09/22/20 at 4:20 PM, RN3 stated that the assessment of P3's decubitus was not documented on 09/02/20. RN3 stated that he/she should have taken pictures, documented the measurements, what the edges of the wound looked like, and the type of drainage noted.

2.Review of P1's EMR showed he/she was admitted on 09/14/20 with diagnoses of sepsis syndrome, altered mental status, and acute pyelonephritis.

Review of P1's physician orders, located under the tab titled "Orders" in the EMR, showed a physician's order on 09/14/20 at 4:21 PM to obtain a stool specimen for C-diff toxin B.

Review of P1's EMR from 09/21/20 through 09/23/20 showed no documented evidence that a stool specimen had been collected for C-diff. Further review showed P1 had a medium loose bloody stool on 09/20/20 at 9:58 PM and a large and loose stool on 09/21/20 at 8:30 AM.

In an interview on 09/23/20 at 10:35 AM, the DON stated P1 was on contact precautions awaiting results for possible C-diff. The DON presented physician orders written on 09/14/20 to obtain a stool sample for C-diff. The DON did not know why the stool specimen wasn't collected, and why there was no documentation P1 had bowel movements in the record. The DON stated that it is the responsibility of the RN providing care to P1 to collect the sample. The DON stated that the tracking system to check that ordered labs are obtained, included placing the request next to the patient's name on the white board in the nursing station and writing the request on the Kardex (card kept at the nursing station on each patient that includes medical information, including lab requests.) The DON stated, "we have lots of methods [for tracking], and I don't know why it failed." The request was written on the white board, but it wasn't placed in the Kardex until today.

In an interview on 09/23/20 at 10:40 AM, RN4 stated he/she was aware of P1's order to obtain a stool for C-diff, but P1 did not have a liquid stool, and the laboratory company used by the hospital would not accept a specimen unless it was "watery."

In an interview on 09/23/20 at 11:10 AM, the Interim Director of Nursing (I-DON) reviewed documentation from P1's EMR and stated no stools were documented between 09/14/20 and 09/19/20. The IDON stated docusate (a medication used to treat occasional constipation) was ordered on 09/19/20 and was held on 09/20/20 due to "loose stools." The I-DON stated the documentation of medium loose bloody stool on 09/20/20 and large and loose stool on 09/21/20 should have resulted in the stool specimen being collected and submitted for testing.

3.Review of P2's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 05/01/20 with a diagnoses of recurrent C diff colitis, fall, and diarrhea. Review of the "Physician Orders" located in the EMR, revealed a physician's order dated 08/02/20 at 1:52 PM to obtain a stool for C difficile toxin.

Review of P2's "Flow Sheet" located in the EMR, indicated P2 had a bowel movement on 08/02/20, 08/03/20, 08/04/20, 08/05/20, 08/06/20, 08/09/20, 08/11/20, 08/13/20, 08/15/20, 08/17/20, 08/18/20, 08/19/20, and 08/20/20. On 08/03/20, 08/04/20, and 08/05/20, the stool was described as loose/watery.

Review of P2's "Results Section" of the EMR a stool was collected for C-Diff on 08/21/20 with a positive result received on 08/25/20.

During an interview on 09/22/20 at 11:00 AM, the DON was asked why the stool specimen for C-Diff was not obtained until 08/21/20. The DON stated that a "watery stool" was needed for the test. The DON reviewed P2's "Flow Sheet" that indicated on 08/04/20 at 1:24 PM there was a watery stool, and several loose stools on 08/03/20 and 08/05/20. The DON stated the stool specimen should have been collected before 08/21/20.

Based on record reviews, policy review, and interviews, the facility failed to ensure medical records were complete, readily accessible, and systematically organized. The Certified Registered Nurse Anesthetist (CRNA) failed to sign, date, and time the pre-anesthesia risk evaluation and post-anesthesia evaluation for seven of seven (Patients (P)16, P17, P29, P30, P31, P32, P33) reviewed for endoscopic procedures. This deficient practice has the potential to affect any future patient having an endoscopic procedure of having a procedure without being assessed for anesthesia risk prior to the procedure and of being fully recovered from anesthesia prior to discharge.

