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600 ST JOHNSBURY ROAD

LITTLETON, NH 03561

PROPER VENTILATION, LIGHTING, AND TEMPERATURE

Tag No.: C0926

Based on observation and record review, the Critical Access Hospital (CAH) failed to follow professional standards for proper temperature control for a refrigerator and salad bar within the facility's food preparation areas.

Findings include:

Review of Food Code, 2017 Recommendations of the United States Public Health Services, Food and Drug Administration, Chapter 3: Temperature, 3-202.11 (A), "... Food shall be at a temperature of 5 degrees Celsius (41 degrees Fahrenheit) or below..."

Observation on 2/15/23 at approximately 10:00 a.m. of the facility's kitchen revealed the "Produce 20" refrigerator was being used to store produce, liquid egg products, and deli meats. Further observation revealed the temperature in the refrigerator was 43 degrees Fahrenheit.

Review on 2/15/23 of the facility's Temperature Logs for the "Produce 20" refrigerator revealed that the acceptable range for temperature was 33-40 degrees Fahrenheit. Further review revealed the "Produce 20" refrigerator temperatures were above 40 degrees Fahrenheit from 2/1/23 to 2/15/23.

Observation on 2/15/23 at approximately 10:15 a.m. of the facility's cafeteria revealed a salad bar in use. Further observation revealed a container of cottage cheese with a temperature of 50 degrees Fahrenheit.

Observation on 2/16/23 at approximately 10:45 a.m. revealed the "Produce 20" refrigerator was being used to store produce, liquid egg products, deli meats, and raw chicken. Further observation revealed the temperature of the refrigerator was 44 degrees Fahrenheit.

Interview on 2/16/23 at approximately 10:50 a.m. with Staff C (Director of Culinary Services) confirmed the temperatures for the "Produce 20" refrigerator was above 40 degrees Fahrenheit and revealed that no corrective action had been taken.

Observation on 2/16/23 at approximately 10:55 a.m. in the facility's cafeteria revealed a salad bar in use. Further observation revealed a container of black beans with a temperature of 65 degrees Fahrenheit and a container of cooked chicken with a temperature of 50 degrees Fahrenheit.

Review on 2/17/23 of the facility's Temperature Logs for "Produce 20" refrigerator from 9/1/22 through 1/31/23 revealed refrigerator temperatures were above 40 degrees Fahrenheit with no documentation of corrective action taken for 27 out of 30 days for September 2022, 31 out of 31 days for October 2022, 30 out of 30 for November 2022, 31 out of 31 for December 2022, 27 out of 31 days for January 2023.

Review on 2/17/23 of the facility's policy titled "Storage Areas" reviewed July 2021 revealed, "...Procedure... Temperature in refrigeration units (34-40 degrees) ...".

Review on 2/17/23 of the facility's policy titled "Salad Bar" reviewed July 2021, revealed, " ...Procedure ... Check container of salad bar items every morning ... Protein foods except cheese, should not be kept for more than 5-7 days (keep at 41 or lower) ..."

NURSING SERVICES

Tag No.: C1046

Based on record review and interview, the Critical Access Hospital (CAH) failed to ensure a registered nurse held a current certification for Cardiopulmonary Resuscitation (CPR) for 1 out of 17 personnel files reviewed for required licenses and competencies.

Findings include:

Review on 2/16/23 at approximately 1:00 p.m. of Staff D's (Registered Nurse) personnel file revealed Staff D was hired in 2016.

Review on 2/16/23 at approximately 3:00 p.m. of Staff D's "Employee Education Record 2022-2023" revealed no current CPR certification.

Interview on 2/17/23 at approximately 8:15 a.m. with Staff F (Director of Quality) revealed Staff D was not currently certified in CPR. Interview further revealed Staff D's current job title was Clinical Supervisor and Infection Preventionist. Staff F was unable to provide any documentation of current CPR certification for Staff D.

