HospitalInspections.org

Based on review of documents and administrative staff interviews the CAH (Critical Access Hospital) failed to maintain personnel files for 25 of 25 contracted employees providing services to the CAH patients. The CAH administrative staff reported using 25 contracted staff worked in the CAH.

Failure to maintain personnel files on contracted employees could potentially result in patients receiving care from unqualified or unlicensed staff.

Findings include:

1. Review of 1 of 13 personnel files revealed the CAH failed to establish or maintain a personnel file for the Consulting Dietitian, who works at the CAH on a weekly basis. Additional investigation revealed the CAH failed to establish and maintain personal files for 25 of 25 contracted employees.

2. Review of the policy/procedures revealed failure of the administrative staff to develop and implement a policy/procedure for personnel files of for the CAH employees or the contracted employees.

3. An interview on 6/18/14 at 11:07 AM, with the Human Resources (HR) Director revealed the CAH failed to establish and maintain personnel files for each of the contracted employees. We maintain a contract with these professionals or organizations providing the service, and the contract guarantees that the individual is qualified for the position being filled. Additional information provided by the HR Director revealed the CAH failed to develop and implement a policy/procedure for the personnel files of employees.

An interview on 6/18/14 at 3:00 PM, with the HR Director revealed she was unable to obtain the professional information from the contracting organization that employed the dietitian. The CAH lacked any evidence to confirm that the contracted dietitian was qualified to function as the dietitian and provide dietary services at the CAH.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure outdated patient supplies were removed from 3 of 7 outpatient areas of the CAH so expired supplies were not available for use in patient care areas (Surgery, Clinic, Specialty Clinic). The CAH staff reported furnishing patient care during approximately 48 outpatient procedures per month in surgery, 100 outpatients per day in the clinic, and 8 outpatients per week in the specialty clinic.

Failure to remove outdated patient supplies from the CAH's supplies available for use in patient care could potentially result in the expired items used for patient care after the date that the manufacturer has determined the supplies were no longer considered appropriate for use in patient care.

Findings include:

1. Observations during tour of the surgery area on 6/16/14 at 2:45 PM, with Staff C, Registered Nurse (RN), revealed the following:

a. Substerile Room:
- 24 of 24 bottles of Protocol 10% Formalin - expired in May 2012

b. CRNA's Epidural Cart for Obstetrics:
- 2 of 2 Pecan Spinal Needle Trays - expired in November 2013

During an interview on 6/16/14 at 3:30 PM, Staff C, RN, verified the outdated patient supplies were found in the surgery area.

2. Observations during tour of the clinic area on 6/17/14 at 10:00 AM, with Staff A, Clinic Director - Registered Nurse, revealed the following:

a. Exam Room A6:
- 3 of 3 Red Top Vacutainers - Expired May 2014
- 1 of 3 Pink Top Vacutainers - Expired February 2014

b. Exam Room A5:
- 6 of 6 Red Top Vacutainers - Expired May 2014
- 5 of 9 Blue Top Vacutainers - Expired April 2014

c. Exam Room B4:
- 4 of 4 Red Top Vacutainers - Expired May 2014

d. Lab:
- 52 of 52 Sedi-Rate Kits - Expired May 31, 2014

e. Minor Procedure Room:
- 2 of 3 Red Top Vacutainers - Expired May 2014
- 4 of 6 Yellow Top Vacutainers - Expired April 2014

During an interview on 6/17/14 at 10:20 AM, Staff A, Clinic Director, RN, verified the outdated patient supplies found in the clinic area. Staff A stated the nursing staff checked for outdates monthly but were last checked 4/23/14.

3. Observations during tour of the specialty clinic area on 6/17/14 at 2:40 PM, with Staff J, Registered Nurse, revealed the following in the chemotherapy cart:

- 3 of 3 Green Top Vacutainers - Expired March 2014
- 2 of 2 Yellow Top Vacutainers - Expired March 2014
- 15 of 15 Blue Top Vacutainers - Expired March 2014

During an interview on 6/17/14 at 2:40 PM, Staff J, RN, verified the outdated patient supplies found in the specialty clinic area and should not have been in the cart.

4. Review of CAH Clinic policy titled "Monitoring of Expired Biologicals", dated 12/5/13, revealed, in part, ". . . PURPOSE: To follow manufacturer expiration dates which will ensure timely and appropriate use of equipment or supplies, which will ensure safety of our patients and accurate testing results. . . Clinical staff will monitor expiration dates on but not limited to, items such as: blood tubes, dressings, topical applications, medications. . . ."

Review of CAH policy titled "Checking Outdated Materials", dated 6/10, revealed, in part, "Manning Regional Healthcare Center shall assure that all drugs and materials are monitored for outdates. . . STANDARDS: The following departments will be checked for outdated materials on a monthly basis: . . . OR. . . ."

I. Based on observation, document and policy review, and staff interviews, the Critical Access Hospital (CAH) failed to ensure that surgery staff followed manufacturers' instructions for the use of an enzymatic disinfectant product (Revital Ox) when cleaning patient care equipment (endoscopy scopes) and CAH policy in the surgery area. The CAH surgery staff reported the CAH surgery staff reported an average of 8 endoscopic procedures are completed per month.

