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CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on August 7-8, 2013 the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see C 231

STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on August 7-8, 2013 the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

See Life Safety Code deficiencies that were cited Also see C220.

Based on review of policy and procedure, observation, and staff interview, it was determined the CAH failed to ensure a system for controlling infection was maintained in the Surgery Department, by ensuring that all emergency respiratory equipment was maintained in a sealed sterile package until needed for use and that single use items were discarded after use and anesthesiology carts were cleaned in accordance with CAH policy. The cumulative result of the failed practices has the potential to affect 100% of the surgical patients, both inpatient and outpatient, serviced by the CAH. As a result of failure to comply with CAH policies, patients are at risk of developing potential infections due to failure of the CAH to keep anesthesia carts cleaned and single use sterile supplies sealed in their original packaging until ready to use and then discarded after each surgical case.
Findings include:

1. The policy "Anesthesia Equipment", revised 12/2011 was reviewed on 9/12/13. Under "PROCEDURE: D. Oral airways, endotracheal tubes, suction catheters should be disposed of after each patient use."

2. The policy "Anesthesiology - Infection Control Guidelines", revised 8/2012, was reviewed on 9/11/13. Under "Equipment and Materials 2. Anesthesia Carts: The top, front, and sides of the cart shall be wiped with a hospital-approved disinfectant. Blood and secretions shall be wiped off promptly. On a monthly basis, the entire cart will be cleaned, all equipment removed, the drawers washed with a hospital-approved detergent and water and then wiped with alcohol by anesthesia providers."

3. A tour of the Surgery Department was conducted on 9/11/13 at 2:00 PM. This surveyor was escorted by E #1 and E #2. In the Anesthesia Room, there were two anesthesia carts. On top of one cart was a surgical cloth covering an opened laryngoscope handle with a blade and 2, opened, 12 cubic centimeters syringes. The outside of the cart had large amounts of dust on the horizontal surfaces. The second anesthesia cart observed in the Anesthesia Room had large amounts of dirt/dust on horizontal surfaces.

4. A staff interview was conducted with E #1 and E #3 on 9/11/13 at 2:30 PM. E #1 confirmed one anesthesia cart had an opened laryngoscope handle with blade and 2 opened syringes and both anesthesia carts contained dirt/dust on horizontal surfaces.

5. A staff interview was conducted on 9/11/13 at 3:30PM with 2 housekeeping staff members who were performing a terminal cleaning of a surgical suite. When inquired who does the cleaning of the anesthesia carts the 2 housekeeping staff stated "we assumed anesthesia."

6. A staff interview was conducted with E #3 on 9/12/13 at 8:00 AM. E #4 and E #1 were present during the interview. E #3 was aware that all single use items should be discarded after use. E #3 confirmed that single use supplies are opened a few minutes before surgery cases begin but was not aware of single use items being opened hours before surgery cases. E #3 was not aware that Anesthesia personnel were responsible for cleaning the anesthesia carts and was not aware the carts had dust/dirt on the horizontal surfaces. E #3 confirmed there was no documentation to indicate the anesthesia carts had ever been cleaned according to CAH policy.