Review on 2/17/23 at approximately 10:30 a.m. of the facility's position summary titled "Clinical Supervisor" revealed, "... Specific duties include:... 12. Provides direct patient care and patient care coverage when appropriate... Certification/Licensure: ... CPR Mandatory..."

Interview on 2/17/23 at approximately 11:00 a.m. with Staff E (Chief Nursing Officer, Vice President of Patient Care Services) confirmed Staff D's CPR expired December 2021.

RECORDS SYSTEM

Tag No.: C1104

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that records were complete and accurate for 12 of 20 inpatient records reviewed (Patient identifiers are #2, #3, #5, #6, #7, #8, #10, #11, #12, #18, #19, #20), for 2 of 18 outpatient records reviewed (Patient identifiers are #21 and #22), for 3 of 10 patient surgical records reviewed (Patient identifiers are #39, #40, and #45), and for 2 of 10 patient emergency department records reviewed (Patient identifiers are #57 and #58).

Findings include:

Inpatients

Review on 2/17/23 of Patient #3, #5, #7, #8, #10, #11, #12, #18, #19, and #20's Electronic Medical Record (EMR) revealed no documentation of a consent for treatment.

Review on 2/17/23 of Patient #2's printed consent to treat with a service date of 2/14/23, revealed a signature with no printed name, no date, and no witness signature.

Review on 2/17/23 of Patient #6's printed consent to treat revealed a signature on the witness signature line with a date of 2/13/23, no patient identifier such as the patient's name, patient's date of birth, or patient's medical record number.

Interview on 2/17/23 at approximately 12:30 p.m. with Staff A (Clinical Quality Specialist) confirmed above findings for Patient #18, #19, and #20.

Interview on 2/17/23 at approximately 2:00 p.m. with Staff B (QI, data and reporting specialist) confirmed the above findings. Staff B stated that the printed consent to treat with no patient identifier was Patient #6's consent to treat and that Patient #6's signed the consent to treat in the witness signature line and that there was no witness signature on Patient #6's consent to treat. Staff B was unable to provide any documentation of an executed consent to treat for Patient #3, #5, #7, #8, #10, #11 and #12.

Review on 2/17/23 of Patient #2's EMR revealed an EMR system triggered order for an activated healthcare power of attorney order (order date of 2/14/23) that was performed and verified by a nurse. Further review of Patient #2's medical records revealed no advance directive or healthcare proxy documentation. Review also revealed no documentation by a provider of an activated healthcare power of attorney.

Interview on 2/17/23 at approximately 12:00 p.m. with Staff B confirmed above findings on Patient #2's activated healthcare power of attorney order. Staff B was unable to provide any documentation of accurate advance directives.

Review on 2/17/23 of Patient #6 and #12's EMR revealed no code status orders.

Interview on 2/17/23 at approximately 2:00 p.m. with Staff B confirmed above findings for Patient #6 and #12.

Patient #5

Review on 2/17/23 of Patient #5's EMR revealed an order for a nutrition assessment dated 2/14/23. There were no documented nutrition assessment completed. Patient #5 was discharged to home on 2/15/23.

Review on 2/17/23 of Patient #5's History and Physical dated 2/13/23 revealed that Patient #5 had a past medical history of neurogenic bladder with suprapubic catheter and history of Urosepsis. Patient #5's admitting diagnosis was COVID-19. Further review of Patient #5's EMR revealed no orders and care plan for Patient #5's suprapubic catheter and care.

Interview on 2/17/23 at approximately 2:00 p.m. with Staff B confirmed above findings for Patient #5.


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Outpatients

Review on 2/17/23 of 18 outpatient records on 2/17/2023 revealed 2 patient records failed to include consent forms.

Interview on 2/17/2023 at 10:05 a.m. with Staff A (Clinical Quality Specialist) confirmed the consent forms were missing in 2 of 18 outpatient records.


27714


Surgical and Emergency Department patients

Review on 2/16/23 of Patient #57 and #58's EMR revealed no documentation of a consent for treatment.