Failure to use disinfectant products as directed by the manufacturer potentially puts patients at risk for exposure to infections and blood borne pathogens.

Findings include:

1. Observations during a tour of the Operating Room Scope Procedure Room on 6/16/14 at 1:00 PM with Staff G, Surgery Technician, revealed a double sink with water in both sections and a pump bottle labeled Revital Ox 2 X Concentrate Enzymatic Detergent beside the sink.

During observation and interview at the time of the tour, Staff G explained the scope cleaning process while the scope was cleaned. Staff G stated she ran hot water into one side of the double sink and placed two squirts of Revital Ox into the water. Staff G acknowledged they did not measure the amount of water or the temperature of the water in the sink. Staff G then placed the scope into the water that contained the enzymatic detergent and proceeded to attach the proper attachments to the scope. Staff G then placed a 20 cc syringe onto the scope port and flushed each port of the scope with 20 cc of the detergent solution three times for a total of 60 cc. Staff G stated they did not time the amount of time the scope soaked in the detergent solution.

2. Review of the manufacturers' product insert for Revital Ox, provided by Staff F, Registered Nurse, revealed, in part ". . .Manual Cleaning Directions: Dilute 1/8 - 1/2 fl oz per gallon of warm water (1 to 4 ml per L) depending on soil load. Activity increases as the water temperature increases. Soak a minimum of 2 to 5 minutes. Soak times may be longer for dried on proteinaceous material. If lower temperatures are used, a longer soak time may be necessary. Do not exceed 130 degrees F. After soaking, rinse thoroughly including lumens/channels. . . ."

Review of undated CAH policy titled "Endoscope Care Instructions", revealed, in part, ". . . Using 35 cc syringe flush detergent solution 3 times in each of the 2 green ports on cleaning hoses (at least 90 cc in each port). . . ."

Review of the documentation revealed it lacked documentation verifying that the scope was cleaned.

3. During an interview on 6/16/14 at 4:00 PM, Staff D, Chief Clinical Officer, acknowledged Staff G failed to clean the scope per manufacturer's recommendation and CAH policy lacked the correct concentration of detergent for the amount of water , the correct temperature of the hot water, the correct soak time, and the proper amount of flush solution utilized.


II. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the surgery staff followed the manufacturer's instructions for testing the disinfection product (Cidex) used in disinfecting endoscopes used in the surgery area and the transvaginal probes used in the ultrasound area of the Radiology Department. (Scope Procedure Room, Central Sterile) The CAH surgery staff identified an average of 8 endoscopic procedures per month, and each would require the use of the disinfecting solutions for cleaning after the procedure. The CAH radiology and central sterile staff were unable to identify an average number of transvaginal probes used per month.

Failure to test the disinfecting solutions prior to each use could result in the disinfecting solution not containing a sufficient strength of the active ingredient to kill all microorganisms, potentially resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations during a tour of the Operating Room Scope Procedure Room on 6/16/14 at 1:00 PM with Staff G, Surgery Technician, revealed a tub labeled Cidex solution. A paper log sitting on the counter revealed surgery staff tested the disinfectant, Cidex, once a day, when the staff used the Cidex during manual cleaning of the scopes.

During an interview on 6/16/14 at 1:00 PM, at the time of the tour, Staff G stated the surgery staff test the Cidex once a day and between scope cleaning but fail to document when the staff test the Cidex solution between cleaning of the scopes. Staff G stated surgery staff did not know the Cidex needed to be tested prior to each use.

2. Observations during a tour of the Central Sterile Area on 6/16/14 at 3:50 PM with Staff F, Registered Nurse, RN, revealed a tub labeled Cidex solution. A paper log available revealed surgery staff tested the disinfectant, Cidex, once a day, when the staff used the Cidex during manual cleaning of the scopes.

During an interview on 6/18/14 at 11:35 AM, Staff F stated the surgery staff test the Cidex solution in Central Sterile once a day and before immersing instruments including the transvaginal probe from Radiology but fail to document when the staff test the Cidex solution between cleaning of instruments. Staff F stated surgery staff did not know the Cidex needed to be tested prior to each use.

3. Review of the policies and procedures revealed the lack of a policy that addressed the use of Cidex for cleaning the endoscopes and the transvaginal probe.

During an interview on 6/18/14 at 3:50 PM, Staff D, Chief Clinical Officer, acknowledged the lack of a policy that addressed the use of Cidex.

4. Review of the manufacturer's directions for Cidex Test Strips, revealed in part, "Test solution before each usage to guard against dilution, which may lower the glutaraldehyde [a disinfectant] level of the solution below its MEC. . . ."


III. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) failed to ensure proper cleaning of the blood glucose monitors in 1 of 3 areas per manufacturer's recommendations and facility policy. (Surgery) The CAH surgery staff identified approximately 50 surgical procedures per month.