Findings include:

Review of the hospital policy titled, "Protocols Governing Anesthesia," effective 05/01/00, showed that a pre-anesthetic evaluation of the patient with appropriate documentation in the medical record must be provided by the anesthetist. The review of the patient's condition immediately prior to anesthesia to determine that the patient remains an appropriate candidate for planned anesthesia will be provided by the CRNA. The post-operative status of the patient is to be evaluated on admission to the post-anesthesia recovery area with documentation in the medical record including a notation relating to the presence or absence of post-anesthetic complications.

There was no documented evidence that the policy addressed the signing, dating, and timing of the medical record entries made by the CRNA.

1.Review of P16's undated "Patient Information" sheet, located in the electronic medical record (EMR), revealed a colonoscopy was performed on 06/25/20 for history of polyps. Review of the "Anesthesia Record" dated 06/25/20 indicated a pre and post evaluation of vital signs was completed. The "Anesthesia Record" did not include the time the evaluations were completed.

2.Review of P17's the "Operative Report" located in the electronic medical record (EMR) showed P17 had an esophagiogastroduodenoscopy (EGD) (a test to examine the lining of the esophagus, stomach, and first part of the small intestine) with balloon dilatation on 07/08/20. Review of the CRNA's "Anesthesia Record" dated 07/08/20 showed documentation of an anesthesia assessment and a post-operative anesthesia assessment. Further review of the "Anesthesia Record" showed typed names of the CRNA, nurse, and physician at the bottom of the record. The "Anesthesia Record" did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.

3.Review of P29's "Physician Operative Report" located in the EMR, medical record showed P29 had colonoscopy (a procedure to examine the inside of the large intestine, specifically the colon and rectum) on 07/08/20. Review of CRNA's "Anesthesia Record" dated 07/08/20 The "Anesthesia Record" did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.
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4.Review of P30's "Operative Report" located in the EMR, showed P30 had an EGD with balloon dilatation, and a colonoscopy through the rectum and stoma on 06/24/20. Review of CRNA's "Anesthesia Record" dated 06/24/20 did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.

5.Review of P31's "Operative Report" located in the EMR, medical record showed P31 had an EGD with balloon dilatation and a colonoscopy into the cecum with multiple polypectomies on 08/26/20. Review of CRNA's "Anesthesia Record" dated 08/26/20 did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.

6.Review of P32's "Operative Report" located in the EMR, medical record showed P32 had an EGD on 08/26/20. Review of CRNA's "Anesthesia Record" dated 08/26/20 did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.

7.Review of P33's "Operative Report" located in the EMR, medical record showed P33 had an EGD with dilatation and a colonoscopy into the distal ileum on 06/25/20. Review of CRNA's "Anesthesia Record" dated 06/25/20 s did not include a signature or time of the anesthesia assessment and the post-operative anesthesia evaluation to determine which staff conducted the evaluations to determine that the anesthesia risk evaluation was conducted prior to the procedure.

In an interview on 09/23/20 at 11:45 AM, Registered Nurse (RN) 4 stated the CRNA begins his/her review of the patient's pre-operative record and visits with the patient in pre-op on the day of the procedure.

In an interview on 09/23/20 at 11:50 AM, RN1 stated the CRNA calls the patient the day before a procedure to review the patient's history and speaks with the patient before the patient is taken for the procedure.

In a telephone interview on 09/23/20 at 12:05 PM, the CRNA stated he/she calls the patient the day before a procedure to review the patient's medical history and does the patient's physical exam the day of the procedure while the patient is in the pre-operative area. The CRNA stated the post-anesthesia evaluation is done when the patient arrives in the post anesthesia care unit. He/she stated the patient is awake at the time of the post-anesthesia evaluation to be able to answer questions to determine recovery from anesthesia. The CRNA stated he/she created the form and did not include an area for signature, date, and time of the pre and post evaluation. The CRNA stated that without the time documented for both evaluations, it would be difficult to assure the pre-anesthesia risk evaluation was done prior to the procedure and the post-anesthesia evaluation was done after the procedure.

Based on observations, record reviews, document reviews, policy reviews, and interviews, the facility failed to meet the requirements of the Condition of Participation of Infection Prevention and Control and Antibiotic Stewardship Program. This failure placed all patients, staff, and visitors at risk for infection and transmission of communicable disease.