Interview on 2/16/23 with Staff L (Emergency Department Clinical Director) confirmed the above finding.

Review on 2/16/23 of Operating Room medical records revealed that Patient #39 had no documentation of a consent for surgery. Further review operative room medical records revealed that Patient #40 and Patient #45's EMR had no documentation of a post-anesthesia report.

Interview on 2/16/23 with Staff K (Registered Nurse) confirmed the above finding.

INFECTION PREVENT & CONTROL POLICIES

Tag No.: C1206

Based on observation, interview, and record review, the Critical Assess Hospital (CAH) failed to label 5 of 5 opened multi-dose vials with open expiration dates in an outpatient clinic, failed to follow professional standards for Transmission Based Precaution and hand hygiene in the inpatient unit, failed to store sterile instruments properly in the Post Anesthesia Care Unit (PACU), failed to document quality control checks for the high level disinfection of endoscopes, and failed to maintain a negative pressure room in the emergency department for patients with respiratory symptoms.

Findings include:

Outpatient clinic

Observation at the Alpine Clinic, in Plymouth, Procedure Room on 2/16/23 at 9:00 a.m. revealed 5 opened multi-dose vials; 1 opened 250 milliliter (mL) multi-dose vial of 0.9 percent (%) Sodium Chloride (NaCl) (Saline, Lot# G146358, Expiration 8/23), 2 opened 30 mL multi-dose vials of 0.9% NaCl (Lot# EX2678, expiration 8/1/23), and 2 opened 10 mL multi-dose vials of Xylocaine (Lot# 6128554, Expiration 5/2024). All 5 of 5 opened multi-dose vials failed to include a revised expiration date.

Interview on 2/16/23 at 9:00 a.m. with Staff B (Quality Improvement (QI), Data, and Reporting Specialist) confirmed 5 of 5 opened multi-dose vials listed above were not labeled with a revised expiration date.


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Emergency Department

Observation 2/15/23 at approximately 10:25 a.m. in the Emergency Department revealed a red light on the pressure monitor outside of closed door for Emergency Respiratory Treatment (ERTA) Area #5, a wing in Emergency Department. A person could be heard from inside the room. Observation revealed 4 other rooms in the ERTA hallway which had green lights on the pressure monitors.

Interview on 2/15/23 at approximately 10:25 a.m. with Staff L (Clinical Director, Emergency Department) confirmed that the light outside ERTA5 was red and that there was a patient inside. Staff L revealed that The ERTA rooms are for patients who present to the Emergency Department with signs or symptoms of COVID-19 or other respiratory disease. The ERTA rooms are supposed to be negative pressure and staff would know that they are negative pressure if the light outside the door on the pressure monitor was green. Staff L revealed that maintenance was responsible for monitoring the rooms.

Interview on 2/17/23 at approximately 10:25 a.m. with Staff K (Facilities Director) confirmed that the ERTA5 room had been in the red on and off. Staff K said that they did not record the pressures for the ERTA rooms.

Observation on 2/17/23 at approximately 10:30 revalued that ERTA5 pressure monitor was red.

Record review on 2/17/23 of the chemical monitoring logs for the ultrasound probe high level disinfectant system for 10/26/22 through 2/15/23 revealed that there was no record of control testing on each new lot or shipment of solution test strips.

Review on 2/17/23 of the solution test strip manufacturer's instructions revealed the following:
"Quality Control (QC) Procedures. 1. Testing frequency. It is recommended that the testing of positive and negative control test solutions for testing, obtain an unopened bottle of high level disinfectant. Verify that the labeled expiration date for the solution is within expiration.


40522


Inpatient Unit

Transmission Based Precaution and Hand Hygiene

Standard:
Review on 2/16/23 of the Centers for Disease Control and Prevention (CDC) website titled "Type and Duration of Precautions Recommended for Selected Infections and Conditions", review date of 7/22/19, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html #C, revealed "...Clostridium difficile...Type of Precaution...Contact + [plus] Standard...".

