HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of six patients. Based on clinical record review, policy review, and staff interview, the CAH failed to assure staff follows their blood transfusion policy for the safety of patients receiving blood products for 2 of 3 patients (patient#'s 24 and 25).

Findings include:

- CAH policy "Nursing Guidelines for Blood Administration" reviewed on 5/23/12 at 12:40pm direct staff to "Sign the compatibility record. This must be done by two professionals. Professionals who sign are validating that the correct blood product is being administered to the correct patient".

- Patient #24's clinical record reviewed on 5/23/12 at 10:30am revealed an admission date 5/9/12 with diagnoses including transient ischemic attacks (mini strokes), weakness, anemia (not enough red blood cells). Patient #24's clinical record revealed Patient #24 received 2 units of packed red blood cells on 5/12/12. Patient #24's clinical record lacked evidence of two professional staff signing the compatibility record to validate the administration of the correct blood product to the correct patient.

- Patient #25's clinical record reviewed on 5/23/12 at 11:30am revealed an admission date 5/2/12 with diagnoses including anemia (not enough red blood cells), weakness and myalgia (muscle pain). Patient #25's clinical record revealed Patient #25 received 2 units of packed red blood cells on 5/2/12. Patient #25's clinical record lacked evidence two professional staff signing the compatibility record to validate the administration of the correct blood product to the correct patient.

- Administrative staff A acknowledged patient #'s 24 and 25 clinical records lacked the required documentation of two professional staff validating the correct blood product administered to the correct patient.

The CAH failed to assure the correct blood was administered to the correct patient.

Based on observations, interviews and review of documents, the CAH failed to meet the regulations that ensured the health and safety of all patients, staff and visitors as evidenced by three patient rooms and one public restroom locked from the inside with no access for staff to unlock the doors from the outside in case of an emergency. On 5/22/12 at 1:33pm, the cumulative affect of the CAH to assure a safe environment in case of an emergency resulted in a finding of Immediate Jeopardy, a situation which is likely to cause serious injury, harm, impairment or death to a patient, staff or visitor.

The CAH abated the Immediate Jeopardy on 5/22/12 at 3:30pm. All locks were removed from tub room, shower room, restroom in hallway and restroom in emergency department.

Findings include:

- The CAH failed to construct and maintain patient bathrooms and visitor bathrooms to ensure access to and safety of patients and visitors. See evidence at C-0221, 42 CFR 485.623(a).

- The CAH failed to ensure the condition of the physical plant and overall CAH environment is developed and maintained in a manner to ensure the safety and well being of patients. See evidence at C-0222, 42 CFR 485.623(b).

The Critical Access Hospital (CAH) reported a census of six patients. Based on observations and interviews the CAH failed to ensure access to and safety of all patients.

Findings include:

- The environmental tour of the CAH on 5/22/12 at 9:35am revealed a restroom in the hallway by the emergency department. The restroom lacked a call light which the patient could activate in case of an emergency in the room.

- Staff A interviewed on 5/22/12 at 2:10pm acknowledged the restroom is a "public toilet" and confirmed the room locked from the inside without a key or other means to get the door unlocked in case of an emergency. The restroom lacked a call light which the patient could activate in case of an emergency in the room.

- Staff L interviewed on 5/22/12 acknowledged the laboratory staff sends patients to that restroom to obtain laboratory samples.

- The environmental tour of the CAH facility on 5/22/12 at 9:45am revealed a patient restroom in the patient care area of the emergency department that locked from the inside without a key or other means to get the door unlocked in case of an emergency.

- During an environmental tour of the CAH facility on 5/22/12 at 11:00am a tub room and a shower room both located in the main patient care hallway had locks on the inside without a key or other means to get the door unlocked.

- Observation of survey staff on 5/22/12 at 1:10pm revealed one survey staff member locking the tub room door from the inside and activating the emergency call light switch. Staff B responded to the emergency call light within 30 seconds. Staff B paged overhead for someone from Staff C's area to call. Staff C came to the door outside the tub room by 1:15pm. Staff C said he/she was located across the street when paged. Staff C used a long straight tool to open the locked door. The locked tub room door became unlocked at 1:17pm, seven minutes after activating the emergency call system.

-Staff B acknowledged he/she did not know how to unlock the locked door to the tub room or the shower room and had to wait for Staff C to unlock the door.

- Staff C acknowledged the lock on the restroom door by the emergency department and the tub room and shower room in the main patient areas lacked a key or other means to unlock the doors.

The Critical Access Hospital (CAH) reported a census of six patients. Based on observations and interviews the CAH failed to assure patient, staff and visitor safety.

