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Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to assure clean and orderly premises including hallways, patient rooms, laundry and radiology. The hospital failed to develop and implement policies and procedures directing staff regarding the housekeeping, maintenance and laundry tasks.

Findings included:

- Observations of the hospital and interview of staff B on 1/20/10 between 9:40am and 12:05pm revealed the following:

1. The east maintenance hallway evidenced heavy debris behind the 2 doors magnetically held open.
2. The 'kitchen' hallway connects the hospital with other services including laundry and the kitchen. The 2 doors at the north end of the hall, magnetically held open, evidenced 2 areas of chipped laminate- a 8 inch by 2 inch area and a 3 inch by 1 inch area. The floor behind the doors evidenced heavy debris.
3. Patient rooms #1, 5, 6 and 9 evidenced heavy debris along the cove base, under the beds, behind movable objects including trash cans and behind the doors to the hallway and to the bathroom. Room #1 evidence heavy debris behind a movable cart.
4. A 5-inch section of cove base with non-cleanable wall surface exposed in the wall west of the nurses station by the offices.
5. The framed items hanging on the walls throughout the hospital including patient care areas and rooms evidenced heavy dust accumulation on the top horizontal surface. Additional interview with administrative staff C on 1/20/10 at 2:30pm confirmed the presence of the dust and concerns regarding infection control.
6. The front visitor's/patient's entrance to the CAH evidenced heavy debris and 2 rags on the floor between the entry doors. Staff B stated that a staff member had been working there, but was uncertain why the rags remained after the staff member left the area. Interview with administrative staff A on 1/20/10 at 12:35pm confirmed the continued presence of the debris and rags.

- Observation of the laundry room and interview with staff E on 1/21/10 between 8:40am and 9:55am revealed the following:

1. Heavy lint and debris build-up on the vertical pipes behind the washers, on the floor behind the washers, under and behind movable items including trash cans and above the doors of the dryers.
2. patchy areas of rust on the front of the 3 dryers
3. 4 laundry carts (2 steel tubs attached to a rolling frame for each cart) evidenced large areas of the unfinished surface and non-cleanable surface exposed on the frames.
4. A 3-shelve cloth-covered cart used to transport linens evidenced extensive areas of chipped paint and exposed/non-cleanable metal surfaces.
5. The table created by a wooden door on a frame evidenced approximately 1/3 of the surface with the finish coating material missing, exposing the bare, non-cleanable wood surface.
6. The table created by a laminated door on a frame evidenced a shelf under the folding surface made of partially painted particle board. Areas of the surface lacked paint rendering the shelf non-cleanable.

Interview with staff E further confirmed the laundry department lacked policies and procedures directing staff how to complete the laundry tasks.

- Observations in the Computed Tomograph (CT) scanner room in the radiology department and interview with staff I on 1/20/10 at 1:50pm revealed part of the west wall had been removed. Staff I stated it was part of a remodeling project for the new equipment soon to arrive. Staff I indicated the remodeling work began 1/19/10. Staff I also indicated as a portion of the wall was removed, a section of suspended ceiling tile, approximately 8 feet by 12 feet, fell. This section of damaged ceiling is directly above the patient's head during a scan. Observation of the open area revealed wooden trusses, water pipes, electrical wires, insulation and the interior of the roof. Staff I further confirmed the CT scanner remained in service. Additional observation of the CT room revealed a blue tarp, wallboard pieces, wood and other construction materials piled in the northwest corner of the room, and wires exposed and cover plates missing from a north wall outlet and a south wall light switch.

Interview with staff J, on 1/20/10 at 2:20pm, confirmed the lack of knowledge of the need to assure patient safety and manage the non-cleanable areas of the room during the remodeling project.

- Interview with administrative staff C on 1/21/10 at 2:30pm confirmed the hospital lacked policies and procedures for the management of patient safety during remodeling or construction. Staff B further confirmed the hospital lacked policies and procedures for the maintenance, laundry and housekeeping departments.

Based on observation and staff interview the Critical Access Hospital failed to develop and implement policies and procedures for the safe use of equipment to prevent the spread of infections for 3 of 3 patients observed who required the use of bedside blood sugar monitoring (#8, 20 and 34).

Findings included:

- Observation on 1/20/10 at 11:20am of staff K performing bedside blood sugar monitoring with a glucometer (an instrument to measure the blood sugar) on patient #'s 8, 20 and 34. Staff K failed to disinfect the glucometer between each patients' use.

Interview on 1/20/10 at 11:35am with staff K verified the failure to disinfect the glucometer instrument between each patients' use.

Interview on 1/20/10 at 11:35am with staff H confirmed the CAH lacked policies and procedures to direct staff in the disinfection of the glucometer between patients' use.


20940

Based on observation, interview and document review, the Critical Assess Hospital (CAH) failed to develop and implement policies and procedures for the maintenance of the hospital including infection control principles during remodeling projects.

- Observations in the Computed Tomograph (CT) scanner room in the radiology department and interview with staff I on 1/20/10 at 1:50pm revealed part of the west wall had been removed. Staff I indicated the remodeling work began 1/19/10. Staff I also indicated as a portion of the wall was removed, a section of suspended ceiling tile, approximately 8 feet by 12 feet, fell. This section of damaged ceiling is directly above the patient's head during a scan. Observation of the open area revealed wooden trusses, water pipes, electrical wires, insulation and the interior of the roof. Staff I further confirmed the CT scanner remained in service. Additional observation of the CT room revealed a blue tarp, wallboard pieces, wood and other construction materials piled in the northwest corner of the room.

