HospitalInspections.org

- Observation on 2/22/11 at 9: 05am revealed staff H appling protective gloves. Staff H provide personal care for patient #26. Staff H removed the protective gloves, opened the door to exit the room and opened the door to the dirty utility room to wash their hands. Staff H failed to perform hand hygiene after removing protective gloves.

- Observation on 2/22/11 at 9:00am revealed staff L cleaning a patient room. Staff L removed a reusable patient care item to the dirty utility room and wiped it with a wet cloth from a bucket of a solution. Staff L stated the solution was prepared by someone else and lacked knowledge of the contents of the bucket.

Staff B, interviewed on 2/22/11 at 2:00pm, lacked knowledge of the contents of the bucket and confirmed the bucket lacked a label.

- Staff D, observed on 2/22/11 at 2:30pm cleaning a patient's room, poured an unmeasured amount of toilet cleaning chemical into the toilet. The manufacturer's instructions for use of the chemical includes to remove the water from the toilet bowl before adding the chemical. Staff D failed to use the toilet cleaning chemical according to the manufacturer's instructions.

- Staff D was observed on 2/22/11 at 2:30pm cleaning a patient room following the patient's discharge. Staff D exited the patient room, removed protective gloves and failed to perform hand hygiene. Staff D then entered the clean utility room and obtained clean linens. Staff D failed to perform hand hygiene after removing protective gloves. Staff D returned to the linen storage area and removed additional linens without performing hand hygiene.

- Observation on 2/16/11 at 10:30am, revealed a child's crib with torn seams on the mattress and rust on the frame and mattress support. Staff B, interviewed on 2/22/11 at 10:30am confirmed the non-cleanable surfaces.



21996

Based on observation, policy review, document review, and staff interview the Critical Access Hospital (CAH) failed to identify infection control issues and implement actions to prevent the potential spread of infection.

Findings include:

- Review of the CAH's policy, "Hand and Nail Hygiene", on 2/23/11 at 3:00pm directed staff to perform hand hygiene before and after wearing gloves. Review of the anesthesia department policy titled, "Hand Hygiene", on 2/23/11 at 2:55pm directed staff to perform hand hygiene before and after removing gloves and after blowing or wiping the nose.

- Observation on 2/22/11 at 10:15am in the recovery room revealed staff E brought a patient from the procedure room to the recovery room wearing gloves they had on in the procedure room. After giving report to the staff in the recovery room, removed gloves and went to the pre-operative area, put on clean gloves to access a patient, and then removed their gloves. Staff E failed to perform hand hygiene before and after wearing the gloves.

- Observation on 2/22/11 at 11:35am in the recovery room revealed staff E brought a patient from the operating room to the recovery room wearing gloves they had on in the operating room. Staff E removed their face mask, wiped their nose with a Kleenex, left the recovery room, went to the operating room, retrieved a medication off of the anesthesia cart, came back to the recovery room, gave the intravenous (IV) medication to the patient and removed their gloves. Staff E then went to the pre-operative area, put on clean gloves and started an IV cannula (a needle in the patient's vein) and removed their gloves. Staff E failed to perform hand hygiene before and after wearing gloves and wiping their nose with a Kleenex.

- Observation on 2/23/11 at 10:10am revealed, Staff G entered an isolation room to clean with universal protective equipment on (disposable cap, mask, disposable gown, and gloves). During the process of cleaning the room from 10:10am to 10:25am staff G left the room to retrieve supplies from the cleaning cart in the hall five times without removing the protective equipment before leaving the isolation room or putting on clean protective equipment when they reentered the isolation room.

Staff A interviewed on 2/23/11 at 10:30am acknowledged staff G failed to remove the protective equipment before leaving the isolation room and did not put on clean protective equipment when entering the room.

- Random observation on 2/21/11 at 9:30am revealed a staff person from housekeeping leave room #2 with gloves on, retrieve a mop and garbage bag from the cleaning cart in the hall. The housekeeping staff person took the garbage bag to room #1 and then walked into room #2 with the mop. The housekeeping staff person failed to remove their gloves when they left room #2, perform hand hygiene or put on clean gloves when they entered another patient's room

- Random observation on 2/21/11 at 1:00pm revealed a staff person from housekeeping leave room #3 with gloves on. The housekeeping staff person placed supplies on the cleaning cart in the hall and retrieved some supplies from the cleaning cart and walked back into room #3. The housekeeping staff person failed to remove the gloves, perform hand hygiene, and put on clean gloves.