Findings include:

- The environmental tour of the CAH on 5/22/12 at 9:35am revealed a restroom in the hallway by the emergency department. The restroom lacked a call light which the patient could activate in case of an emergency in the room.

- Staff A interviewed on 5/22/12 at 2:10pm acknowledged the restroom is a "public toilet" and confirmed the room locked from the inside without a key or other means to get the door unlocked in case of an emergency. The restroom lacked a call light which the patient could activate in case of an emergency in the room.

- Staff L interviewed on 5/22/12 acknowledged the laboratory staff sends patients to that restroom to obtain laboratory samples.

- The environmental tour of the CAH facility on 5/22/12 at 9:45am revealed a patient restroom in the patient care area of the emergency department that locked from the inside without a key or other means to get the door unlocked in case of an emergency.

- During an environmental tour of the CAH facility on 5/22/12 at 11:00am a tub room and a shower room both located in the main patient care hallway had locks on the inside without a key or other means to get the door unlocked.

- Observation of survey staff on 5/22/12 at 1:10pm revealed one survey staff member locking the tub room door from the inside and activating the emergency call light switch. Staff B responded to the emergency call light within 30 seconds. Staff B paged overhead for someone from Staff C's area to call. Staff C came to the door outside the tub room by 1:15pm. Staff C said he/she was located across the street when paged. Staff C used a long straight tool to open the locked door. The locked tub room door became unlocked at 1:17pm, seven minutes after activating the emergency call system.

-Staff B acknowledged he/she did not know how to unlock the locked door to the tub room or the shower room and had to wait for Staff C to unlock the door.

- Staff C acknowledged the lock on the restroom door by the emergency department and the tub room and shower room in the main patient areas lacked a key or other means to unlock the doors.

The Critical Access Hospital (CAH) reported a census of six patients. Based on observations, interviews and review of documents, the CAH failed to establish a policy to maintain the CAH and assure patient, staff and visitor safety.

Findings include:

- The CAH lacked a policy to maintain the CAH and assure patient, staff and visitor safety from doors in the building that lock that have no means for immediate access.

- The environmental tour of the CAH on 5/22/12 at 9:35am revealed a restroom in the hallway by the emergency department. Staff A interviewed on 5/22/12 at 2:10pm acknowledged the restroom is a "public toilet" and confirmed the room locked from the inside without a key or other means to get the door unlocked in case of an emergency. The restroom lacked a call light which the patient could activate in case of an emergency in the room. Staff L interviewed on 5/22/12 acknowledged the laboratory staff sends patients to that restroom to obtain laboratory samples.

- The environmental tour of the CAH facility on 5/22/12 at 9:45am revealed a patient restroom in the patient care area of the emergency department that locked from the inside without a key or other means to get the door unlocked in case of an emergency.

- During an environmental tour of the CAH facility on 5/22/12 at 11:00am a tub room and a shower room both located in the main patient care hallway had locks on the inside without a key or other means to get the door unlocked.

- The tub room, observed on 5/22/12 at 1:10pm revealed the nurse call light activated and the door to the room locked. Staff B responded to the emergency call light within 30 seconds and acknowledged the lack of a method to enter the room to assure patient safety. Staff B paged maintenance to assist. Staff C came to the tub room door at 1:15pm. Staff C stated they were out of the building when paged. Staff C used a long straight tool to open the locked door. The locked tub room door became unlocked at 1:17pm, seven minutes after activating the emergency call system. Staff C acknowledged the nursing staff lacked a method to open the tub room door to assess a patient in the event of an emergency.

- Staff B interviewed on 5/22/12 at 1:11pm, acknowledged he/she did not know how to unlock the locked door to the tub room or the shower room and had to wait for Staff C to unlock the door.

- Staff C interviewed on 5/22/12 at 1:15pm, acknowledged the lock on the restroom door in the hallway by the emergency department, the restroom inside the patient care area in the emergency department, and the tub room and the shower room in the main patient areas lacked a key or other means to unlock the doors.

The CAH failed to provide for the protection and safety of the patients in case of an emergency.

The Critical Access Hospital (CAH) reported a census of six patients. Based on document review and staff interview, the CAH failed to assure a mid-level practitioner participates in the development, implementation and review of the CAH's policies.

Findings include:

- Policy manuals for nursing services, infection control, quality assurance, and other patient care services, reviewed on 5/23/12 at 2:00pm revealed the policy review within the last year. The medical staff, department directors, outside reviewer and administrator reviewed the policies. The manuals lacked evidence of a physician assistant or nurse practitioner participation in the review.

- Staff A interviewed on 5/23/12 at 2:00pm confirmed the CAH's documentation of policy development, review and implementation lacked evidence of a mid-level practitioner's participation.

