HospitalInspections.org

The regulatory language, due to a system error, failed to include the regulation found at C-0229

485.623(c)(3) Providing for an emergency fuel and water supply: and

This STANDARD is not met as evidenced by:

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the provision of adequate emergency water supplies (potable and/or non-potable) during an interruption in water service. Failure to ensure the water supply company could provide sufficient water (potable and/or non-potable) could potentially result in the CAH staff lacking sufficient water to adequately meet patient needs in the event of an interruption of water service to the CAH. The administrative staff identified a census of 3 inpatients at the time of the survey, and reported an average daily census of 3 inpatients. The CAH employed 198 employees at the time of the survey.

Findings include:

1. Review of a maintenance Memorandum of Understanding, dated February 9, 2018, revealed in part "... [Water Company A's Name], without putting our employees in harm's way, will align our efforts with your current disaster plan and regulatory requirements, deliver emergency products and supplies, including bottled water, to critical infrastructure customers as our first priority ..."

The document lacked information specifying the quantity of water that Water Company A could provide to the CAH, in the event the CAH experienced an interruption of the water supply. The document lacked information on the length of time Water Company A would require before Water Company A could provide water to the CAH in an emergency.

2. During an interview on 4/11/19 at 10:20 AM, the Maintenance Manager verified the Memorandum of Understanding lacked information on the quantity of water and frequency of delivery that Water Company A could provide to the CAH, in the event the CAH experienced an interruption in water service.

Based on observation, document review, and staff interviews, the critical access hospital's (CAH) administrative staff failed to ensure staff performed preventative maintenance on 3 of 3 Laerdal Suction Units in 3 of 3 ambulances (Ambulance 89-51, Ambulance 89-52, and Ambulance 89-53), 1 of 1 EcoLab Solution Warmer, and 1 of 1 glidescope in the Operating Room (OR). Failure to perform preventative maintenance could potentially result in the equipment failing to function when needed for the care and treatment of a patient, resulting in delayed care, treatment and patient harm. The CAH's administrative staff identified an average of 669 ambulance runs per year, and 154 OR procedures per month.

Findings include:

1. Observations on 4/9/19 at approximately 9:00 AM, during a tour of Ambulance 89-51, Ambulance 89-52, and Ambulance 89-53 revealed each ambulance had 1 of 1 Laerdal Suction Unit (a machine used in emergency situations to suction blood or other fluids from a patient's airway) with a preventative maintenance sticker indicating the equipment required inspection during January 2019.

2. Observations on 4/10/19 at 7:50 AM, during a tour of the Surgical Department, revealed 1 of 1 EcoLab Solution Warmer with a preventative maintenance sticker indicating the equipment required inspection during 8/2019. Further observations revealed 1 of 1 glidescope (an instrument designed to allow a physician better views when inserting a breathing tube into a patient), which lacked a preventative maintenance sticker.

3. Review of the policy "Utility Systems Preventative Maintenance," revised 4/2019, revealed in part, "... Maintenance Department or the contracted Bio-Med technician will perform annual preventative maintenance and inspections of ... equipment. Purpose: To assure the safety of our staff, patients ... and compliance of our equipment."

4. During an interview on 4/9/19, at the time of the ambulance tours, the Ambulance Manager verified the 3 of 3 Laerdal Suction Units in the observed ambulances had preventative maintenance stickers which indicated the maintenance staff should have inspected the suction units in January 2019.

5. During an interview on 4/10/19, at the time of the Surgery Department tour, the Assistant Chief Nursing Officer acknowledged the Ecolab Solution Warmer had a preventative maintenance sticker which indicated the maintenance staff should have inspected the solution warmer in August 2018. The Assistance Chief Nursing Officer acknowledged the glidescope lacked a sticker to inform the maintenance staff when they needed to inspect the glidescope for safety.

6. During an interview on 4/11/19 at 11:20 AM, the Assistant Chief Nursing Officer acknowledged the CAH staff lacked any additional documentation of preventative maintenance which occurred after the reinspection date listed on the sticker for the 3 of 3 ambulance Laerdal Suction units, the EcoLab Solution Warmer, and the glidescope.



II. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) staff failed to follow the manufacturer's directions when staff utilized the FreeStyle Lite Blood Glucose Monitoring System, manufactured for individual patient use, for more than 1 patient on the Medical Surgical Unit, Emergency Department, Cardiac Rehab, and on the ambulances. Failure to follow the FreeStyle Lite Blood Glucose Monitoring System manufacturer's instructions for use could potentially result in the blood glucose monitor providing inaccurate blood glucose readings, potentially resulting in the CAH staff failing to recognize and treat a patient's high or low blood sugar, which are potentially life-threatening conditions. Failure to follow the manufacturer's instructions could potentially result in the CAH staff performing inadequate cleaning and disinfection of the FreeStyle blood glucose monitor, potentially resulting in the spread of life-threatening infections between patients at the CAH. The CAH staff reported the CAH staff utilized the FreeStyle Lite Blood Glucose Monitor to monitor a patient's blood glucose level approximately 175 times per month in the Medical/Surgical unit, 14 times per month in the Emergency Department, and 19 times per month in the Ambulances. The CAH staff used the FreeStyle Lite Blood Glucose Monitor to monitor a patient's blood glucose level less than once per month at Cardiac Rehabilitation.

Findings include:

1. Observations on 4/8/19 at 2:05 PM in the Emergency Department (ED) revealed the ED staff utilized the FreeStyle Lite Blood Glucose Monitor if the staff needed to determine a patient's blood glucose level.

2. Observations on 4/10/19 at 8:35 AM in the Cardiac Rehabilitation department revealed the Cardiac Rehabilitation staff utilized the FreeStyle Lite Blood Glucose Monitor if the staff needed to determine a patient's blood glucose level.

3. Observations on 4/8/19 at 11:45 PM in the Medical/Surgical inpatient unit revealed the Medical/Surgical staff utilized the FreeStyle Lite Blood Glucose Monitor if the staff needed to determine a patient's blood glucose level.

4. Observations on 4/9/19 at 9:50 PM in Ambulance 89-51, Ambulance 89-52, and Ambulance 89-53, revealed the emergency medical services staff staff utilized the FreeStyle Lite Blood Glucose Monitor if they needed to determine a patient's blood glucose level.

5. Review of the FreeStyle Lite manufacturer's booklet, dated 8/01/07 revealed in part, "Caring for Your Meter ... Avoid getting ... water or any other liquid in the meter's test strip and data ports. Clean the outside of the meter using a dampened cloth ... Mild detergent/mild soap and water."

6. During an interview on 4/9/2019 at 9:50 AM, the Ambulance Manager acknowledged the FreeStyle Lite Blood glucose monitor's manufacturer only intended the monitor for individual patient use.

7. During an interview on 4/9/1:02 PM, the Assistant Chief Nursing Officer acknowledged the nursing staff in the ED, Medical/Surgical Unit, and Cardiac Rehabilitation department utilized a single FreeStyle Lite Blood Glucose Monitor to check the blood glucose level for multiple patients. The Assistant Chief Nursing Officer acknowledged the emergency medical services staff used a single Freestyle Lite Blood Glucose Monitor in each ambulance to check the blood glucose level for multiple patients. The Assistant Chief Nursing Officer reported the CAH staff did not know they could only use the FreeStyle Lite Blood Glucose Monitor for a single patient, until they contacted the glucose monitor's manufacturer during the survey.

8. During a telephone interview on 4/16/2019 at 9:30 AM, an Abbott Diabetes Care Representative revealed that Abbott Diabetes Care manufactured the FreeStyle Lite for individual patient use. Due to the sensitive electronics, the manufacturer did not recommend the CAH staff to clean the glucose monitor, due to the possibility of the liquid cleaning solution getting into the meter, potentially damaging the unit, and result in inaccurate blood glucose readings.




