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Based on observations, interviews and record review the Critical Access Hospital (CAH) failed to ensure that care and services were provided in accordance with currently established written policies and procedures regarding the provision of care to include appropriate infection prevention practice for hand hygiene and discharge process from the Emergency Department (ED) for 3 of 10 applicable patients. (Patient #1, 2 & 10) Findings include:

1. On 5/27/19 Patient #2 sought treatment in the ED for a chief complaint of a right hand laceration/avulsion (wound that happens when skin is torn) due to injury while working on heavy equipment. The patient was placed in a 2 stretcher room in the ED and noted a second patient occupied the other stretcher and the curtain between the 2 patients had been drawn. Patient #1 had been receiving treatment for a hand laceration requiring suturing. Upon completion of the suturing of Patient #1's hand, the ED physician failed to follow hospital policy for hand hygiene by failing to remove contaminated gloves worn during the suturing procedure. Without removing the contaminated gloves, the physician proceeded to visit briefly with Patient #2, who was awaiting care in the adjoining stretcher. The physician informed Patient # 2 s/he was next to receive treatment for the hand injury and during this encounter touched Patient#2's affected hand with the contaminated gloves. Family members of Patient #2 who witnessed the event requested immediate action regarding this breach of infection control practice for hand hygiene. As a result, Patient #2's wound and hand were cleansed and specific blood testing was offered and accepted by both Patient #1 and Patient #2 to rule out transmission of potential blood borne infections to include: Hepatitis B; Hepatitis C and/or HIV.

Per review of CAH policy Hand Hygiene last revision: 05/22/19 states: "Purpose: Effective hand hygiene is the best practice at reducing risk of transmission from healthcare workers hands to patients". The policy further states: " When to Perform Hand Hygiene: All healthcare personnel shall wash hands during but not limited to these times: Before entering a patient environment and after leaving patient environment; before and after touching the patient; and before and after the use of any gloves: sterile or non-sterile.

Per interview on 10/15/19 at 9:15 AM, the Chief Medical Officer (CMO) confirmed a peer and Quality/Compliance review was conducted after the event on 5/27/19. The ED physician acknowledged the breach in infection control practice by not removing his/her contaminated gloves and performing hand hygiene after suturing Patient #1 and prior to having physical contact with Patient #2. Both patients did receive follow-up regarding blood test results from the CMO and apology for the adverse event.

2. During treatment in the ED on 5/27/19 for a right hand laceration, Patient #2 was x-rayed; examined for superficial abrasions and avulsion. The wound was cleaned and a dressing applied and the patient was determined to be stable for discharge. Verbal education was provided as per ED physician progress note, however no written instructions were provided to Patient #2 regarding the care and management of the wound and the potential follow-up of the event of possible blood exposure/cross contamination while being treated in the ED.

3. Patient #10 presented to the ED on 9/23/19 with a chief complaint of exposure to body fluids. The individual was a healthcare worker with a EMS provider who was concerned after touching blood in an ambulance with ungloved hand 2 days prior to seeking treatment. Although the ED physician stated possible exposure to infectious disease was a low probability related to the skin encounter, the ED physician offered blood testing for the EMS employee but also discussed obtaining testing of the "source patient", whose blood Patient #10 may have been exposed to with ungloved hands. After discussion of options, the patient declined to have Hepatitis B, Hepatitis C & HIV testing conducted. The patient was advised to follow-up with their Primary Care Physician. No discharge instructions regarding the visit and treatment options were provided when Patient #10 was discharged from the ED.

Per review of CAH policy Discharge Instructions for the Emergency Department current version dated 07/11/2011 states "2. Patients receive written instructions for "Discharge" from the Emergency department as evidence by signing 'I have received and understand instructions'...the date and time of departure must also be documented. 3. The discharge instructions will be reviewed with the patient by the Emergency Department Physician and/or Registered Nurse."
Per interview on the morning of 10/15/19 the Director of ED Services confirmed the absence of signed acknowledgment by either Patient #2 or Patient #10 upon discharge or evidence of written instructions for care of a wound and/or follow-up with a primary care physician associated with each patient's specific diagnosis and treatments. The Director of ED services further confirmed staff failed to follow the CAH policy Patient Discharge Instructions.

Based on staff interview and record review, the CAH failed to ensure that all policies directing care and services in the ED were reviewed at least annually. Findings include:

Per review of ED policy Discharge Instructions noted the policy had not been reviewed and updated since 3/22/15, 4 years beyond the required time for review and/or revisions. The lack of policy and procedure update was confirmed by the Director of ED Services on the morning of 10/15/19. The Director did confirm all ED policies are in the process of review, however acknowledged several others are also in need of review. In addition, per CAH policy titled: Policy Development, Approval, and Maintenance last revisions: 09/04/2018 states: " Policy: All policies and procedures are reviewed annually and updated to remain current with best practice standards and regulatory requirements". The policy further states: "Patient care policies required of Critical Access Hospitals includes but are not limited to: "Policies and procedures for emergency medical services".