HospitalInspections.org

Based on observation(s), record reviews, and interview(s), the Critical Access Hospital failed to ensure preventative maintenance was completed for 2 of 2 new pieces of equipment in use in the Emergency Department (ED).

The findings include:

Observations in ED Trauma Room #2 on 01/04/23 at 10:00 AM revealed a Bear Hugger (body warmer) unit and a Hotline Fluid Warmer Unit without an inventory and/or preventative maintenance (PM) sticker. Review of an invoice for the Bair Hugger body warmer revealed the unit was purchased by the facility and delivered on 01/14/22. Review of an invoice for the Hotline fluid warmer revealed the unit was purchased by the facility and delivered on 04/19/22. The hospital had no documentation related to required maintenance and/or preventative maintenance completed. On 01/04/23 at 1:30 PM, the Director of Nursing stated, "We have had those units for some time, and have used them on patients. I did the training on them." On 01/04/23 at 10:25 AM, the Maintenance Supervisor stated, "The units arrived last year. I did not order it, and was unaware of its existence in the ED."

Hospital policy, entitled, "Incoming Equipment Approval", revealed, "All clinical equipment entering the facility, whether it is purchased, leased, rented, loaned or returned after repair, must be given a visual inspection or electrical safety test and checked for proper operation. Equipment must be approved as soon as possible. Upon equipment approval, it shall be included into the PM(preventative maintenance) program. If included in the PM program, the equipment history record is then to be completed with all necessary information and filed in the facility's Equipment Management Manual".

Based on observations and interviews, the hospital failed to ensure the hospital was clean and sanitary in the ED and Patient Care unit for sprinkler heads, missing floor tiles, and dusty vents.
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The findings include:

Observations on 01/04/23 at 10:15 AM in the Emergency Department (ED) revealed a sprinkler head located by the nurse station, by ED room #6 and #7 with a thick accumulation of dust on the sprinkler heads.
On 1/4/23 at 10:20 AM, the Maintenance Supervisor, present during the tour, stated, "I don't clean the sprinklers. I would imagine housekeeping does it, but I wouldn't want them to do it either."

Observations on 01/04/23 at 10:30 AM in the patient care unit revealed missing floor tile, and a black substance on and around four ceiling intake vents in the hallway. On 01/04/23 at 10:35 AM, the Maintenance Supervisor stated, "We are supposed to be getting a grant to fix it, and the black substance is from the condensation when the vents sweat. This is an old building."

Based on observation(s), record reviews, and interview(s), the Critical Access Hospital failed to ensure there is proper ventilation, lighting, and temperature control in all patient areas.

The findings include:

During a tour of Patient Room #53 on 01/04/23 at 1:30 PM, the water temperature was 91 degrees Fahrenheit (F) at the sink, and 89 degrees (F) at the shower after running the water at both faucets for at 5 minutes. The Maintenance Supervisor was present and confirmed the water temperature readings. Observations of the the hospital's water heater with the Maintenance Supervisor on January 4 at 1:50 PM revealed the water heater temperature was set at 125 degrees F. On January 4 2023 at 1:55 PM, the Maintenance Supervisor stated " ...the temperature measurements are correct, but we can't help the heat loss between the water heater and the patient room(s) as the pipe runs a long distance."


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Observations on 01/03/23 at 1:28 PM in the Plant Operations building revealed a digital hot water heater temperature of 125 degrees F. Observations of the Plant Operations building on 01/03/23 at 1:30 PM revealed the temperature gauge for the water going into the hospital had a reading of 98 degrees F. On 01/03/23 at 1:32 PM, the Maintenance Director stated, "The water runs from the outside of the building, and it takes the longest to get to that side of the building because it's hardly ever used. I have contacted someone about possibly getting a water heater in the basement, but they haven't shown up yet. When it's cold outside, it does take a long time for it (the water) to heat up. I really don't know much about this system out here or these heaters. I don't know how to turn up the heater. I don't check the water in the rooms as I wasn't told that I had to". On 01/03/23 at 1:40 PM, Certified Nursing Assistant (CNA) #1 stated, "We have to cut the water on at least an hour in advance to use it. It takes that long for it to heat up".

Based on record reviews and interviews, the hospital failed to ensure it had a contract or agreement with an Activity Director to provide activities for swing bed patients.

The findings include:

Review of the hospital's contracted services on 01/03/23 at 2:45 PM revealed there was no contract for an Activity Director for swing bed patient(s). On 01/03/23 at 1:40 PM, with Certified Nursing Assistant (CNA) #2 stated, "The patient used to go across to the nursing home for activities before COVID, but has not been over there lately."

On 01/03/23 at 3:00 PM, the Chief Executive Officer (CEO) stated, "We do not have a contract with the nursing home staff because we are one organization, and therefore we do all of our billing as one. The Activities Director works for the hospital and the nursing home."

On 01/04/23 at 1:50 PM, the Activity Director stated, "I'm primarily at the nursing home and do activities over there. Patient #1 used to come over there, but hasn't since his health has declined. The staff has been facilitating activities here with the patient. The patient likes to do his/her own thing. It's been a while since I've done an assessment for the patient. There used to be an activities person over here(hospital), but he/she left. I am certified as an Advanced Activity Professional Board Certified".

Personnel record review on 01/05/23 at 11:36 AM for the Activity Director revealed there was no job description for the staff member performing the services as activity specialist for the hospital. Further review revealed the "Advanced Activity Professional-Board Certified" certificate had a renewal date of 01/31/21. During an interview on 01/05/23 at 12:20 PM with the Director of Nursing (DON) #2, the DON stated, "The Activity Director works for the nursing home and is my employee."

Based on record reviews and interviews, the hospital failed to ensure an individualized comprehensive care plan with measurable objectives and timeframes completed by an interdisciplinary group (IDG) reviewed and revised after each comprehensive and quarterly assessments for 3 of 3 swing bed patients. (Patient #1, #2, and #3)

The findings include:

Record review for Patient #1 on 01/04/23 at 12:30 PM revealed the patient was admitted to the swing bed unit on 04/01/21 to present. Review of the patient's chart revealed there was no comprehensive care plan with measurable objectives and timeframes for medical, nursing, mental, and psychosocial needs for the patient during the swing bed hospital stay.

Record review for Patient #2 on 01/04/23 at 11:00 AM revealed the patient was admitted to the swing bed unit from 09/14/22 to 10/03/22. Review of the patient's chart revealed there was no comprehensive care plan with measurable objectives and timeframes for medical, nursing, mental, and psychosocial needs for the patient during the swing bed hospital stay.

Record review for Patient #3 on 01/04/23 at 12:00 PM revealed the patient was admitted to the swing bed unit from 11/01/22 to 11/16/22. Review of the patient's chart revealed there was no comprehensive care plan with measurable objectives and timeframes for medical, nursing, mental, and psychosocial needs for the patient during the swing bed hospital stay.

On 01/05/23 at 11:23 AM, Director of Nursing (DON) #1 stated, "We don't see any activity information in the patient's charts or any care plans."