Findings include:

1. The Infection Prevention and Control Program (IPCP) did not employ methods for preventing and controlling the transmission of infections according to hospital policies related to hand hygiene, glove use, implementation of contact precautions, use of the "Accu-Chek Inform II" system (device used to measure a patient's blood glucose by a finger stick sample of blood), and decontamination of instruments. (Refer to C1206)

2. The Infection Control Officer failed to track, trend, and investigate identified infections. (Refer to C1206)

3. The Infection Control Officer failed to educate staff on the proper procedure of donning and doffing personal protective equipment (PPE) and failed to conduct staff competencies for donning and doffing of PPE during the COVID-19 pandemic. (Refer to C1206)

4. The Governing Body of the hospital failed to ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control in order to demonstrate the implementation, success, and sustainability of such activities. No documented evidence was provided to demonstrate the Governing Body's oversight of the ICPC of the hospital. (Refer to C1225)

Based on observations, record reviews, policy reviews, document reviews, and interviews, the facility failed to ensure the Infection Prevention and Control Program (IPCP) employed methods for preventing and controlling the transmission of infections according to hospital policies related to hand hygiene, glove use, implementation of contact precautions, use of the "Accu-Chek Inform II" system (device used to measure a patient's blood glucose by a finger stick sample of blood), and decontamination of instruments. The facility failed to ensure the Infection Control Officer tracked, trended, and investigated identified infections, failed to ensure education was provided to staff on the proper procedure of donning and doffing personal protective equipment (PPE) and failed to ensure competencies were conducted during the COVID-19 pandemic. The facility also failed to ensure dietary staff conducted proper handwashing. These failed practices had the potential to spread infections to the current nine patients and future patients to the hospital, to hospital staff and visitors.

Findings include:

1. Review of the policy titled ,"Infection Prevention and Control Program," effective 01/23/12, showed that the hospital's IPCP ensures that the organization "develops, implements, and maintains an active, organization-wide program for the prevention, control, and investigation of infections and communicable diseases in order to reduce the risk of endemic and epidemic infections in patients, visitors, and healthcare workers." Elements of the program included "implementing policies and procedures to reduce the likelihood and spread of infections and communicating and educating staff, patients, and visitors regarding infection control processes."
Further review showed that the Infection Control professional would "develop and maintain a system for identifying, reporting, investigating, and controlling infections and communicable diseases. . . maintain a log of incidents related to infections and communicable diseases. . . assist with staff infection control education. . . require disinfectants and germicides to be used in accordance with the manufacturer's instructions. . . conducting surveillance. . . on a hospital-wide basis in order to identify infectious risks or communicable disease problems. . ."

Review of the policy titled, "Hand Hygiene - CDC [Centers for Disease Control and Prevention] Guidelines, " effective 01/23/12, , showed that hand hygiene with either soap and water or an alcohol-based hand rub should be performed "when hands are soiled, before each patient encounter, before applying gloves. . . after coming in contact with patient's skin. . . after working on a contaminated body site and then moving to a clean body site on the same patient, after coming in contact with bodily fluids, dressing, mucous membranes and such and hands are not visibly soiled. . . after contact with medical equipment/supplies in patient areas, always after removing gloves, leaving an isolation area."

Observation on 09/21/20 at 11:30 AM showed RN2 preparing to perform blood sugar finger sticks to test blood glucose for P3 and P6. RN2 sanitized his/her hands and applied gloves. RN2 entered P3's room and placed the glucometer on a stool., then RN2 placed the glucometer on a paper towel on the bed next to P3. RN2 noticed Patient 3 did not have a name band on the wrist and checked for the name band on the arms and legs, lifting the bed linens to look at P3's arms and legs. Once a new name band was provided, RN2 took an alcohol wipe out of his/her pocket and with the same contaminated gloves touched the IV pole next to P3's bed, checked the name band, inserted the test strip in the glucometer, wiped P3's left middle fingertip, and pierced the skin to obtain the blood sample.. RN2 then removed his/her gloves and donned a new glove to the left hand without performing hand hygiene. RN2 picked up the supplies used to obtain P3's blood specimen with his/her left hand, placed the needle in the sharps container, and left the room. RN2 went to the medication room (where the glucometer was stored in a wall-mounted docking station), removed the left glove, and donned new gloves without performing hand hygiene between glove use. After disinfecting the glucometer, RN2 then removed his/her gloves and did not perform hand hygiene.