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III. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 3 of 21 patient bathroom sinks tested in the patient care area (Room 202, Room 204, and Room 207), and 2 of 2 sinks tested (Treatment Room and General area) in the Physical Therapy department. Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in the water causing burns to patients of the CAH. The CAH identified a census of 3 patients on entrance and had approximately 59 Physical Therapy patients per month.

Findings include:

1. Observations on 4/8/19 at 11:45 AM, during a tour of the Inpatient Unit, revealed:

a. Room 202 bathroom sink, water temperature was 122 degrees Fahrenheit
b. Room 204 bathroom sink, water temperature was 124.9 degrees Fahrenheit
c. Room 207 bathroom sink, water temperature was 124.5 degrees Fahrenheit

2. During an interview, at the time of the tour, the Assistant Chief Nursing Officer acknowledged the water temperatures were greater than 120 degrees Fahrenheit.

3. Observations on 4/9/19 at 1:25 PM, during a tour of the Physical Therapy Department, revealed:

a. PT Treatment Room sink water temperature was 126.1 degrees Fahrenheit
b. General PT area sink water temperature was 125.6 degrees Fahrenheit.

During an interview at the time of the tour, Director of Rehab acknowledged the water temperatures exceeded 120 degrees Fahrenheit.

4. Review of the policy, "Preventive Maintenance of Water Distribution Systems," last approved 4/2019, revealed in part, "Domestic hot water is required to be at 110 [degrees Fahrenheit] - 120 [degrees Fahrenheit] at distribution."


VI. Based on observation and staff interviews, Critical Access Hospital (CAH) staff failed to remove outdated supplies from the radiology department. Failure to remove outdated patient supplies, could potentially result in the staff utilizing supplies past the date which the manufacturer guaranteed the sterility and safety of the supply, which could potentially result in the supplies failing to work as the staff expected, potentially resulting in a life-threatening situation for a patient, or the supply lacking sterility, which could potentially result in the patient developing a life-threatening infection. The CAH staff performed approximately 350 radiology procedures per month.

Findings include:

1. Observations on 4/9/19 at 9:10 AM, during a tour of the Radiology Department, revealed the following expired supplies:

a. X-Ray room, 1 of 1 MediPak Hydrogen Peroxide 16 ounce bottle, open, undated
b. X-Ray room, 1 of 1 MediPak 70% Isopropyl Alcohol 16 ounce bottle, open, undated
c. X-Ray room, 1 of 1 BD 20 milliliter syringe, expired 10/2013
d. X-Ray room, 1 of 1 BD Spinal Needle, 22 gauge, expired 1/2014
e. X-Ray room, 1 of 1 Liquid Polibar Plus Barium Sulfate suspension, 1900 milliliters, open, undated
f. CT room, 1 of 1 BD Insyte Autoguard 24 gauge IV needle, expired 12/15
g. CT room, 28 of 28 BD Insyte Autoguard 18 gauge IV needle, all expired 1/18

2. During an interview at the time of the tour, Radiology Manager acknowledged the radiology staff failed to remove the expired supplies from the patient care areas.

Based on review of the Performance Improvement Plan, Quality Improvement activities, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 3 of 3 contracted patient care services (MRI - Magnetic Resonance Imaging, Nuclear Medicine, speech therapy). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care. The CAH administrative staff reported a census of 3 patients at the beginning of the survey. The CAH administrative staff reported the following average number of procedures per month - MRI 20, Nuclear Medicine 1, speech therapy 2.

Findings include:

1. Review of the CAH Performance Improvement Plan 2019, revealed in part, "... commitment of this hospital to continuously improve the quality of the treatment and services it provides. Performance improvement involves ... Measuring and assessing the performance of services ... through the collection and analysis of data...."

2. Review of the CAH's Performance Improvement Plan - Appendix A, revealed a calendar indicating when the different departments of the CAH reported their information to the Performance Improvement Committee. The Performance Improvement Plan lacked information indicating the Performance Improvement Plan included information to monitor and evaluate quality improvement activities related to patient care from the contracted MRI, Nuclear Medicine, and Speech Therapy services.