The CAH failed to assure a mid-level practitioner participates in the development and review of policies.

The Critical Access Hospital (CAH) reported a census of six patients. Based on observation, staff interview, and directions for use of cleaning the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices to ensure staff followed acceptable standards for one of one cleaning of a discharged patient's room.

Findings include:

- Directions for use of the cleaning solution Re-Juv-Nal states " ...wet all surfaces thoroughly. Allow to remain wet for 10 minutes, the remove excess liquid. "

- Observation of terminal cleaning of patient room on 5/21/12 from 2:50pm to 3:20pm of the CAH revealed the following:

- Observation of Staff J and K on 5/21/12 at 2:50pm revealed the patient room and its contents cleaned with Re-Juv-Nal prepared cleaning solution. A clock in the patient room revealed the solution on the surfaces evaporated in less than five minutes.

- Staff J acknowledged Re-Juv-Nal cleaning solution is to stay wet on surfaces for a total of 10 minutes to work properly. Staff K acknowledged Re-Juv-Nal cleaning solution is to stay wet on surfaces for a total of 10 minutes to work properly.

The CAH failed to assure the proper use of chemicals for the disinfecting of patient care surfaces.


- Patient #14's clinical record, reviewed on 5/21/12 at 3:30pm, revealed diagnoses including "sacral wound with cellulitis (a skin infection), offending organism Staph Aureus (an infection). The diagnostic laboratory report, reviewed on 5/22/12 at 8:30am revealed a wound culture obtained on 5/10/12 and reported 5/15/12. The laboratory reported the patient has Methcillin Resistant Staph Aureus (MRSA) (an infection that does not respond to most antibiotics) and Prevotella (an infection).

Patient #14's wound care, observed on 5/22/12 at 8:35am, revealed staff E and G entering patient #14's room and washing their hands. Staff G assisted the patient to position on their right side while in bed. Staff E applied protective gloves, moved the patient's bedclothes and underclothes and washed the wound with soap and water on the washcloth. Staff E used another washcloth with water to rinse the wound. Staff E used a hair blow dryer on the low, cool setting to dry the wound. Staff E removed the protective glove and applied another pair of gloves. Staff E applied Silvadine cream (a prescription wound care cream), replaced the underclothes and bedclothes. Staff E did not wear personal protective equipment other than gloves while cleaning the wound, using a blow dryer to move air over the infected wound bed to dry it.

Patient #14's wound care, observed 5/23/12 at 9:20am, revealed staff F entering patient #14's room and washing their hands. Staff F applied protective gloves and positioning patient #14 on their right side while resting in bed. Staff F used a wet washcloth with soap to wash the wound. Staff F removed the gloves and applied another pair of gloves. Staff F then used a washcloth with water to rinse the wound. Staff F used a hair blow dryer on a low/cool setting to dry the wound. Staff F's hair moved with the air movement created by the blow dryer. Staff F applied Silvadine cream to the wound and removed the gloves. Staff F replaced the patient's underclothes and bedclothes. Staff F placed the used washcloths in the hamper in the patient's room, washed their hands and exited the patient's room. Staff F did not wear personal protective equipment other than gloves while cleaning the wound, using a blow dryer to move air over the infected wound bed to dry it.

Staff B interviewed on 5/23/12 at 9:00am and 10:30am, confirmed patient #14 has a multidrug-resistant infection and confirmed the hospital staff fail to follow their policy to place the patient in isolation and assure all staff follow precautions for the protection of themselves, other patients and community members.

The CAH's policy title "Infection control", reviewed on 5/23/12 at 3:45pm, refers to the Center for Disease Control (CDC) for instructions for the care for the patient in contact isolation.

The CDC Guidelines for "Management of Multidrug-Resistant Organisms (MDRO) on Healthcare Settings 2006", reviewed on 5/23/12 at 6:30pm, revealed V.B.6.a.i. "Implement Contact Precautions routinely for all patients...infected with the target MDRO".

The CAH failed to assure staff were protected from a patient with a known infection and failed to protect other patients from exposure to the infection.

- Tour of decontamination area in surgery, observed on 5/21/12 at 9:45am revealed the following non-cleanable surfaces:
1.) The wall above the sink for instrument processing is unsealed brick and is a porous, non-cleanable surface.
2.) The shelf above the sink contained clean mop heads and other cloth items in open bins
3.) Two large oxygen tanks and pipes which could be spattered during the processing of contaminated equipment
4.) A small rolling step stool with rust on the sides.

