HospitalInspections.org

Based on review of manufacturer's recommendations, facility documents, observation, and staff interview, it was determined the Administrator failed to ensure that glucometer controls and test strips were labeled with an open date and expiration date and expired glucometer controls and test strips were removed and not available for use in patient care. This deficient practice poses a potential risk to the health and safety of patients if expired glucometer controls are used leading to false and inaccurate blood glucose readings and leading to improper treatment which could cause hypo/hyperglycemic episodes, injury, or death.

Findings include:

Review of the manufacturer's recommendations titled, "Accu-Chek Inform II Instructions for Use (IFU)", revealed: " ...Write the discard date on the bottle label. The control solution is stable for 3 months after opening or until the Expiration date on the bottle label ...."

Hospital document titled, " Accu-Chek Inform II Skills Annual Competency", revealed: " ...instructing the staff that controls must be dated when opened, expire in 3 months after the date the bottle was opened, and expire on the date printed on the vial if before the open date ...Skills checklist reveals: " ...Understands that controls expire 3 months from opening and ensures that the open expiration date is written on the control solution ...."

Observation during tour conducted on 05/06/2025 revealed 2 Accu-Chek Inform II test strips and controls with no documented open date or expiration date on the controls or test strips in both the Acute Care Unit and the Operating Room.

Employees #1, #17, and #20 confirmed the Controls and Test strips bottles must be labeled to identify when to remove the equipment from patient care use.

Based on review of policies/procedures, documents, staff interviews, and observations, it was determined the administrator failed to ensure that the wheelchairs were inspected for rips and tears; and safe handles were used and cleaned in between patient usage. This deficient practice poses a risk to patient health and safety of patients and employees.

Findings include:

Policy titled, "Cleaning, Disinfecting, and Sterilizing of Patient Care Equipment" revealed: " ...non-critical items: Items which normally contact intact skin only (e.g., wheelchairs ...will be cleaned with the hospital-approved disinfectant between use ...Nursing staff is responsible for cleaning patient equipment if soiled/contaminated while in use ...."

Policy titled, "Infection Control" revealed: " ...Cleaning/Disinfection/Sterilization ...All patient care items must be clean. Wash with a detergent and rinse with water if soiled ...Articles which contact mucous membranes or non-intact skin must be disinfected or sterilized prior to reuse if not disposable ...."

Policy titled, "Environmental Services Scope of Service" revealed: " ...Adequate housekeeping chemicals and supplies are made available to patient care areas for sanitizing and cleaning by hospital staff when housekeeping staff are not scheduled ...In addition, maintenance repairs/needs are identified and reported for all areas. Work orders submitted in Maintenance tracking system ...."

Observation conducted on 05/06/2025, revealed 4 black wheelchairs in Lobby and Emergency Room area had rips and tears in the seats. During observation revealed: 3 wheelchairs with broken hand grips. Two (2) of the wheelchairs had exposing sharp metal from the broken hand grips and 1(one) wheelchair had red colored Coban wrapped and no hand grips.

Employee #1 confirmed during observation and interview 05/06/2025, that chairs are to be cleaned between patients' use and the wheelchairs should have been taken out of use. Employee #1 confirmed patients sit in these chairs from Lobby, Acute care, and Emergency room.

Employee #19 confirmed all public areas are thoroughly cleaned nightly with disinfectant, if items are functional, we still use them. Housekeeping observes the wheelchairs and reports rips and tears to Maintenance for removal.

Employee # 4 and #5 confirmed ripped and torn items cannot be thoroughly cleaned and must be replaced.

Based on record reviews and staff interview, it was determined the facility failed to ensure the medical staff bylaws and medical staff rules and regulations were reviewed and updated every three years. This deficient practice poses a potential risk of medical staff members not knowing the updated requirements for privileges, and their responsibilities in quality patient care services that meet current hospital, State, and Federal standards.

This is a repeat deficiency from Event #93JH11 on 01/11/2022, Tag 0962.

Findings include:

Hospital document titled, "Restated Bylaws of the Medical Staff of Community Hospital Associations, Inc. dba Wickenburg Community Hospital and Clinics," revealed last revision date of 07/23/2019.

Hospital document titled, "Medical Staff Rules and Regulations for Wickenburg Community Hospital," revealed: " ...General ...These rules and related Hospital policies are designed to comply with standards of state and federal regulatory agencies, federal Medicare and Medicaid programs. All patient/resident care and related activities in the Hospital will be conducted in a manner consistent with these rules, Hospital policies and the indicated standards ...." The document also revealed last revision date of 06/23/2008.

