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Based on observation, document review, and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure expired supplies were removed from the patient care area to avoid the potential for use. This has the potential to affect all patients receiving care in the CAH.

Findings include:

1. On 11/26/18 at 11:30 PM, a tour of the Medical Surgical Department was conducted with the Chief Nurse Executive (E #1). The following items on the emergency cart were found expired: (1) pediatric, bag valve mask, expired 03/06/2017 and (1) disposable carbon dioxide detector, expired 02/2018.

2. On 11/29/18 at 10:00 AM, a review of CAH policy "Supply/Equipment Disposal" revised 05/11/11 was reviewed. The policy required, "Procedure 1." it reads "1. Expired supplies should be taken from inventory immediately to prevent possible use."

3. On 11/26/18 at 12:45 PM, an interview with (E #1) was conducted. E #1 confirmed the pediatric bag valve mask and carbon dioxide detector were expired and explained they should have been removed from the patient care area and replaced with non-expired equipment.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-certification Survey conducted on December 12, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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 Re-certification Survey conducted on December 12, 2018, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure endoscopes were properly stored, in order to control infectious agents. This has the potential to affect all patients receiving endoscopic services in the CAH.

Findings include:

1. On 11/27/18 at 9:45 AM, a tour of the endoscopic storing room was conducted with the Director of Surgery (E #3). Two endoscopes were hanging on a metal hanger and the tips of the scopes were touching clean towels placed on the ground. Also in the room was a soiled linen container. The room was approximately 12 feet by 15 feet.

2. On 11/27/18 at 10:00 AM, an interview with the Director of Surgery (E #3) was conducted. E #3 confirmed the endoscope tips were in contact with towels laying on the ground and explained those scopes would be re-processed before use and they would no longer store the scopes that way.

B. Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure endoscopes were properly cleaned prior to patient use in order to prevent the transmission of infectious agents. This has the potential to affect all patients receiving endoscopic services in the CAH.

Findings include:

1. On 11/27/18 at 9:45 AM, a tour of the endoscopic cleaning room was conducted with the Director of Surgery (E #3). The room contained a sink used for pre-cleaning and an automated liquid chemical endoscope cleaning machine. The facility utilizes PENTAX Endoscopes. There was no evidence the endoscopes were being flushed with isopropyl alcohol.

2. On 11/29/18 at 2:15 PM The Manufactures guidelines titled, "Cleaning-Disinfection-Sterilization: PENTAX Endoscopes" required, "...flush all channels of the scope with air to purge remaining disinfectant...Dry thoroughly...after water rinsing with sterile water or bacteria free water whose microbial quality has been confirmed via monitoring. after water rinsing. 70-90% ethyl or isopropyl alcohol should be flushed through all channels, followed by compressed air... Following an alcohol rinse the following steps may be performed to aid in the drying process..."

3. On 11/29/18 at 2:00 PM, the 2016 Society of Gastroenterology Nurses and Associates, Inc. (SGNA), Standards of Infection Prevention in Reprocessing of Flexible Gastrointestinal Endoscopes" was reviewed. Under "Endoscope Reprocessing Protocol, 8. Drying" it reads "In order to ensure that endoscopes are thoroughly dried, they must be flushed with 70% to 90% isopropyl alcohol and dried with pressurized, filtered, air....."

4. On 11/27/18 at 10:00 AM, an interview with the Director of Surgery (E #3) was conducted. E #3 confirmed the endoscope were not being flushed with alcohol and stated "The representative for the scopes told us we didn't have to flush the scopes with alcohol because the detergents in the automatic cleaning machine killed all the bacteria. We used to flush the scopes with alcohol, but quit doing it when the representative told us we didn't have to." When asked which nationally recognized infection control guidelines has the Critical Access Hospital selected for its program, E #3 replied "We utilize the Association of periOperative Registered Nurses and Association for Professionals in Infection Control and Epidemiology, Inc. We do not utilize SGNA guidelines."




















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