Review on 2/16/23 of the CDC website titled, "Transmission-Based Precaution", review date of 1/7/16, retrieved from:https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html, revealed "Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. See Guidelines for Isolation Precautions for complete details...Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patients' environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens....".

Review on 2/16/23 of the CDC website titled, "Isolation Precaution", review date of 7/22/19, retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html, revealed "...IV.A. Hand Hygiene...Perform hand hygiene ~ in the following clinical situations:...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...After removing gloves...Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores...".

Observation on 2/15/23 at approximately 10:30 a.m. with Staff D (Director of Quality Services) at the Inpatient Unit revealed that outside there was a Personal Protective Equipment (PPE) cart outside of Patient #1's room.

Observation on 2/16/23 at approximately 8:50 a.m. at the Inpatient Unit revealed that Staff I (Registered Nurse) doffed PPE outside of Patient #1's room then walked towards the Omnicell (automated medication dispensing system), approximately 10 steps from Patient #1's room, without washing their hands with soap and water and spoke to another nurse then Staff I utilized the hand sanitizer.

Observation on 2/16/23 at approximately 8:58 a.m. at the Inpatient Unit revealed that Staff H (Medical Director of the Intensive Care Unit) revealed that Staff H entered Patient #1's room, with a PPE cart outside the room and a Transmission-Based Precautions (TBP) sign posted outside of Patient #1's door, with a N95 mask, donned gloves, and no gown.

Interview on 2/16/23 at approximately 9:10 a.m. with Staff G (Clinical Director of Inpatient Services) confirmed the above findings. Staff G stated that Patient #1 was on an enteric contact precaution for Clostridium difficile (C-diff).

Observation on 2/16/23 at approximately 12:38 p.m. at the Inpatient Unit revealed that Staff I entered Patient #1's room with a N95 mask, gloves, and no gown. Staff I then went out of Patient #1's room, used the hand sanitizer and did not performed hand washing with soap and water.

Interview on 2/16/23 at approximately 12:38 p.m. with Staff I confirmed the above observation related to Staff I. Staff I stated that he/she was giving Patient #1 their medications this morning at approximately 8:50 a.m. and he/she was giving Patient #1 hot packs at approximately 12:38 p.m. Staff I also stated that he/she would not need to wear a gown when there was no patient contact and that he/she would utilize the hand sanitizer for hand hygiene on a enteric contact precaution for C-diff.

Interview on 2/16/23 at approximately 1:00 p.m. with Staff D (Registered Nurse) revealed that he/she was the Lead Infection Control Preventionist. Staff D stated that all staff entering a patient's room with contact precaution for C-diff should wear, gloves, and gown. Staff D also stated that proper hand hygiene technique for patients with contact precaution for C-diff was hand washing with soap and water. Staff D also stated that they utilized the CDC and Association of periOperative Registered Nurses (AORN) for nationally recognized infection control guidelines.

Review on 2/16/23 of the facility's policy titled, Transmission Based Precaution, with no date, revealed "...Contact Precaution are used in addition to Standard Precaution...Refer to Table 1 for general information, and the CDC Appendix A for types and duration of selected infections and conditions...Contact Precaution require:...In addition to Standard Precaution..., staff must wear gloves whenever entering the room...Remove gloves before leaving the patient's room and was hands immediately with hospital-approved liquid soap and warm water...In addition to Standard Precaution...wear a gown upon entering the room to protect from contact with body fluids, environmental surfaces, or items in the patient's room...Contact Precaution...Examples of such illness include:...Clostridium difficile...".

Post Anesthesia Care Unit (PACU)

Storage of Sterile Supplies and Instruments

Standard
Review on 2/16/23 of the Guidelines for Preoperative Practices (2016 Edition), Published by the Association of periOperative Registered Nurses (AORN), revealed "...Sterilization and Disinfection...Recommendation XV Sterilized materials should be labeled and stored in a manner to ensure sterility and each item should be marked with the sterilization date...Sterile items should be stored in closed cabinets or covered carts. Open shelving may be used if it is located in a secure, environmentally controlled, clean area...".