Failure to clean patient care equipment as directed by the manufacturer potentially puts patients at risk for exposure to infections and blood borne pathogens.

1. Observation during a tour of the Pre/Post Surgery area 6/16/14 at 2:45 PM with Staff C, Registered Nurse (RN), revealed two Contour Blood Glucose monitors used to check patient's blood sugars in the area.

2. Review of manufacturer's directions for glucometer care revealed, in part, ". . . The exterior of the Meter can be cleaned using a moist (not wet) lint-free tissue with a mild detergent or disinfectant solution, such as 1 part bleach mixed with 9 parts water. . . ."

3. Review of CAH undated policy titled "Blood Glucose Monitoring Accu-Check Advantage", revealed the policy failed to address how the monitor was to be cleaned between patients.

Review of CAH policy from Lipincott's Nursing Procedures - Blood Glucose Monitoring, revealed, in part, ". . . Clean and disinfect the blood glucose monitor between each patient contact, according to your facility's policy. . . ."

4. During an interview on 6/16/14 at 3:00 PM, Staff C, RN, stated they used an alcohol pad to clean the glucometers between patients.

During an interview on 6/18/14 at 9:05 AM. Staff E, Infection Prevention, stated the CAH follows APIC (Association for Professionals In Infection Control) guidelines. Staff E acknowledged alcohol was an antiseptic agent and not a disinfectant. Staff E provided a document from APIC that stated, in part, ". . . an antiseptic agent is defined as an antimicrobial substance applied to the skin to reduce the number of microbial flora. . . ."

Based on observation, review of documents, and staff interview the CAH (Critical Access Hospital) stored food directly on the floor in 1 of 1 pantry and 1 of 1 walk in freezer. The CAH administrative dietary staff reported serving 75-80 meals per day including patients, staff, and visitors.

Failure to store food in areas other than the floor in the pantry and freezer could potentially result in contaminated food products.

Findings include:

1. Observation on 6/16/14 at 1:14 PM, with the Environment Service Supervisor/Certified Dietary Manager, revealed 1 box of Jell-O cheese cake mix containing 5 of 6 bags of mix on the floor of the dietary pantry, and I box of guacamole dip on the floor of the walk in freezer.

2. Review of the procedure titled Food Storage dated 6/1/2010, revealed Procedure 4. Storage should be 6 inches off the floor.

3. An interview with the Environment Service Supervisor/Certified Dietary Manager on 6/16/14 at 1:14 PM, agreed no food in the kitchen should be stored on the floor at any time. These items were immediately removed from the floor and placed on a shelf in the pantry and freezer.

Based on observation, review of policies and procedures, and interviews with staff, the CAH (Critical Access Hospital) staff failed to secure and protect patient information from unauthorized users in 1 of 2 outpatient clinics (Manning Healthcare Clinic). The clinic staff reported providing clinic services to approximately 100 patients a day.

Failure to secure the patient information could potentially cause a misuse of patient information and a loss of identity for the individual patients.

Findings include:

1. An observation on 6/17/14 at 9:40 AM, during the initial tour of the outpatient clinic with Staff A, Director of the Clinic revealed approximately 300 patient medical records on the nurse's desk, in a cupboard above the nurse's desk and in a room by the nurse's station. Each medical record contained patient information consisting of name, name of provider, medical record number, date of birth, age, and admit date. The medical records also had laboratory results, radiology results, and information of the visit with the provider.

2. During an interview on 6/17/14 at 9:40 AM, Staff B, Licensed Practical Nurse, stated the housekeeping staff clean the clinic area at 2:00 AM when the clinic is not staffed. The housekeeping staff would have access to the medical records and should not have access to the records.

3. Review of policy titled, Protection of Record Information, dated 5/15/2014 stated in part ..." Policy: Manning Regional Healthcare Center shall maintain the confidentiality of patient information and record information and provide safeguards against loss, destruction or unauthorized use. Purpose: 1. To ensure that only authorized persons are permitted access to records maintained by the medical records department."

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) surgery staff failed to ensure delineation of current privileges for 1 of 3 Certified Registered Nurse Anesthetists (Staff H). The CAH surgery staff reported approximately 8 procedures performed per month by Staff H.

Failure to ensure current delineation of privileges for practitioners providing services in the operating room potentially allows the practitioner to perform activities outside those that their privileges allow and places the CAH at risk for failing to ensure the continued competency of the practitioner.

Findings included:

1. Review of anesthesia providers privileges available to the surgery staff revealed Staff H's last re-appointment and privileging was dated 2/29/2012.

Review of Medical Staff Bylaws, dated 6/20/2013, revealed, in part, ". . . Appointments to the Medical Staff and grants of clinical privileges must be renewed through application for reappointment and approval of reappointment every two (2) years. . . ."

2. During an interview on 6/17/14 at 9:05 AM, Staff C, Registered Nurse, acknowledged the lack of current privileges available to the surgery staff for Staff H.

During an interview on 6/17/14 at 10:00 AM, Staff D, Chief Clinical Officer, stated the privileges on surgery for Staff H, Certified Registered Nurse Anesthetist, needed to be current.