HospitalInspections.org

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on November 1, 2020, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on November 1, 2020, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated November 1, 2020.

Based on document review, and staff interview, it was determined for 2 of 4 (Pt #15, Pt #20) patients with wounds, the Critical Access Hospital (CAH) failed to ensure the nursing care plan addressed skin integrity issues. This has the potential to affect all patients receiving services with wounds. (Current census of 2)

Findings include:

1. On 11/18/2020 at 1:30 PM, the medical record of Pt #15 was reviewed. Admission Date: 10/21/2020; Diagnoses: Weakness. "Physical Assessment" on 10/10/2020, indicated wounds on the buttocks was abrasions from a fall at home. The "Problem List" (Care Plan) did not address those wounds.

2. On 11/18/2020 at 3:00 PM, the medical record of Pt #20 was reviewed. Pt #20 was admitted to the hospital on 8/11/20 with diagnoses of rhabdomyolysis, pancreatic cancer and developmental disability. Documentation in the nurse notes dated 8/12/20 is: "notified by CNA (certified nurse assistant) that pt. has a decub (decubitus) on coccyx. Area assessed and measured there is a 6 cm (centimeter) X 3.5 cm area on the coccyx." Documentation in the "Problems/Goals" indicates "Problem 1, Skin Integrity, actual impairment." There is no intervention in the care plan for the treatment of the decubitus ulcer on Pt #20's coccyx.

3. On 11/18/2020 at approximately 2:45 PM, an interview with the Chief Nursing Officer (E #1) was conducted. E #1 confirmed that Pt #1's medical record had documentation of wounds to the buttocks, and that the plan of care did not address the wounds. E #1 stated "The plan of care should have addressed the patient's wounds."

4. An interview was conducted with Chief Nursing Officer (E#1) on 11/19/20 at 8:45 AM. E#1 reviewed the record of Pt #20 and reported there was no intervention for care and stated "the documentation of the wound is inconsistent." E#1 agreed the care plan should have included physician orders and interventions related to decubitus ulcer and overall skin integrity.

5. On 11/18/2020 at approximately 4:00 PM, CAH policy "Skin Integrity Program: Prevention, Pressure Ulcer Care and Wound Protocol" (no revision date), was reviewed. Under "Policy" it reads "Skin integrity assessment is initiated on admission. An appropriate program of skin care is followed during the patient's hospital stay. A Registered nurse will assess the level of skin integrity; implement any ordered skin care program...." "Provide intervention that: 3. Enhances healing of skin that has been impaired."

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure the Surgical Department (SD) staff maintained acceptable dress standards to prevent and control the transmission of infections. This has the potential to affect all patients receiving care in the OR. (approximately 37 cases a month)

Findings include:

1. On 11/17/2020 at approximately 3:30 PM, a tour of the Surgical Department was conducted while being escorted with the Chief Nursing Officer in training (E #2). SD Registered Nurse (E #3) had piercing in the nose.

2. On 11/18/2020 at 10:00 AM, CAH policy "Dress Code" revised 11/8/19 was reviewed. Under "2.c" it reads "Aside from earrings, jewelry may not be worn in any visible body piercing including, but not limited to, piercing's in the tongue or nose."

3. On 11/18/2020 at approximately 10:15 am, an interview with the Chief Nursing Officer (E #1) was conducted. E #1 stated "Nose Piercing's are not allowed to be worn by staff while in the hospital." At 10:20 am, E #1 confirmed that E #3 was wearing a nose piercing in the Surgical Department.