HospitalInspections.org

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to check 1 of 5 staff regularly exposed to radiation for the level of radiation exposure in the operating room.

Findings include:

Review on 11/15/2022 of the CAH's dosimetry report dated April 6, 2022 revealed Staff A (Doctor of Podiatric Medicine) was not included in the personnel monitored for radiation exposure.

Interview on 11/15/2022 at 12:45 p.m. with the Staff B (Director of Radiology) confirmed Staff A did not have a dosimetry badge assigned and was not monitored for radiation exposure.

Interview on 11/15/2022 at 1:30 p.m. with Staff C (Director of Surgical Services) confirmed Staff A used the C-arm for X-Rays while performing surgeries in the operating room.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to adequately document that patients were discharged in the company of a responsible adult for 6 out of 10 surgical patient records reviewed. (Patient identifiers are #27, #28, #30, #32, #34, and #35.)

Findings include:

Review on 11/15/22 of 6 surgical patients' records (#27, #28, #30, #32, #34, and #35) revealed no documentation that the patients were discharged into the care of a responsible adult.

Interview on 11/15/22 at approximately 3:00 p.m. with Staff C (Director of Surgical Services) confirmed there was no documentation that the patients were discharged with a responsible adult.

Review on 11/16/2022 of the facility's policy titled "Discharge Criteria" revised 04/2016 revealed, "Discharge Criteria" ...Procedure... #2. The responsible person or escort will be an adult who was identified at the time of admission. ...#5 Discharge criteria... h. presence of a responsible adult required.

Based on interview and record review, the Critical Access Hospital (CAH) failed to document verification testing of endoscopes after the dissinfection process.

Findings include:

Review on 11/15/22 of central sterile logs for September and October 2022 revealed there were no records of verification testing of endoscopes after the disinfection process with the Rapicide PA test strips.

Interview on 11/16/22 at approximately 9:00 a.m. with Staff D (Central Sterilization Technician) confirmed the above finding. Further interview with Staff D revealed that during the verification testing process, staff did not record the pass or fail results of the Rapicide PA test strips to provide proof that the disinfectant minimum recommended concentration was met.

Review on 11/16/22 of the Medivator System manufacturer's manual... Complete the Disinfection Process states... "When the disinfection process is complete, the LCD screen (and optional alarm) prompts the operator to verify the disinfectant minimum recommended concentration has been met by the Rapicide PA High-Level Disinfectant Test Strips Instructions for Use."