HospitalInspections.org

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Based on observation, record review and staff interview, the critical access hospital failed to provide a safe and secure environment for the provision of patient care.
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The findings documented on the accompanying Life Safety Code survey demonstrated that the Condition of Participation for Physical Plant and Environment was NOT MET.
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Cross Reference Tag C0231

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Item #1- Equipment Maintenance

Based on observation and document review, the critical access hospital failed to maintain equipment necessary for patient care.

Failure to maintain patient care equipment, puts patients at risk from injury due to poor equipment maintenance.

Findings included:

1. The document titled "Hydrocollator Mobile Heating Units user manual", shows that units should be cleaned "usually every two weeks, using a low-abrasive bathroom cleaner."

2. On 07/26/17 at 9:05 AM, Surveyor #2 toured the physical therapy department, and reviewed the cleaning log for the department hydrocollator. The surveyor found no documentation to indicate the hydrocollator received cleaning for the months of May or June.

3. On 07/26/17 at 8:45 AM, Surveyor #2 reviewed equipment on the "crash cart" (equipment used for emergency resuscitation). The surveyor asked staff to engage the oxygen tank to assess the amount of oxygen available in the tank. Staff were unable to turn on the tank and they removed it from service at the time of the observation.


Item #2- Equipment Inventory

Based on observation and interview, the critical access hospital failed to maintain a complete inventory of all patient care equipment.

Failure to maintain a complete inventory of all patient care equipment puts patients at risk from inoperable or unmaintained equipment.

Findings included:

On 07/26/17 between 4:15 and 5:00 PM, Surveyor #2 reviewed the hospital's biomedical program with the clinical adminstrative assistant (Staff A). The surveyor asked to see maintenance history on two items in use in the physical therapy department (recumbant bicycle and arm machine). The items did not appear on the hospital's equipment inventory. Staff A confirmed that those items were not part of the inventory list.

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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.
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Findings included:
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Refer to deficiencies written on the accompanying Critical Access Hospital Fire Life Safety Code Survey, ASE Shell ID #SQ9U11.
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Based on document review and interview, the critical access hospital's governing body failed to ensure that medical staff had documented competencies for requested medical privileges.

Failure to ensure appropriate training for credentialed practitioners puts patients at risk of injury or death from practitioners working beyond their scope of practice.

Findings included:

On 07/26/17 beginning at 3:15 PM, Surveyor #2 reviewed the credentialing files for 7 physicians privileged by the governing board. One of 7 records showed the physician checked the box for "moderate sedation" which included a requirement for documented continuing education for this procedure and/or practice during residency. The file indicated that the requested privilege received an approval signature from both the Chief of the Medical Executive Committee and the Governing Body.

At the time of the review, the credentialing specialist (Staff B) contacted the credentialed physician. She stated that the physician did not know what the additional privilege request indicated, and had not intended to include moderate sedation in his practice.

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Based on document review and interview, the critical access hospital failed to ensure that its professional health care staff completed an annual review of all patient care policies.
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Failure to conduct an annual policy review puts patients at risk of unsafe or inadequate care.
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Findings included:
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1. The hospital's policy titled, "Policies, Procedures, Bylaws, Medical Staff Rules and Regulations, and Allied Health Professional Manual" Reference #060-106 dated 04/27/09, showed that policies and procedures were to be reviewed at least annually.
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2. Surveyor #1 reviewed the hospital's patient care policies and found numerous policies which had not been reviewed within the last year.
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3. On 07/26/17 at between 2:00 PM and 3:30 PM Surveyor #1 reviewed the hospital's Quality Assurance Program. During discussion regarding annual policy review with the Director of Quality and Risk (Staff C), and the Director of Nursing (Staff D), they stated that many policies had not been reviewed annually. They stated that a new policy and procedure program had been initiated and the hospital was in the process of reviewing and updating all policies and planned to review going forward on an annual basis.

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Item #1- Water Management Plan

Based on interview and document review, the critical access hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30), subject line, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires ' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings included:

On 07/27/17 at 8:45 AM, Surveyor #2 interviewed the Plant Services Manager (Staff E) about the hospital's water management plan. Staff E stated that the hospital was aware of the requirement but had not yet implemented a plan.



