HospitalInspections.org

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Based on a review of selected patient care policies and staff interview, the group of professionals failed to ensure the policies were reviewed at least annually and revised as necessary. This failed practice put patients at risk of not receiving the most recent and up to date medical interventions and best practices. The facility reported an acute census of four on the first day of the survey.

Findings:

1. Policy labeled " Infection Control Program" dated 3-2012 included the outdated terminology of "universal precautions" which was no longer the standard of care for patient isolation practices as "standard precautions" were the current recognized practice recommended by the Centers for Disease Control and Prevention. The program also used the terminology "Infection Control" which was replaced by Infection Prevention practices in 2013.

2. The undated Legionella Water Management plan had a reference of 6-5-2017.

3. The Patient Visitation Rights p0olicy had a last review date as 4-2014.

4. An interview with the Director of Nursing on 3-21- at 11:30 AM confirmed that the facility patient care policies had not been reviewed or updated.

Based on a review of the Legionella plan, staff interview and a lack of written documentation; the critical access hospital failed to implement a plan to protect patients from the potential risk of Legionella. The hospital reported four acute patients on the first survey day. This failed practice had the potential to put all patients at risk of harm.

Findings:

1. A review of the facility Legionalla Risk Assessment identified "dead leg" plumbing fixtures (fixtures that are located in underutilized areas that contain a space where water does not flow through on a regular basis) in three locations. Two were located on exterior walls outside patient rooms and one was outside the physical therapy area.

2. The plan specified that plumbing fixtures in rooms that were located in underutilized areas would be flushed twice per month and water in showers would be run for 3 to 5 minutes. This was to be completed by maintenance staff and documented on a spread sheet.

3. Interviews with the Administrator and the Director of Maintenance on 3/20/19 at 2:15 P.M. confirmed the Legionella Risk Assessment had been performed, but the identified preventative measures had not implemented.
(Legionella pneumonphila is a waterborne bacteria that can become a health problem in stagnant water in pipes in building water systems)