Continuous observation on 09/21/20 at 11:42 AM showed RN2 opened the container of Glucometer test strips and removed a test strip and gathered his/her supplies and walked to P6's room, sanitized his/her hands, and applied gloves. RN2 placed the glucometer on the overbed table, placed a paper towel on Patient 6's bed and transferred the glucometer to the paper towel. RN2 obtained a blood sample from P6's left index finger, removed his/her gloves, and donned new gloves without performing hand hygiene between glove use.

Review of the "Acute Infection Control Plan 2020," presented by DON, showed the risk assessment had not identified hand hygiene as a risk to be included in the priority list to be monitored.

In an interview in the medication room on 09/21/20 at 11:50 AM, RN2 stated the glucometer had to remain wet for at least 30 seconds, but he/she usually makes sure it remains wet for one minute. When the above observations were reviewed with RN2, he/she stated he/she did not follow hospital policy and Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. He/she stated he/she was a travel nurse and had not received infection control and COVID-19 training at the hospital. He/she stated his/her training consisted of following a hospital-employed nurse for a day.

2. Review of the policy titled, "Transmission-Based Precautions (Isolation Precautions)," effective 01/23/12,, showed that contact precautions shall be used for "patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. . . gloves shall be worn whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (i.e. medical equipment and bed rails . . . Gowns shall be worn whenever it is anticipated that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient."

Observation on 09/22/20 at 11:12 AM from the hall outside Room 1 (P1's room) that had the door open showed a sign outside the door that documented P1 was on contact isolation. Observation showed Certified Nursing Assistant (CNA) 1 entered the room wearing a mask and gloves, opened the bathroom door inside P1's room, obtained a measuring cup, emptied P1's urine bag that was attached to the bed, and discarded the urine in the toilet. CNA1 removed his/her gloves, sanitized his/her hands and came out the room, donned an isolation gown, and entered P1's room.

In an interview on 09/22/20 at 11:20 AM, CNA 1 stated that he/she thought a gown was needed to be worn when having contact with the patient. CNA 1 was unaware t that a gown was needed when having contact with the environmental in P1's room.

3. Review of the policy titled, "Accu-Chek Glucometer," effective 04/01/00 and revised 07/23/10, showed that for cleaning/disinfecting after use, the glucometer should be wiped "of any observed blood or debris" and wiped with "a bleach wipe after each patient use and allow to air dry." Further review showed that the policy did not include the specific bleach wipe to use and proper procedure for disinfecting the "Accu-Chek Inform II" system in accordance with the manufacturer's guidelines as outlined below.

Review of the "Accu-Chek Inform II Operator's Manual," Version 6, showed that acceptable active ingredients and products for cleaning and disinfecting are "Clorox Germicidal Wipes" or "Super Sani-Cloth Germicidal Disposable Wipes." Further review showed the process for cleaning and disinfecting the device included the following: "place the meter on a level surface" prior to cleaning; "when using pre-moistened cleaning cloths, squeeze off excessive cleaning solution to remove an excess cleaning solution . . . before cleaning the surface of the meter . . . clean by gently wiping the outside of the meter and carefully wipe around the test strip port area, making sure that no liquid enters the strip port area and then wipe dry with a tissue." Further review showed that after allowing the meter to remain damp with the recommended disinfecting solution for 1 minute (for Clorox wipes), "dry the meter thoroughly with a dry cloth or gauze . . . visually verify that no solution is seen anywhere on the meter at the completion of cleaning and disinfecting."

Observation on 09/21/20 at 11:30 AM, showed RN2 preparing to perform P3's blood sugar finger stick to test blood glucose. After performing the finger stick on P3, RN2 went to the medication room where the glucometer was stored in a wall-mounted docking station, wiped the entire glucometer with "Clorox Bleach Germicidal Wipes," and immediately placed the glucometer in the docking station without wiping the glucometer with a dry cloth (per direction in the manufacturer's manual.)

Observation on 09/21/20 at 11:42 AM, showed RN2 completed P6's fingerstick blood glucose, walked to the medication room, and placed the glucometer on a paper towel on the counter in the medication room. RN2 wiped the entire surface of the glucometer and immediately placed the glucometer in the docking station without wiping the surface with a dry cloth.