Interview with staff J, on 1/20/10 at 2:20pm, confirmed the lack of knowledge of the need to assure patient safety and manage the non-cleanable areas of the room during the remodeling project. Interview with staff G on 1/22/10 at 1:00pm confirmed the infection control nurse lacked knowledge of the remodeling project and confirmed the potential infection control concerns.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and implement a nursing care plan for four (4) of 20 sampled inpatient records (#'s 7, 11, 13 and 20).

Findings included:

- Patient #7's medical record revealed an admission date of 1/19/10 with diagnoses of Arrhythmias and elevated Blood Pressure. The medical record lacked evidence of a nursing care plan todirect the nursing care based on assessment and needs of the patient.

- Patient #11's closed medical record revealed an admission date of 11/24/09 and a discharge date of 12/3/09. The record revealed a diagnosis of an open wound to the head after a fall. The medical record lacked evidence of a nursing care plan to direct the nursing care based on assessment and needs of the patient.

- Patient #13's closed medical record revealed an admission date of 11/23/09 and a discharge date of 11/30/09. The record revealed diagnoses of Congestive Heart Failure, Atrial Fibrillation and Cellulitis of the foot. The medical record lacked evidence of a nursing care plan to direct the nursing care based on assessment and needs of the patient.

- Patient #20's medical record revealed an admission date of 1/20/10 with a diagnosis of Bi-lateral lower extremity weakness. The medical record lacked evidence of a nursing care plan to direct the nursing care based on assessment and needs of the patient.

Interview on 1/19/10 at 2:25pm with staff D confirmed the CAH failed to develop and implement a care plan for each inpatient.

Interview on 1/22/10 at 1:15pm with staff A verified the CAH failed to develop and implement a policy and procedure that directs staff to develop a nursing care plan for each inpatient.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to assure the closed medical record included documentation of the procedure performed, health status of the patient and a care needs assessment for 1 of 1 patient who had a procedure performed by an allied health professional (#17).

Findings included:

- Patient #17's closed medical record revealed an admission date of 12/18/09 as an outpatient for a Peripherally Intravenous Central Catheter (PICC) line placement by an allied health professional. The record contained a Patient Registration Report, Consent For Treatment, Consent For the Procedure, faxed orders from the Family Care Center clinic and Discharge Instructions. The record lacked documentation of the procedure performed, a physical assessment to determine the health status of the patient and an assessment to determine the care needs of the patient.

Interview on 1/21/10 at 9:00am with staff A verified the medical record lacked documentation of the procedure performed, a physical assessment to determine the health status of the patient and an assessment to determine the care needs of the patient.


20940

Based on document review and interview, the Critical Access Hospital (CAH) failed to provide the patient with teaching regarding their medical condition and/or when to seek additional medical care. The CAH's failure to provide teaching effected 2 of 4 emergency care patients who were discharged (#'s 22 and 27).

Findings included:

- Review of the clinical record for patient #22 revealed an emergency room visit date of 12/15/09 with complaints of chest pain The patient left the hospital Against Medical Advise (AMA). The hospital staff failed to document teaching provided to the patient during the visit.

- Review of the clinical record for patient #27 revealed an emergency room visit date of 11/12/09 with complaints of vaginal bleeding during pregnancy. The hospital failed to document teaching regarding potential changes in status or reason to return for additional medical care.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to develop a policy and procedure that directed the providers to date and time all entries in the medical record when authenticated and failed to assure providers dated and timed all entries in the medical record when authenticated for 25 of 32 open and closed sampled records reviewed (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 19, 20, 21, 22, 23, 24, 25, 26, 29 and 30).

Findings included:

- Patient #1's record revealed an admit date of 1/13/10 to swing bed. Record review revealed between 1/14/10 to 1/19/10, 3 telephone or verbal orders lacked a date and time when authenticated (signed), 8 orders for renew of medications lacked the time the orders were authenticated and 8 orders written by the physician lacked the time the orders were written.

- Patient #8's record revealed an admit date of 1/13/10 to the hospital. Record review revealed between 1/16/10 to 1/20/10, 2 telephone or verbal orders lacked a date and time when authenticated, 4 orders for renew of medications lacked the time the orders were authenticated and 6 orders written by the physician lacked the time the orders were written.

- Patient #10 admitted to the hospital on 12/4/09 and discharged from the hospital on 12/9/09. Record review revealed the pre-printed admission orders lacked a date and time when authenticated, 5 telephone or verbal orders lacked the date and time when authenticated, 8 orders for renew of medications lacked the time the orders were authenticated, 1 order written by the physician lacked the time the physician signed the order and 3 progress notes lacked the date and time the notes were authenticated.

Interview on 1/21/10 at 3:00pm with staff A confirmed the providers failed to date and time when they authenticate their orders.

Interview on 1/22/10 at 4:30pm with staff F verified the CAH failed to develop a policy and procedure that directed providers date and time all entries in the medical record when authenticated.

Document review of the medical staff Rules and regulations indicated, "All orders for treatment shall be in writing and signed by the attending physician." The medical staff failed to include date and time of all entries in their rules and regulations.

This deficient practice also affected patient (#' 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 16, 19, 20, 21, 22, 23, 24, 25, 26, 29 and 30).

Based on document review and interview, the Critical Access Hospital failed to assure all services effecting patient care are evaluated as part of the CAH's Quality Assurance (QA) program. The hospital's maintenance department failed to submit data on QA indicators as part of the hospital's QA program.

Findings included:

- Review of the QA program description with administrative staff on 1/21/10 at 2:30pm revealed the lack of information provided by the maintenance department for QA review. Review of the "Quality Improvement Calender 2009" revealed the hospital failed to assure maintenance submitted quality indicator information for 3 of the 4 quarters in 2009. The hospital failed to assure all services are evaluated.