HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to ensure the Important Message from Medicare was received and signed before discharge for 3 of 5 swing bed patients (Patients 32, 34 and 36) reviewed. This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 2022 was 64.

Findings are:

A. Review of Patient 32's medical record (7/13/22 at 7:00 AM) revealed a swing bed admission of 1/10/22-1/13/22 for weakness and strengthening related to fall with left arm fracture. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare delivered and signed before discharge.

-Review of Patient 34's medical record (7/13/22 at 7:35 AM) revealed a swing bed admission of 3/11/22-3/21/22 for chronic lower back pain with inadequate pain control. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare delivered and signed before discharge.

-Review of Patient 36's medical record (7/13/22 at 8:15 AM) revealed a swing bed admission of 6/18/22-7/1/22 for post-hip fracture therapy. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare delivered and signed before discharge.

B. Review of policy and procedure titled Utilization management guidelines (Last Approval 10/21) revealed "Swing Bed: ...3. If the patient is changing from inpatient, a notice is provided to the patient/family via the "Important Message from Medicare"."

C. Interview with the Chief Operating & Quality Officer (7/13/22 at 1:30 PM) confirmed the above medical records lacked evidence of an Important Message from Medicare notice as per facility policy and procedure.

Based on staff interviews and record review, the facility failed to prevent and control the transmission of potential infections related to Legionella as evidenced by lack of any internal policy/system to continually assess and promote water safety to prevent the growth of Coliform spore bacteria that promotes Legionella growth which can cause Respiratory infection known as Legionnaire's Disease. This failed practice had the potential to affect all patients and patrons of the hospital campus. The facility served the community with Emergency Care, Acute Care, Delivery of newborns, a primary care clinic, an outpatient specialty clinic, a cafeteria open to the community for Breakfast and Lunch (Monday- Friday) and a community YMCA attached to the hospital open 7 days per week for members and visitors. The 2020 population of Gothenburg was listed as 3469 - which did not include all the rural area patients/patrons/customers that utilize services at the Hospital campus.

Findings include:

Tour of the facility with Maintenance Supervisor (MS) and Chief Nursing Officer (CNO) on 7/12/2022 from 10:15am - 11:00am revealed that regular (weekly) flushing of water fixtures was not being completed by any staff members through out the two story facility including a community YMCA attached to the Hospital. Interview with MS during tour revealed no knowledge of any flushing by any staff on a weekly basis. No documentation was provided that any department was conducting weekly water safety flushing.

Review of documents provided on 7/13/2022 revealed that a water safety management company Garrett Callahan (GC) was contracted on 11/6/2020 for onsite testing of 10 areas annually. An onsite test report from 12/28/2021 revealed 10 area location water samples were taken. The Laboratory Analysis report titled "LEGIONELLA TEST RESULTS SUMMARY LOG"
showed Five (5) of the 10 (ten) areas sampled had positive (+) Coliform (CFU - Coliform unit) totals.
(Coliform microbiology definition - rod shaped Gram-negative nonspore forming bacteria that can ferment lactose with the production of acid and gas when incubated at 35-37 degrees Celsius (95-98 degrees Fahrenheit) - and used as an indicator for food and water sanitary quality - with high CFU levels creating a potential for spread of infectious bacteria linked to Legionnaire's Disease - a serious respiratory infection).

The GC concentration report indicated "potable water action level/control limit is exceeded if any Legionella is present" per CDC (Centers for Disease Control). The percent positive for Gothenburg Health was listed at 50% for site visit testing on 12/29/2021- and overall rating of buildings health at > 30 % (greater than) indicated higher that acceptable Legionella levels throughout building and actions should be taken to lower below 30%. Samples tested positive in LDRP (Labor Delivery Recovery PostPartum) bath, acute care area ice machine, clinic hand sinks, the main facility hot water heater and Sleep Study bathroom. Routine flushing should be continued and replace pre-filters. Three (3) locations were positive and should be flushed while two locations were on the edge of equipment detection limits (warranting replacement).

Director of Nursing (DON) and MS confirmed during interview on 7/12/22 at 3:30pm that the Acute care Ice machine was replaced and flushing of main hot water system was done after the site report for 12/28/21, however, NO Routine flushing process was being provided by staff at the time of this DHHS survey week of 7/11/22. (Six months after report of 5 (five) detectable unsafe CFU samples.)

The facility failed to have a complete Legionella Risk Assessment and action plan to include:
- any schematic specific to the Water Distribution System for Gothenburg Health.
- any meetings to assure risk factors were routinely evaluated/mitigated.
- any noting of non-used fixtures/ areas/ rooms requiring additional flushing of water lines.
- any evidence of routine flushing of hot and cold water outlets (sinks, showers, hoses) at least two times/week.
- any ongoing controls implemented after the contractor GC identified systemic CFU presence.
- any program TEAM identified with Building description and location of water fixtures through out the facility.

Based on medical record review and staff interview the CAH (Critical Access Hospital) failed to ensure a discharge summary included a recapitulation of the patient's stay for 3 of 5 swing bed patients (Patients 34, 35 and 36) reviewed. This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 2022 was 64.

Findings are:

A. Review of Patient 34's medical record (7/13/22 at 7:35 AM) revealed a swing bed admission of 3/11/22-3/21/22 for chronic lower back pain with inadequate pain control. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patient's stay.

-Review of Patient 35's medical record (7/13/22 at 7:55 AM) revealed a swing bed admission of 4/5/22-4/15/22 for chronic renal failure and diverticulitis (inflammation or infection in one or more small pouches in the digestive tract). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patient's stay.

-Review of Patient 36's medical record (7/13/22 at 8:15 AM) revealed a swing bed admission of 6/18/22-7/1/22 for post-hip fracture therapy. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patient's stay.

B. Interview with the Chief Operating & Quality Officer (COQO) (7/13/22 at 1:25 PM) confirmed the above medical records lacked evidence of a discharge summary that included a recapitulation of the patient's stay. The COQO also confirmed the facility lacked a policy and procedure for recapitulation completion.