Observation on 2/16/23 at approximately 3:30 p.m. at the closed PACU, Room 5, in the Surgical Suite revealed 5 sterilization containers, 4 with a date of 11/9/22 and 1 with a date of 2/9/23. Further observation revealed that the 5 sterilization containers were in a room with no doors, the temperature and humidity monitoring device had a temperature reading of 66 degrees Fahrenheit and humidity of 28, and the 5 sterilization containers were exposed to the temperature and humidity of the closed PACU.

Interview on 2/16/23 at approximately 3:30 p.m. with Staff J (Central Sterile Technician) revealed that the closed PACU became a storage space when the new PACU opened. Staff J stated that the 5 sterilization containers had instruments for spinal surgery inside and that they were sterilized on the dates mentioned in the label attached to the containers. Staff J was unable to provide information if the sterilization container with a date of 2/9/23 was sterilized/reprocessed before use. Staff J was also unable to provide information if Room 5 in the closed PACU was an environmentally controlled, clean area.

Interview on 2/16/23 at 3:42 p.m. with Staff K (Director of Support Services) confirmed the above observation. Staff K stated that Room 5 in the closed PACU was not an appropriate storage area for the 5 sterilization containers with sterilized instruments as it was not an environmentally controlled, clean area.

Review on 2/17/23 of the facility's policy titled, Event Related Shelf Life for Sterile Supplies and Equipment, with no date, revealed "...The policy covers all items sterilized in house...Exposure to a contaminated or unsafe environment: Items exposed for more than three hours at a temperature above 75 deg [degrees] F [Fahrenheit] and/or relative humidity exceeding 6% [percent] will be considered contaminated and reprocessed...".

Quality Control Test for Endoscopes

Review on 2/16/23 of the January 2023 channel check testing logs (3 in 1 Residual Soil Test for Internal Channels) for the endoscopes revealed no documented quality control test.

Interview on 2/16/23 at approximately 10:00 a.m. with Staff J confirmed the above findings related to the quality control test logs. Staff J stated that they would do a control test when opening a new bottle of the ChannelCheck Residual Soil Test Strip. Staff J also stated that they do not document the results of the control test. Staff J was unable to provide any documented control testing for the Rapicide (Trademark) PA (High Level Disinfection (HLD)). Staff J stated that when the endoscopes undergo high level disinfection in the machine, a printout would state "HLD PASS", which indicated that HLD was achieved for the endoscopes.

Review on 2/16/23 of the manufacturer's instruction for the ChannelCheck Residual Soil Test Strip revealed "...Instruction for Using Product...Control Test: The first step when opening a new bottle of ChannelCheck (Trademark) Residual Soil Test Strips is to check the performance of the lot with the included vial of control soil. This is to be done once per bottle and 2 control vials (1 per bottle) are included...Record Results: On a log sheet, record the results of each pad...".

Review on 2/16/23 of the manufacturer's instruction for the Rapicide (Trademark) PA test strips (HLD), revealed "...TEST STRIP VALIDATION: [brand name omitted] certifies that the test strips indicate a pass reaction with a solution mixed to a concentration of 1100 ppm [parts per million] ± 20 ppm of PAA, and indicate a fail reaction (any response other than solid black) with a solution mixed to a concentration of 850 ppm ± 20ppm. The statistical analysis and approved test procedure is on file and available for review if requested. A Certificate of Conformance is available at http://www.[brandnameomitted].com/applications/ DocumentLibrary Manager/index.asp by entering the lot number for the test strips. The customer can also verify that the reaction of the test strips by conducting the following test. Dilute one (1) part of RAPICIDE (Trademark) PA High-Level Disinfectant and Sterilant Part A with 49 parts of purified (RO) Water. The solution will develop a strip color equal to the PASS color block. Further dilute the solution by mixing three (3) parts RO water with one (1) part of the solution. The dilute solution should provide a test strip result within the range of the FAIL response block.