In an interview on 09/21/20 at 1:30 PM, the Interim Director of Nursing (I-DON) stated he/she didn't know the glucometer had to be dried after being disinfecting.

In an interview on 09/22/20 at 10:30 AM, RN2 stated he/she knew the glucometer had to be wiped dry, but thought waiting the amount of contact time would be enough. When told by the surveyor that observation showed RN2 had immediately placed the glucometer in the docking station after disinfecting after use on P3 and P6, RN2 offered no explanation for not wiping the glucometer dry with a dry cloth or gauze.


4. Review of the policy titled, "Steps for Cleaning and Processing of Instruments and Supplies," effective 04/01/00 and revised 07/23/19, showed that "cleaning with an enzymatic detergent is preliminary to disinfection and sterilization . . . After gross soil has been cleaned from items, they may be placed into the ultrasonic cleaner for deep cleaning . . . All items washed with enzymatic detergent shall be rinsed in clear water to remove soap residue that may cause discoloration and pitting of instrument surfaces . . . All items shall be dried prior to packaging and sterilization . . . Prior to sterilization, all items shall be appropriately packaged."

Review of the label on the container of "Medline Dual Enzymatic Detergent and Presoak," the agent used by the hospital for decontaminating instruments used in the emergency room (ER), showed that manual cleaning included the following instructions: "while "Medline Dual Enzymatic Detergent and Presoak" is effective at room temperature, water temperatures between 90 degrees Fahrenheit (F) to 110 degrees F will optimize enzyme performance; Manual Cleaning: remove gross soils from instruments prior to soaking or cleaning; for optimal enzyme action, mix fresh solution immediately prior to use . . . mix one-half ounce to one ounce of concentrated solution per gallon of water; allow a minimum of one to two minutes contact time; rinse instruments thoroughly . . . to remove traces of enzymatic detergent; change cleaning solution after every . . . batch of soiled items."

Observation in the Central Supply Room (where clean supplies are stored) during the tour of the hospital on 09/21/20 at 11:10 AM with the DON and Interim Director of Nursing (I-DON) present, showed a plastic bin on the counter next to the sink that had 1 scissor, 1 bayonet, and 1 clamp placed on a paper towel in the bottom of the uncovered bin. Central Supply Clerk (CS) stated that the instruments were from the ER, and the staff in the ER washed them before bringing to Central Supply. The CS stated the instruments would be placed in the ultrasonic cleaner situated next to the sink and afterwards placed in bags to be sterilized.

Observation in the Central Supply Room on 09/23/20 at 9:32 AM showed the scissor, bayonet, and curved clamp that were observed on 09/21/20 remained in the uncovered plastic bin on the counter next to the sink.

In an interview on 09/23/20 at 9:12 AM, RN1 stated he/she cleans sterile instruments with soap and water and then soaks them in Dual Enzymatic Detergent and Presoak for 5 to 10 minutes in an emesis basin (plastic basin used for patients to vomit into.) RN1 stated he/she doesn't measure the solution and mix it with water and doesn't check the water temperature. RN1 stated that he/she didn't know the manufacturer guidelines for use of the detergent.

In an interview at the time of the observation on 09/23/20 at 9:32 AM, after review of the Dual Enzymatic Detergent and Presoak label, CS stated he/she could not say that the instruments had been decontaminated, and thus, they should not be in the clean Central Supply Room.

5. In an interview on 09/23/20 at 2:20 PM with DON and I-DON present, the hospital's Infection Control Program was reviewed. The DON stated he/she does surveillance on catheter-associated urinary tract infections and isolation precautions, but does not have a formal procedure for hand hygiene surveillance. The observations made during the survey were reviewed with the DON and I-DON, who both stated the observations reviewed were actual breaches in infection control. The DON stated that an infection log was not maintained per hospital policy and stated there was not any documentation of the tracking, trending, and investigation of infections that were identified. The DON stated that employees take online training for infection control, but competencies were not completed on staff for proper donning and doffing of PPE.

In an interview in the medication room on 09/21/20 at 11:50 AM, RN2 stated he/she was a travel nurse and had not received infection control and COVID-19 training at the hospital. RN2stated his/her training consisted of following a hospital-employed nurse for a day.