Review of the Plan of Correction submitted to the Centers for Medicare & Medicaid Services dated 02/23/2022, revealed: " ...The WCH Medical Staff Committee will review and modify the WCH Medical Staff bylaws and Rules and Regulations. The WCH Medical Staff Committee meets on a quarterly basis and will review and approve the bylaws and rules and regulations at the July 12, 2022 Quarterly Medical Staff meeting. The WCH Board of Directors will hold a special meeting in July 2022 to review and approve the WCH Medical Staff bylaws and rules and regulations ...."

Employee #1 confirmed during an interview conducted on 04/29/2025 that the provided medical staff bylaws, and medical staff rules and regulations are the most current approved documents. Employee #1 confirmed legal counsel were consulted on the content of the documents, but the governing body had not approved any revisions. Employee #1 confirmed the medical staff bylaws, and rules and regulations are outdated.

Based on a review of hospital records and staff interviews, it was determined the administrator failed to follow restraint policies and procedures for three (3) patients (Patient #3, Patient #4, Patient #5). This deficient practice poses a threat to the public's health and compromises the patients safety in following the proper protocols for restraints.

Policy titled, "Restraints And Seclusion Policy," revealed: "...A. Authorizing and Ordering Restraints and Seclusion ...2. All Restraint or Seclusion orders must be dated and timed when signed by the Licensed Practitioner responsible for the care of the patient and include: 1) criteria for release ...4) and specify duration of Restraint or Seclusion order ...7. Violent/Self -Destructive Restraints a. For Restraints used to manage Violent or Self-Destructive Behavior, a licensed Practitioner responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of Restraint or Seclusion ...The in-person evaluation and documentation must include: i. Evaluation of patient ' s immediate situation , ii. Patient reaction to the intervention ...a. A face-to-face physical examination is required by the Licensed Practitioner responsible for the care of the patient and authorized to order Restraints or Seclusion every 24 hours for violent/self-destructive restraint to determine the clinical justification for the continued use ...3. When Restraint or Seclusion is used, there must be documentation in the patient ' s medical record of the following ...g. Date and time of Restraint or Seclusion discontinuation...1. A patient in 3- or 4-point restraints shall have continuous observation/monitoring ...Care will not be compromised by the use of Restraints and shall include: a. Provision of nutritional needs, b. Provision of hydration needs, c. Provision of elimination needs, d. Provision of hygiene needs, e. Provision of range of motion exercises, f. Provision of patient safety and comfort, and...."

Document titled, "Medical Staff Rules and Regulations for Wickenburg Community Hospital," revealed "...O. Restraints:...The use of a restraint or seclusion must be- -...(2) In accordance with the order of a physician or other licensed independent practitioner permitted by the State and Center to order seclusion or restraint ...The time any restraint is initiated, the behavioral basis for doing so ...the time it is discontinued shall be documented in the patient record ...The condition of the patient who is in a restraint or in seclusion must continually be assessed, monitored, and reevaluated...A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention ...."

Document titled, "Registered Nurse (RN)," revealed "...Appropriately documents in the electronic health record all assessments, interventions, and other information as required ...Performs physical/social assessment on assigned patients; accurately perceives patient condition changes or complications through effective assessment skills ...."

Document titled, "Restraint Checklist," revealed: "...It is recommended that a restraint Checklist be completed with any restraint use ...6. Documented Time of restraint removal: Date:... Time:...."

Patient #3's medical record contained a note titled "Order Sheet," dated 10/18/2024, which revealed: "...Restraints (soft) (Monitor/document every 15 mins ...Orders expire in 4 hours ...."

Patient #3's medical record failed to contain documentation of a face to face.

Patient #3's medical record failed to contain documentation of monitoring of Patient #3 while in four point restraints.

Further review of Patient #3's medical record failed to contain criteria for release.

Patient #4's medical record contained a note titled "Order Sheet," dated 06/09/2024 which revealed: "...Restraints (soft) (Monitor/document every 15 mins, Restraint 2 point) (Protect pt. from immed. injury, Orders expire in 4 hours...."

Patient #4's medical record failed to contain documentation of a face to face.

Patient #4's medical record failed to contain a completed restraint checklist identifying restraint removal.

Further review of Patient #4's medical record failed to contain criteria for release.

Patient #5 's medical record contained a note titled "Order Sheet," dated 02/13/2025 which revealed: "...Restraints (soft) (Restraint 4 point) (Protect pt. From immed.(sic) injury)...."

Patient #5's medical record failed to contain documentation of a face to face.

Patient #5's medical record failed to contain documentation of monitoring of Patient #5 while in four point restraint.

Further review of Patient #5 ' s medical record failed to contain the duration of restraints in restraint order.

Further review of Patient #5's medical record failed to contain criteria for release.