3. During an interview on 4/10/19 at 2:30 PM, the Nurse Manager of Quality acknowledged the Performance Improvement Plan failed to include quality improvement information for monitoring and evaluation of the contracted MRI, Nuclear Medicine, and Speech Therapy services for quality improvement activities related to patient care.

4. During an interview on 4/10/2019 at 2:30 PM, the Assistant Chief Nursing Officer confirmed the CAH's Performance Improvement program failed to monitor the contracted patient care services MRI - Magnetic Resonance Imaging, Nuclear Medicine, and Speech Therapy for quality improvement activities related to patient care.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to inform each swing bed (bed used for extended care services) Medicaid-eligible patient, in writing, at the time of admission to the facility and when the patient becomes eligible for Medicaid, of the items and services included in nursing facility services under the State plan and for which the patient may not be charged, those items and services that the facility offers and for which the patient may be charged, and the amount of charges for those services, and inform each Medicaid-eligible patient when changes are made to the items and services. Failure to present all of the required rights to the patients admitted to swing bed status and/or their legal representative could result in the patients and/or their legal representatives lacking knowledge of all their rights as swing bed patients while they continued to receive skilled level of care. This lack of knowlege could potentially compromise the patients' ability to exercise their rights. The CAH administrative staff identified a census of 1 swing bed patient at the beginning of the survey, and admits approximately 2 swing bed patients per month.

Findings include:

1. Review of "[Hospital] Swing Bed Bill of Rights", revealed CAH failed to include the following swing bed patient rights:

a. Inform each Medicaid-eligible patient, in writing, at the time of admission to the facility and when the patient becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the patient may not be charged, those items and services that the facility offers and for which the patient may be charged, and the amount of charges for those services, and inform each Medicaid-eligible patient when changes are made to the items and services.


2. Review of Patient #1's open swing bed record revealed the the CAH staff admitted Patient #1 to Swing Bed status on 3/31/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

3. Review of Patient #2's closed swing bed record revealed the the CAH staff admitted Patient #2 to Swing Bed status on 3/14/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

4. Review of Patient #3's closed swing bed record revealed the the CAH staff admitted Patient #3 to Swing Bed status on 1/8/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

5. Review of Patient #4's closed swing bed record revealed the the CAH staff admitted Patient #4 to Swing Bed status on 1/21/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

6. Review of Patient #5's closed swing bed record revealed the the CAH staff admitted Patient #5 to Swing Bed status on 2/1/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

7. Review of Patient #6's closed swing bed record revealed the the CAH staff admitted Patient #6 to Swing Bed status on 12/21/19. The "[Hospital] Swing Bed Bill" of Rights failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

8. During an interview on 4/11/19 at approximately 11:40 AM, the Chief Nursing Officer acknowledged CAH staff failed to inform patients of the items and services which the facility can charge the patient for and which items and services the facility does not charge the patient for.

Based on policy and patient medical record review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure activity personnel developed and implemented an ongoing activity program that included an activities care plan for 1 of 1 open swing bed patient (Patient #1) and for 5 of 5 closed swing bed patients (Patients #2, #3, #4, #5 and #6). Failure to provide an activity program that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well being and independence possible. The CAH administrative staff identified a census of 1 swing bed patient at the time of the survey and an average of 2 skilled patients per month.

Findings include:

1. Review of the CAH's policies revealed the CAH staff failed to create a policy addressing the development and implementation of an ongoing activity program which included an activities care plan for swing bed patients.

2. Review of 1 of 1 active swing bed patient medical record revealed a physician ordered swing bed services for Patient #1 on 3/31/19. Staff A, designated as the activity person, completed an activity assessment on 4/2/19 with the activity plan documented only as "PRN (Latin for 'as needed')."

Patient #1's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

3. Review of 5 of 5 closed swing bed patient medical records revealed the following information:

a. A physician ordered swing bed services for Patient #2 on 3/14/19 and was discharged on 3/19/19. Staff A, designated as the activity person, failed to complete an activity assessment for Patient #2.