In an interview on 09/23/20 at 2:20 PM with DON and I-DON present, the hospital's infection control program was reviewed. DON stated the employees take online training for infection control, but he/she had not conducted competencies of proper donning and doffing of PPE since the outbreak of COVID-19. The DON stated he/she did not have policies and procedures for training in infection control, but all employees complete an online training in infection control. Review of the training document presented by DON during the interview showed training on bloodborne pathogens was a 30-minute course and the basics of infection control was a 15-minute course.

6. Review of the facility policy titled, "Hand Washing," revised 04/2018, "Policy: Employee will wash hands as frequently as needed throughout the day using proper hand washing procedures ... Procedure... 1. When to wash hands... f. After handling soiled equipment or utensils ..."

During observation in the kitchen on 09/23/20 at 12:15 PM, Cook2 was observed to wash dishes with gloves on in the three-compartment sink. After stacking the dishes on a tray, Cook2 took the dishes to the dish room and placed them in the dishwasher. Cook2 then took clean dishes out of the dishwasher and brought the dishes to the kitchen while wearing the same gloves.

During an interview on 09/23/20 at 12:20 PM, Cook2 was asked if the same gloves were worn when the dirty dishes were taken to the dish room and the clean dishes brought into the kitchen. Cook2 stated he/she did not change gloves when handling dirty dishes and then clean dishes. Cook2 stated that the gloves should have been changed and handwashing done before bringing the clean dishes into the kitchen.

During an interview on 09/23/20 at 12:30 PM, the Dietary Manager (DM) was asked if Cook2 should have washed hands before bringing the clean dishes into the kitchen. The DM stated, "Yes. Always wash hands between the clean and dirty tasks."

Based on observation, interview and record review, the facility failed to ensure and maintain a clean and sanitary environment in the kitchen to avoid sources of transmission of infection. This failed deficient practice had the potential to transmit unwanted particles in the food distributed to patients leading to cross contamination of infection.

Findings include:

During an observation on 09/21/20 at 10:30 AM, uncovered food was observed on the stove and the Maintenance Supervisor and an assistant had a latter next to the stove and was pulling a vent and filter out of the hood above the stove just above the food.

During an interview on 09/21/20 at 10:32 AM, Cook1 was asked if there was uncovered food on the stove. Cook1 stated yes there was uncovered food and staff should not be working in the kitchen when food was being prepared for service.

During an interview on 09/21/20 at 10:35 AM, The Dietary Manager (DM) was asked if it was an infection control issue when maintenance was pulling the vent and filter out over the uncovered food. The DM said it was "poor timing" and stated it was not good to have maintenance in the kitchen during the time of food preparation or service.

Review of the facility policy titled, "Food Preparation Area" dated 09/2020 revealed, " Definition: The facility maintains a clean, sanitary and safe food preparation area ...4. When equipment is being serviced, no food must be present ..."

Based on document review and interview, the Governing Body of the critical access hospital failed to ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control in order to demonstrate the implementation, success, and sustainability of such activities. The hospital failed to provide documented evidence to demonstrate the Governing Body provided oversight to the Infection Prevention and Control Program of the hospital. This deficient practice had the potential to affect the spread of infections and communicable diseases to all patients and staff of the hospital.

Findings include:

Review of the "Board Meeting Minutes" dated 10/24/19 and 12/19/19 showed the infection control report was reviewed by the Director of Nursing (DON) and included "(Copy attached to original minutes. MGGH [Mount Grant General Hospital] Employee call ins for illness were very high in GI [gastrointestinal] complaints. In addition, the SNF [skilled nursing facility] has had no flu to report."

Review of the "Board Meeting Minutes" dated 06/25/20 showed no documented evidence that an Infection Control Report was included and discussed in the meeting.

In an interview on 09/23/20 at 2:20 PM with the DON and Interim I-DON present, the hospital's Infection Control Program was reviewed. The DON stated the hospital did not maintain an infection log, and did not document the tracking, trending, and investigation of infections that were identified.

In an interview on 09/23/20 at 3:30 PM, the Administrator stated the infection control information is reviewed at the Governing Body board meetings. When asked why the hospital did not have documentation that infection control was reported and discussed at the 06/25/20 board meeting, the Administrator was unable to explain why infection control was not discussed. The Administrator stated that the DON presented infection control reports monthly to quality assurance who printed the reports for the surveyor to review. As of the time of the exit conference on 09/23/20 at 5:45 PM, infection control reports were not provided by the Administrator.