- Document review of the disinfectant "pH7Q Ultra" manufacturer's guidelines on 2/23/11 at 3:30pm instructed the solution can be applied with a cloth, mop, sponge or spray and let the solution remain on the surface for a minimum of ten minutes. Rinse or allow to air dry.

- Document review of the toilet bowl cleaner/disinfectant, "CBC Plus", manufacturer's guidelines on 2/23/11 at 3:30pm instructed to clean and disinfect toilet bowls remove water from bowls. Remove excess water from applicator and pour one ounce of "CBC Plus" on applicator. Allow to remain 10 minutes.

- Observation on 2/23/11 at 10:10am of Staff G cleaning a room, revealed staff G using "pH7Q Ultra" disinfectant solution. Staff G wiped the bedside table, sink, night stand, and chairs, and other flat surfaces. These areas remained wet for a contact time of three to five minutes, not the required ten minutes. Staff G cleaned the toilet bowl with the "CBC Plus" toilet bowl cleaner/disinfectant by squirting an unmeasured amount of the solution into the toilet bowl and swishing with a toilet bowl mop. Staff G failed to remove the water from the toilet bowl and measure the amount of the solution squirted into the toilet bowl per recommendations of the manufacturer.

Staff A interviewed on 2/23/11 at 10:30am acknowledged the surfaces cleaned with the "pH7Q Ultra" need to remain wet for ten minutes to achieve disinfection, and the toilet bowl cleaning did not follow the manufacturer's recommendations.

Based on clinical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure providers sign verbal/telephone orders and date and time all entries in the medical record when authenticated for 10 of 21 patient medical records reviewed (#'s 13, 14, 15, 16, 17, 18, 19, 20, 22 and 26).


Findings include:

- Patient #26's clinical record revealed an admit date of 5/16/08 to a swing bed with diagnoses including dementia and stroke. The record revealed 12 physician orders given verbally or by telephone between 9/13/10 and 1/26/11. The CAH failed to ensure the physician signed the 12 orders. Interview with Staff B and I on 2/16/11 at 11:20am confirmed the lack of authentication by a physician.


- The Medical Staff Rules and Regulations, reviewed on 2/23/11 at 2:50pm revealed "Section II, List of Rules and Regulations II" revealed "...orders shall be authenticated by the prescribing or attending Practitioner within seventy-two (72) hours".





21996

- Patient #17's medical record reviewed on 2/21/11 revealed an admit date of 2/16/11. Patient #17's medical record revealed between the dates of 2/17/11 to 2/21/11 , two orders written by the provider, three telephone orders and one standing order, and four progress notes, that lacked a date and/or time when signed by the provider.

- Patient #20's medical record reviewed on 2/22/11 revealed an admit date of 2/11/11. Patient #20's medical record revealed between the dates of 2/11/11 to 2/21/11, six orders written by the provider, ten telephone and/or verbal orders, one set of admission orders, and three progress notes that lacked a date and/or time when signed by the provider.

This deficient practice also affected patient #'s 13, 14, 15, 16, 18, 19, and 22.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to be informed of their health information in a language they understand (patient #26).

Findings include:

- The CAH's patient's right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to be informed in a language they understand of their health status and medical condition.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to refuse to participate in research (patient #26).

Findings include:

- The CAH's patient's right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to refuse to participate in research.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to choose an attending physician (patient #26).

Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to choose an attending physician.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to participate in planning care and treatment or changes in care and treatment unless adjudged incompetent (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to participate in planning care and treatment or changes in care and treatment unless adjudged incompetent.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to personal privacy (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to personal privacy.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to perform or refuse to perform work (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to perform or refuse to perform work.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to access writing equipment and to send and receive unopened mail (patient #26).

Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to access writing equipment and to send and receive unopened mail.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to receive visitors (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to receive visitors.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to retain and use personal property (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to retain and use personal property.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.

The Critical Access Hospital (CAH) reported a census of 1 swing bed patient. Based on document review and staff interview, the CAH failed to inform their one swing bed resident of their right to share a room with their spouse (patient #26).


Findings include:

- The CAH's patient right document reviewed on 2/21/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #26 of their right to share a room with their spouse.

- Staff B and J, interviewed on at 2/21/11 at 3:40pm confirmed the CAH failed to inform the swing bed patient #26 of their rights.