HospitalInspections.org

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Critical Access Hospital Sample Validation Survey conducted on October 3, 2016, 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 C231.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Critical Access Hospital Sample Validation Survey conducted on October 3, 2016, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated October 3, 2016.

Based on document review and interview, it was determined the Governing Body failed to ensure that the policy for therapy pool maintenance was updated to reflect current practice. This has the potential to affect all patients receiving aqua therapy.
1. On 10/5/16 at 11:00 AM, the Critical Access Hospital's policy titled "Therapy Pool Maintenance" (Effective 03/09 and reviewed 4/16) was reviewed. The policy required under, "Procedure for Disinfection and Quality of Water, 4. Not more than 3 of any 5 consecutive samples collected .... 6) Water quality readings (pH, free and total chlorine, water temperature) are recorded daily. "

2. On 10/5/16 at 2:00 PM, an interview with the Physical Therapy Director (E # 4) was conducted. E #4 stated, "No samples are collected for bacteria analysis. It is not in the manufacturer ' s guidelines. " E #4 also stated, " The facility uses Bromine instead of chlorine for disinfection and has since 2010, therefore we do not measure chlorine. This policy needs to be reviewed and updated. "

Based on document review and interview, it was determined the Critical Access Hospital (CAH) failed to follow manufacturer ' s maintenance guidelines for the physical therapy pool to prevent the potential for cross contamination. This has the potential to affect all patients receiving aqua therapy.

1. On 10/5/16 at 9:30 AM, the Hydroworx manufacturer ' s guidelines were reviewed. The " Pool Maintenance Schedule " was reviewed.
Weekly:
Check Bromine level in Brominator
Calibrate pH on CAT 2000
Clean baskets in both pumps
Clean skimmer baskets
Check alkalinity and calcium hardness surface water chemical levels.

Monthly:
Test the main breaker GFCI

Every 2 months:
Clean the tips of the sensors in the CAT 2000

Every 4 Months:
Drain and clean the pool.

2. On 10/5/16 at 9:35 AM, an interview with a Physical Therapy Assistant (PTA) (E # 3) was conducted. E #3 reviewed the recommendations. E # 3 stated that the facility does not follow the pool maintenance schedule for weekly, monthly, every 2 months, and every 4 month recommendations. E # 3 stated the facility " drains and cleans the pool 2 times a year."

3. 10/5/16 at 2:00 PM, an interview with the Physical Therapy Director (E # 4) was conducted. E # 4 reviewed the recommendations and confirmed that the facility does not drain and clean the pool every 4 months as per the manufacturer ' s guidelines.

Based on document review and staff interview, it was determined for 1 of 3 (Pt #19) patient with wounds, the nurse failed to assess the wound upon admission and with each subsequent daily dressing change. This failure has the potential to affect all patients with skin breakdown.

Findings include:

1. The procedure for "Alteration in Skin Integrity - Actual" was reviewed on 10/5/2016 at approximately 2:20 PM. The policy indicates under "Documentation: Wound assessment completed on admission, daily or with each dressing change...".

2. The clinical record of Pt #19 was reviewed on 10/4/2016 with the Director of Medical Surgical/Intermediate Care Unit (E #1) at approximately 2:00 PM. Pt #19 was admitted to the CAH (Critical Access Hospital) on 8/26/2016 with a diagnosis of cellulitis of bilateral lower extremities. Order written 8/10/16 at 2:56 PM for Wound Care1: Change dressing daily...
A. Documentation in the initial nursing assessment of 8/10/2016 at 4:10 PM stated "Lower extremities intact except noted wounds. Unable to visualize wounds due to dressings in place".
B. Documentation indicated the wound assessment which included wound measurement with dressing change was performed on 8/12/2016 and 8/26/2016. Pt #19 was admitted on 8/10/2016 and discharged 8/26/2016. Wound measurements were only completed on 2 of 16 days.

3. On 10/5/2016 at 3:30 PM, an interview was conducted with E #1. E #1 reviewed the record of Pt #19 and stated that wounds are to be assessed on admission as well as on each dressing change; assessments were not documented.

Based on document review and staff interview, it was determined for 3 of 20 (Pt's #7,
#15, and #16) patients, the Critical Access Hospital (CAH) failed to ensure medical records were accurate and complete. This has the potential to effect all patients served by the CAH.

Findings include:

1. The policy titled "Orders (Telephone, Verbal, Written, Electronic) (Approved 9/13/16) was reviewed on 10/5/2016 at approximately 12:15 PM. The policy required, "Verbal orders are to be signed before the member of the medical staff leaves the area".

2. The medical record of Pt #7 was reviewed with the Director of the Medical Surgical/Intermediate Care Unit (E #1) on 10/4/2016 at approximately 1:00 PM. Pt #7 was admitted on 10/2/2016 with the diagnosis of asthma. On 10/2/2016 at 9:40 AM a verbal order for solu-medrol 125 mg/2 ml (milligram/milliliter) 15 mg (milligram) IV (intravenous) push every 6 hours and at 9:45 AM an order for continuous IV fluids of D 5 1/2 (Dextrose) at 50 ml/hr (milliliters/hour). Both verbal orders indicated the physician signature was pending as of 10/3/2016 at 1:00 PM.

3. An interview was conducted with E #1 on 10/4/2016 at approximately 1:30 PM. E #1 stated the verbal orders should have been signed before the physician left the unit.

4. The policy titled "Confidentially/Release of Information Policy/Procedure (reviewed 7/16) was reviewed on 10/6/2016 at approximately 10:00 AM. The policy required under, "I. B. Copying of the medical record upon receipt of valid authorization. II. H. When releasing information in person to authorized individuals, positive identification must be made, i.e. driver's licence verification."

5. The document titled "Release of Information Authorization for Disclosure of Health Information" form was reviewed for Pt #15 and Pt #16 on 10/4/2016 at approximately 2:00 PM with the Health Information Manager (E #2). The areas on the form where documentation for address, telephone number, covering the periods of treatment from and to, and proof of identity "driver license number" lacked completed information.

6. An interview was conducted with E #2 on 10/5/2016 at approximately 11:30 AM.
E #2 stated "We do not have a policy of how to complete the Release of Information form, the expectation would be all the required fields be completed. This form is scanned into and becomes a part of the patients medical record. A driver's license is needed for positive verification."