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Item #2- Hand Hygiene
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Based on observation, interview and review of policy, the hospital failed to ensure that staff adhered to hand hygiene (HH) standards in the flow of direct patient care.
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Failure to follow HH standards creates a risk for transmission of infection to patients, visitors and facility personnel.
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Findings include:
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1. The hospital policy and procedure titled, "Hand Hygiene" Procedure #PR 238-015 effective 05/12/16, showed that healthcare personnel were to perform hand hygiene prior to contact with the patient or their immediate care environment.
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2. On 07/25/17 at 9:50 AM, Surveyor #1 observed a registered nurse (RN) (Staff F) enter Patient #2's room to administer medication. The RN did not perform HH prior to entering the room and touched the patient and the patient's care environment prior to gloving. The RN did not perform HH prior to donning gloves and administering patient's medication.

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Based on interview and document review, the critical access hospital failed to implement actions to address deficiencies identified through the quality assurance program.
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Failure to take appropriate remedial actions to address identified deficiencies in patient care practice puts patients at risk of unsafe care.
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Findings included:
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On 07/26/17 between 2:00 PM and 3:30 PM, Surveyor #1 reviewed the hospital Quality Assurance Program. During the review, Surveyor #1 reviewed a Root Cause Analysis (RCA) for an incident that involved Patient #1 who was agitated and violent. During the incident, an Emergency Department Technician (Staff G) was injured. The RCA detailed interventions to be implemented to avoid future similar events. Each intervention was assigned to hospital staff members. The target dates for completion of actions were 05/04/17 and 05/20/17. The Director of Quality (Staff C) and the Director of Nursing (Staff D) were unable to provide evidence that assigned staff had completed ongoing monitoring of corrective action plans and fully implemented corrective actions based on the results of their evaluation.

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Based on patient record review, interview and review of the critical access hospital's policy and procedure, the hospital failed to ensure that staff obtained an order for placing a patient in manual restraints in 1of 5 records reviewed and failed to document when staff released patients from restraints in 1 of 5 records reviewed.
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Failure to document restraint orders and time of release from restraints could lead to patient harm and failure to protect patient rights.
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Findings included:
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1. The hospital policy titled, "Restraints" #PR009-006 effective 10/28/13, showed that an order for the application of restraints for management of violent behavior must be obtained within one hour of application, renewed every 4 hours for a total of 24 hours and after 24 hours a new order must be written. Additionally, the policy showed that restraints must be discontinued at the earliest possible time.
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2. Surveyor #1 reviewed the record of Patient #1 who was seen in the hospital's emergency room on 03/24/17 for agitated, aggressive, delusional and manic behavior. Review of the restraint flowsheet documented by the registered nurses on duty (Staff H and I) showed the patient arrived at 6:32 PM. Manual restraints were applied to patient's wrists at 9:51 PM to protect the patient and others from harm due to his agitation. During this time healthcare providers attempted to obtain a mental health evaluation and find appropriate placement for the patient. At 03:18 AM the patient became extremely agitated and combative and was placed in 4-point restraints. The patient remained in manual restraint until he was transferred to a different facility on 03/25/17 at 11:51 PM. Review of the provider's orders (Staff J) showed that manual restraints were never ordered for this patient.

3. The review of the record with the Director of Nursing (Staff D) showed that there were no provider orders for the initial application of manual restraints, or for continued manual restraints at 4 hour intervals and no new order after 24 hours as outlined in the policy.
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4. Surveyor #1 reviewed the record of Patient #2 who was seen in the hospital's emergency room (ER) on 02/03/17 for decreased mental status and alcohol intoxication. The patient arrived at the ER by ambulance at 7:39 PM. At 8:20 PM the patient became agitated and required restraints to protect her from harm. The patient was monitored approximately every 15 minutes until discharge at 11:20 PM. There was no entry that stated actual time of patient's release from physical restraints. There was a late entry made at 8:08 AM on 02/04/17 by the RN (Staff F) who cared for the patient during the initial placement of the restraints. It showed that restraints were released, but did not state a time.

5. The review of the record with the Director of Nursing (Staff D) showed that there was not a time documented for the release of restraints.