Employee #13 confirmed during an interview conducted on 04/29/2025, that a face-to-face should occur with a physician an hour after the restraints are applied.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be a criteria for release documented for the restraints applied to the patients.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be a specified length of time the restraints are kept on the patient in the order.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there needs to be reassessment of the patients in restraints.

Employee #13 confirmed during an interview conducted on 04/29/2025, that a restraint checklist is completed for each patient that is in restraints.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no documentation of restraint removal. Employee #13 also confirmed during the interview that nurse added an addendum to Patient #4 ' s medical record approximately eight hours after Patient #4 was transferred to remove restraints.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there was not a duration specified time to release restraints documented in the order for Patient #5.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no reassessments documented for Patient #3 and Patient #5.

Employee #13 confirmed during an interview conducted on 04/29/2025, that a face-to-face was not documented in the medical records for Patient #3, Patient #4, and Patient #5.

Employee #13 confirmed during an interview conducted on 04/29/2025, that there was no indication documented for the criteria of release for Patient #3, Patient #4, and Patient #5.

Based on record reviews and staff interview, the Department determined the nursing staff failed to ensure the facility's Fall Prevention policy was by failing to notify four (4) patients' ( #18, #19, #20, and # 21) emergency contact after a patient fall. This deficient practice poses a risk to a patient safety if a patient's family member or emergency contact is not notified after a fall leading to delay time-sensitive medical decisions, prevent the care team from obtaining important background information, and reduce necessary family involvement in monitoring and supporting the patient's recovery.

FINDINGS INCLUDE:

Policy titled,"Fall Prevention", revealed: "...POLICY: The purpose of this policy is to:... Establish guidelines to define action in the event of a fall and complete the required follow-up ...Notification after a patient fall includes:... Patient's emergency contact ...."

Hospital documents titled Investigation Reports revealed:

Patient # 18's investigation report revealed no documentation that the emergency contact was
notified after patient fall.
Patient # 19's investigation report revealed no documentation that the emergency contact was
notified after patient fall.
Patient # 20's investigation report revealed no documentation that the emergency contact was
notified after patient fall.
Patient # 21's investigation report revealed no documentation that the emergency contact was
notified after patient fall.

Medical records revealed:

Patient # 18 s medical record dated 10/06/2024 revealed no documentation that the emergency
contact was notified after patient fall.
Patient # 19's medical record dated 07/26/2024 revealed no documentation that the emergency
contact was notified after patient fall.
Patient # 20's medical record dated 03/07/2025 revealed no documentation that the emergency
contact was notified after patient fall.
Patient # 21's medical record dated 02/03/2025 revealed no documentation that the emergency
contact was notified after patient fall.

Employee #4 confirmed while reviewing medical records and investigation reports on 04/28/2025, there was no documentation regarding family notification for Patients #18, #19, #20, and #21.

Based on facility records, Title 9 Chapter 8 Article 1, Observation and interview, it was determined the facility failed to ensure all staff wore proper hair coverings while working in the dietary department/kitchen. This deficient practice poses a risk to the health of staff, patients, and visitors when staff do not maintain sanitation practices by preventing hair from contacting exposed food, clean equipment, utensils, and linens.

Findings include:

Policy titled "Dress Code" revealed: " ...POLICY: Food Service employees will dress for work in clothing suitable to the image and sanitation needs of the department. These requirements will be in addition to the facility-wide policy ...PURPOSE: To ensure all Food Service employees maintain a professional and clean appearance, protect themselves from injury, and reduce the risk of cross-contamination ...PROCEDURE: ...Hair Covering: For hair shorter than 1 ½ inches, you must wear a hair net or ball cap. For hair longer than 1 ½ inches, hair must be pulled back and secured in a hair net so there is no possibility of hair contaminating food ...."

Document titled, "Title 9 Health Services Chapter 8 Department of Health Services, Food, Recreation and Institutional Sanitation. Article 1 Food and Drink", revealed: "...Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single services and single use articles ...."

Observation conducted on 04/29/2025 revealed that Employee # 16 was not wearing any beard restraints while working in the kitchen preparing food.

Observation conducted on 04/30/2025 revealed a dietary worker with hair longer than 1 ½ inches wearing her hairnet on the upper part of her head with hair on the lower part of her head was exposed.

While on tour of the kitchen, surveyors were told by employee # 24, that the surveyors did not have to wear a hair net in the kitchen area. Employee # 24 was not wearing a hair net or the required beard restraints.

Employee # 1 confirmed during an interview conducted on 04/28/2025, that all dietary employees working in the kitchen are required to wear the proper hair coverings. There is signage posted on the door to remind all who enter that proper hair coverings are required.