- Observation of the surgical suite on 5/21/12 at 9:45am revealed a foot pump machine sitting directly on the floor near the patient's head of the bed and storage for the extra parts of the surgical bed stored in uncovered bins in the southwest corner of the room. Staff H interviewed on 5/21/12 at 9:50am confirmed the items stored on the floor and the items stored without being covered in the surgery suite.

- Staff H observed on 5/21/12 at 9:55am, preparing the enzyme soaking solution for the endoscopes. Staff H acknowledged the enzyme solution is prepared with an unmeasured volume of water and an unmeasured volume of enzyme cleaner.

The manufacturer's instructions for "Endozime" enzymatic detergent (used to remove debris from endoscopes) , reviewed on 5/23/12 at 2:00pm revealed four mL (milliliters) of the chemical is to be added to one liter of warm water.

The CAH failed to use chemicals by the manufacturer's instructions and failed to assure all surfaces are cleanable.

The CAH failed to identify, report, investigate and control the potential for infections of patients and staff.

The Critical Access Hospital (CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform swing bed patients of their rights.


Findings include:


- The CAH failed to inform the swing bed patients of their right to refuse to participate in experimental research. See evidence at C-362, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patient of their right to to be notified of any charges for services not covered by Medicaid or the CAH's per diem rate. See evidence at C-363, 42 CFR 485.645(d)(1).


- The CAH failed to inform the swing bed patients of their right to choose an attending physician. See evidence at C-364, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patients of their right to be fully informed in advance about care and treatment and any changes made to their care and treatment. See evidence at C-365, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patients of their right to participate in the planning of their care unless adjudged incompetent. See evidence at C-366, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patients of their right to send and receive mail and to have access to writing supplies. See evidence at C-369, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patients of their right to visitors at any time. See evidence at C-370, 42 CFR 485.645(d)(1).

- The CAH failed to inform the swing bed patients of their right to refuse to have and use personal possessions. See evidence at C-371, 42 CFR 485.645(d)(1).

- The CAH failed to inform the five swing bed patients of their right of married couples to share a room. See evidence at C-372, 42 CFR 485.645(d)(1).

- The CAH failed to inform patients of their right to be informed if transfer or discharge might be appropriate. See evidence at C-374, 42 CFR 485.645(d)(2).

- The CAH failed to employ a qualified professional to direct the CAH's swing bed activities program. See evidence at C-385, 42 CFR 485.645(d)(4).

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to refuse to participate in experimental research (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patients of their right to refuse to participate in experimental research.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to to be notified of any charges for services not covered by Medicaid or the CAH's per diem rate (Patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the swing bed patients upon admission revealed the CAH failed to inform the patients of their right be notified prior to admission and periodically during their stay of the items and services the CAH will provide for Medicaid eligible patients, items the patient may not be charged for and the amount of any charges.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to choose an attending physician (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patients of their right to choose a personal attending physician.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to be fully informed in advance about care and treatment and any changes made to their care and treatment (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patients of their right to be fully informed in advance about their care and treatment.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to participate in the planning of their care unless adjudged incompetent (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patients of their right to participate in care planning unless adjudged incompetent.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to send and receive mail and to have access to writing supplies (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patient of their right to send and receive unopened mail and to have access to writing supplies.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to visitors at any time (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patient of their right to visitors at any time.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to refuse to have and use personal possessions (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patient of their right to have and use personal possessions.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform the five swing bed patients of their right to share a room with his or her spouse when married residents live in the same facility (patient #'s 11, 12, 13, 14 and 15).


Findings include:

- The CAH's patient's rights document reviewed on 5/22/12 at 7:30pm and given to the patient on admission revealed the CAH failed to inform patients of their right as a married couples to share a room.


- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access hospital (CAH) reported a census of five swing bed patients. Based on document review and staff interview, the CAH failed to inform patients of their right to be informed if transfer or discharge might be appropriate for five of five patients (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The Patient's Rights document, reviewed on 5/22/12 at 7 :30pm, failed to inform patient's of their right to be informed if transfer or discharge is appropriate.

- Staff A interviewed on at 5/23/12 at 12:40pm confirmed the CAH failed to inform the swing bed patients of their rights.

The Critical Access Hospital (CAH) reported five swing bed patients. Based on staff interview and document review, the CAH failed to employ a qualified professional to direct the CAH's swing bed activities program for five of five swing bed patients (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- Staff D's personnel file, reviewed on 5/23/12 at 11:30am revealed the lack of evidence they are a qualified professional to direct the swing bed activities program.

- Staff A interviewed on 5/23/12 at 1:15pm, confirmed the CAH failed to assure qualified staff direct the activities program.

The CAH failed to assure the swing bed patients are offered an activities program directed by a qualified activities professional.