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800 SCHOOL ST

CARROLLTON, IL 62016

EMERGENCY AND SUPPLIES

Tag No.: C0888

Based on observation, and staff interview, it was determined the Facility failed to ensure expired supplies were not available for patient use. This failure has the potential to affect all patients, staff, and visitors serviced by the facility.

Findings include:

1. On 3/14/2022 at approximately 11:00 AM, an observational tour was conducted in the emergency room. During the tour it was noted there were expired and open sterile supplies available for immediate patient use to include the following:
a. One (1) Greenline / D LED Disposable Laryngoscope Handle with an open sterile package inside of the Crash Cart.
b. One (1) package of Quik-Combo AED, Adult Pads with an expiration date of 8-20-21 on the Crash Cart.
c. One (1) Ultra Sterile Surgical gown set, XX-large, open with all contents still inside and available for use.

2. A policy or procedure for the disposition of expired supplies was requested on 3-14-22 at approximately 12:00 PM and 3-15-22 at approximately 9:00 AM. The facility was unable to produce a policy or procedure for expired supplies.

3. During an interview on 3-14-2022 at approximately 11:30 AM, the RN/Compliance Officer (E #2) agreed the items should have been disposed of. E# 2 stated, "expired supplies and open sterile supplies should not be available for patient use".

MAINTENANCE

Tag No.: C0914

Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH) failed to ensure all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients serviced by the CAH.

Findings include:

1. On 3/15/22 at approximately 11:30 AM, a tour of the medication room (located on the medical unit) was conducted. On a shelf was a Phillips Heart Start defibrillator. The last preventative maintenance inspection of the defibrillator was conducted December 2020.

2. On 3/15/22 at approximately 11:45 AM, an interview with the Chief Executive Officer (E #1) was conducted. E #1 stated "I don't think we even use that, but it still should have been checked by the biomedical guy."

3. On 3/16/22 at approximately 3:00 PM, the CAH policy regarding preventive maintenance (policy not titled and with no revision date) was reviewed. The policy noted "All equipment specified as biomedical equipment will be inventoried and checked on a regular basis...all equipment...will be inspected no less than annually."

DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE

Tag No.: C0922

Based on observation, document review and staff interview, it was determined the CAH (Critical Access Hospital) failed to ensure that oxygen cylinders were secured safely to avoid injury, property damage or fire in the facility. This has the potential to affect all patients who receive care at the facility with a current in patient census of one patient and an emergency room average monthly census of 100 patient.

Findings include:

1. On 3/14/2022 at approximately 1:00 PM a tour of the Emergency Room was conducted with the Registered Nurse/Compliance Officer (E #2). During the tour, the following was observed in the oxygen room. One (1) full medical oxygen cylinder, one (1) full industrial helium cylinder, one (1) full liquid nitrogen cylinder, and 4 empty white cylinders were observed standing free, unsecured and failed to have a label identifying content.

2. On 3/15/2022 at approximately 3:00 PM the policy titled "Medical Gas/Liquid Storage" (revised 2/2022) was reviewed. The policy required, "To protect the patients, patrons, and staff Medical gas/Liquid cylinders will be properly stored in the proper containment devices or secured with a chain to the wall to prevent the large cylinders from falling over."

3. During an interview on 3/14/2022 at approximately 1:15 PM, E #2 verbally agreed the oxygen cylinders should have been secured in a stand or secured to the wall with chains and labeled.

RADIOLOGY SERVICES

Tag No.: C1030

Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH) failed to protect patients from radiation hazards by ensuring that shielding aprons were maintained and routinely inspected. This has the potential to affect all patients receiving x-ray imaging in the radiology department.

Findings include:

1. On 3/15/22 at approximately 11:00 AM, a tour of the Radiology Department was conducted with the Chief Executive Officer (E #1). One protective apron, used for shielding patients during x-ray procedures, was discovered to have multiple half inch cracks located on the outer body of the vest.

2. On 3/15/22 at approximately 12:30 PM, an interview was conducted with the Chief Executive Officer (E #1) was conducted. E #1 stated "That should not be available for patient use and it will be disposed of."

3. On 3/16/22 at approximately 3:00 PM, the CAH policy "X-Ray Inspection" (no revision date) was reviewed. The policy noted "Every 6 months each apron is inspected visually and also radiographed to check for defects. If any defects are found that particular apron is removed from service immediately."

NURSING SERVICES

Tag No.: C1049

Based on document review and interview, it was determined for 1 of 5 (Pt #17) patients, the Critical Access Hospital (CAH) failed to ensure verbal orders were signed by the physician per CAH policy. This has the potential to affect all patients receiving care at the CAH.

Findings include:

1. On 3/16/22 at approximately 1:00 PM, Pt #17's record was reviewed. Pt #17 presented to the Emergency Department 2/25/22 with a diagnosis of Chest Pain. The record contained verbal orders from the Emergency Room physician dated 2/25/22 that had not been authenticated (signed) by the physician.

2. On 3/17/22 at approximately 11:00 AM, the CAH policy "Verbal, Faxed, and Telephone orders" (revised 9/2008) was reviewed. The policy noted "When verbal orders are given, the order should be reviewed and signed before the prescribing member of the medical staff leaves the area in accordance with 42 CFR Part 482.24 under the Condition of Participation...Medical Record Services."

3. On 3/17/22 at approximately 11:30 AM, an interview was conducted with the Chief Executive Officer (E #1). E #1 stated "the last time that physician worked was 3/2/22 so I would have expected that to be the latest date for that verbal order to be signed."

INFECTION PREVENT SURVEIL & CONTROL OF HAIs

Tag No.: C1208

A. Based on observation, document review and staff interview it was determined the CAH (Critical Access Hospital) failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. This failure has the potential to effect all patients receiving at the facility.

Findings include:

1. On 3/14/2022 at approximately 1:30 PM, a tour of the Oxygen Room was conducted with Registered
Nurse (E #2). During the tour, dry leaves and various debris were observed on the floor of the medical
gas storage area floor that had blown into the room from an outside vent.

2. On 3/15/2022 at approximately 3:00 PM, the policy titled "Daily Cleaning" (updated 6/2020) was reviewed. The policy noted "Cleaning of non patient care areas: Storage areas are to be organized and cleaned periodically."

3. During an interview on 3/14/ 2022 at approximately 1:40 PM, E #2 observed floor and verbally agreed the floor needed to be cleaned.

B. Based on observation, document review, and staff interview, it was determined the CAH (Critical Access Hospital) failed to ensure infection control supplies were labeled properly to ensure proper disinfection of patient care areas and equipment. This has the potential to affect all patients receiving care in the emergency room, with an average monthly census of 175 patients.

Findings include:

1. On 3/14/2022 at approximately 1:00 PM, an observational tour of the Emergency Room was conducted with the Registered Nurse/Complaince Officer (E #2). In Trauma room #2, an unlabeled spray bottle contained approximately 25 fluid ounces of liquid, was observed on the shelf.

2. On 3/15/2022 at approximately 12:00 PM the policy was reviewed. The policy noted "No department or employee will use, store or allow any other person to use or store, any hazardous substance...if the container does not meet the labeling requirements, which include but are not limited to: Identify of the chemical and appropriate hazard warnings are shown on the label..."

3. During an interview on 3/14/2022 at approximately 1:15 PM, E #2 stated that a cleaner called Maxima was in the spray bottle to sanitize the room between patients. E #2 stated that the Maxima cleaner comes in a bulk container and is then transferred to a smaller spray bottle. E #2 stated the bottle should have been labeled.