Patient #2's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

b. A physician ordered swing bed services for Patient #3 on 1/4/19 and was discharged on 1/8/19. Staff A, designated as the activity person, completed an activity assessment on 1/8/19 with the activity plan documented only as "PRN."

Patient #3's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

c. A physician ordered swing bed services for Patient #4 on 1/21/19 and was discharged on 1/29/19. Staff A, designated as the activity person, completed an activity assessment on 1/22/19 with the activity plan documented only as "PRN."

Patient #4's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

d. A physician ordered swing bed services for Patient #5 on 2/1/19 and was discharged on 2/28/19. Staff A, designated as the activity person, completed an activity assessment on 1/11/19 with the activity plan documented only as "PRN."

The activity assessment was completed by Staff A during Patient #5's previous swing bed admission and lacked evidence the assessment had been updated for this admission.

Patient #5's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

e. A physician ordered swing bed services for Patient #6 on 12/21/18 and was discharged on 12/28/18. Staff A, designated as the activity person, completed an activity assessment on 12/26/18 with the activity plan documented only as "PRN."

Patient #6's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

4. During an interview on 4/10/19 at 10:45 AM, Staff A, designated as the activities person, acknowledged she was responsible for completing an activity assessment and providing an activity program for swing bed patients. Staff A revealed, in addition to activity calendars, swing bed patients had a variety of activities available to them at the hospital. Staff A verified she failed to develop and implement an ongoing activities program which included an activities care plan for swing bed patients. Staff A also confirmed she failed to document any activities provided to the patients.

5. During an interview on 4/11/19 at 10:10 AM, the Chief Nursing Officer (CNO) acknowledged the CAH lacked a policy addressing the development and implementation of an ongoing activities program, which included an activities care plan for swing bed patients. The CNO verified the lack of documentation of activities and activity care plans for Patients #1, #2, #3, #4, #5, and #6 during patient medical record review on 4/10/19 at 4:00 PM.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the CAH staff informed patients (or support person where appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend, for all inpatients and outpatients. Failure to provide all patients with current visitation rights could potentially result in staff limiting/restricting access of visitors to patients which infringed on the patient's right to have a support person when the patient received any type of care, services, or treatment modalities. The CAH staff identified a current census of 3 at the start of the survey and an average of approximately 687 outpatients per month and 172 Emergency Department patients per month.

Findings include:

1. Review of CAH "Registration Policy" dated 2/2019, revealed in part, "Appropriate documents will be provided to the patients depending upon the [patient's registration] ... staff will explain each document given [to the patient]." The policy failed to require registration staff to provide patients with information on their Patient Visitation Rights.

2. Review of the "Van Buren County Hospital and Medical Clinics Your Rights and Responsibilities As A Patient - Acute Care" dated 5/1/2006, provided to inpatients, revealed the brochure lacked information on Patient Visitation Rights.

3. Observations where registration of outpatients occurred included the following:

a. During tour of the Emergency Department registration area on 4/9/2019 at 9:00 AM, and interview with the Ambulance Manager, revealed the "Patient Rights" posted behind the Nurses Station and document "Van Buren County Hospital Patient Service Agreement" provided to patients lacked information related to the Patient Visitation Rights. The Ambulance Manager acknowledged he assisted with Emergency Department patient registration. The Ambulance Manager revealed he did not provide any information related to Patient Visitation Rights during the registration process.

b. During a tour of the CAH Patient Registration area on 4/10/19 at approximately 11:00 AM, staff did not provide information to patients on their Patient Visitation Rights during the registration process.

4. During an interview on 4/10/19 at 11:13 AM, the Revenue Cycle Manager reported she was responsible for all inpatient and outpatient registration services. The Revenue Cycle Manager acknowledged that the patients coming to Van Buren County Hospital did not receive information related to Patient Visitation Rights prior to receiving care and the CAH lacked patient's visitation rights information available in print form to provide to all inpatients and outpatients.