Based on record reviews, policy review, and interviews, the critical access hospital failed to ensure a patient's discharge plan included a regular re-evaluation of the patient's condition to identify changes that require modifications of the discharge plan for two of 21 sampled (Patients (P) 1 and P6) reviewed for discharge planning. This failure had the potential for patients to be released from the hospital without needs being met and to cause delays in discharge.

Findings include:

Review of the policy titled, "Discharge Planning," effective 04/01/00 and revised 09/28/04, showed that discharge planning is to be started "on the day of admission . . . done by the Registered Nurse (RN) . . . updated as needs change . . . The discharge plan is detailed and includes barriers that must be addressed to accomplish the goals of the discharge plan." There was no documented evidence that the risk manager was involved with discharge planning and the role and responsibility of the risk manager in discharge planning.

1. Review of P1's electronic medical record (EMR) showed P1 was admitted on 09/14/20 with diagnoses of sepsis syndrome, altered mental status, and acute pyelonephritis. Review of the "Discharge Planning Acute Care" dated 09/14/20 showed assistance required after discharge included food preparation, shopping, transportation, home making, and long-term care. "Siblings" was documented in the space after "Family/Friends." The discharge planning note showed P1, "will be evaluated and assessed to current living situation. Pt [patient] will be placed in long term care if be if found to be unable to return to independent living completing activities to daily living." There was no documentation that discussions were conducted and documented with P1 or his/her siblings related to discharge planning and possibly long-term care placement. There was no documented evidence that P1's "Discharge Planning Acute Care" was revised since admission on 09/14/20.

In an interview on 09/22/20 at 11:25 AM, the Risk Manager (RM) stated he/she spoke with P1's sister about long term care. After having that conversation, the RM stated that he/she spoke with P1 who wanted to return home. RM stated a mental health evaluation was ordered and scheduled. The RM stated that he/she documents conversations with P1, P1's sister, and the physician regarding discharge planning, but the documentation is not placed in P1's medical record. RM stated he/she was involved in discharge planning, but that information does not become part of the patient's medical record.

2. Review of P6's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 09/04/20 with diagnoses of acute gastroenteritis and cerebral vascular accident. Further review showed the "Discharge Planning" form located in P6's paper medical record was initiated on 09/15/20, eleven days after P6's admission.

During an interview on 09/22/20 at 11:31 AM, the Director of Nursing (DON) was asked about the discharge plan and why it was not started when P6 was admitted. The DON did not know why the discharge plan was not initiated on P6's admission, but stated that discharge planning should start upon admission to the hospital.

Based on interview and record review, the facility failed to ensure one of one sampled patient (Patients (P) P2) in swing bed status had a comprehensive assessment completed within the required time frame. This deficient practice had the potential for the patient to not receive the appropriate care to meet the medical needs.

Findings include:

Review of P2's undated "Patient Information" sheet, located in the electronic medical record (EMR), revealed an admission date of 05/01/20 with diagnoses of recurrent Clostridium difficile colitis and diarrhea. Further review of the EMR revealed an "Admission and Quarterly Data Collection Tool" assessment dated 05/01/20. Review of the EMR showed P2 was discharged to the hospital on 06/20/20 and readmitted to the swing bed unit on 07/15/20 and was discharged to the hospital on 08/25/20 and readmitted to the swing bed unit on 08/31/20. Review of the EMR failed to show subsequent comprehensive assessments were completed.

During an interview on 09/22/20 at 11:31 AM, the Director of Nursing (DON) was asked to find an updated assessment for P2. The DON stated there was just the one assessment completed on 05/01/20. The DON stated the resident went back and forth between inpatient and swing bed status and stated that a new assessment should have been completed when the patient was readmitted back to swing bed status.

Review of the facility policy titled "Assessment and Reassessment ..." with an "Effective Date of 04/01/00, Revised on 09/09/04 showed, Policy: ...each patient admitted to the Medical Surgical Unit shall receive a completed head- to- toe assessment ... The assessment of care and treatment needs of the patient will be ongoing throughout the patient's hospital stay ..."