HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of 14 patients. Based on observation, policy review and interview the hospital failed to develop a system to monitor for outdated emergency supplies in one of one treatment room, one of one emergency room, and one of two crash carts.

Findings include:

The CAH's policy for "Responsibility of Accessibility of Emergency Room Equipment and Supply" reviewed on 12/20/11 at 12:35pm directed "...To ensure availability of emergency room equipment and supplies for immediate response...A designated CNA (Certified Nurse Aide) is assigned to the emergency room, treatment room, and autoclave rooms per shift ...these rooms are checked each shift for cleaning and restocking on a daily basis ..."

- Observation on 12/19/11 at 11:00am in the treatment room revealed the following outdated supplies:

1. Four packages of Provodone-Iodine (a topical anti-infective agent) swab sticks with an expiration date of 5/2011.
2. Five packages of Provodone-Iodine swab sticks with an expiration date of 9/2010.
3. Five packages of Provodone-Iodine swab sticks with an expiration date of 11/2010.
4. Two packages of Provodone-Iodine swab sticks with an expiration date of 12/2010.
5. Two open partially used 4-ounce bottles of Hibiclens with an expiration date of 5/2011.

- Observation in the emergency room on 12/19/11 at 11:15am revealed a Broselow Pediatric Emergency Kit with the following outdated supplies:

1. Two Intravenous (IV) start kit with an expiration date of 8/2010.
2. Four IV extension sets with an expiration date of 3/2011.
3. One 18-gauge Jelco IV needle with an expiration date of 6/2011.
4. One, #14 French Nasogastric tube with an expiration date of 8/2011.
5. One intubation (a kit to provide an emergency airway) module with an expiration date of 2/2011.

The emergency room Crash Cart contained a cardiac monitor/defibrillator with two packages of pediatric electrodes with an expiration date of 8/11/2008.

- Observation on 12/19/11 at 11:30am in the emergency room revealed the following outdated supplies:

1. Three 4-ounce bottles of Provodone-Iodine scrub solution with an expiration date of 6/2011.
2. One 4-ounce bottle of Provodone-Iodine prep solution with an expiration date of 9/2011.
Staff A interviewed on 12/19/11 at 12:00pm, acknowledged the outdated supplies and pediatric electrodes on the Crash Cart.

- Observation in the Transitional Care Unit on 12/27/11 at 11:10am revealed a crash cart in the north hallway with the following outdated supplies:

1. Five 18-gauge Jelco IV needle with an expiration date of 8/2007.
2. One 20-gauge Jelco IV needle with an expiration date of 4/2009.
3. Two 22-gauge Jelco IV needles with an expiration date of 5/2007.
4. Two 24-gauge Jelco IV needles with an expiration date of 2/2011.
5. Two IV clave adapters with an expiration date of 9/2007.
6. One Quik-Pace external pacing electrodes with an expiration date of 9/28/08.
7. One Quik-Pace external pacing electrodes with an expiration date of 3/28/10.
8. One Fast-Patch Plus defibrillation/ECG electrodes with an expiration date of 5/28/10.
9. One Fast-Patch Plus defibrillation/ECG electrodes with an expiration date of 10/28/10.

Staff L interviewed on 12/27/11 at 11:20am, acknowledged the outdated supplies on the Crash Cart.

The Critical Access Hospital (CAH) reported a census of 14 patients. Based on observation and staff interview, the CAH failed to ensure the premises are clean and orderly.

Findings include:

- The CAH, toured on 12/20/11 at 2:00pm with staff F revealed the following:

1. In the equipment storage area, 5 intravenous pumps on rolling stands evidenced
significant rust, a non-cleanable surface on the wheels
2. A foam mattress on a shelf in a storage closet with torn seams and exposed foam, a
non-cleanable surface,
3. The women's shower with two cracked wall tiles with exposed rough surface and gaps
rendering the surface non-cleanable,
4. Significant debris along the metal threshold at the entrance to the women's shower stall.

Staff F, interviewed on 12/20/11 at 2:50pm, acknowledged the non-cleanable surfaces and confirmed the CAH lacked a process to identify and report housekeeping and maintenance to ensure the premises are clean and orderly.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to assure safety of food storage and date juices and desserts in two of two kitchen refrigerators.

Findings include:

- The CAH's policy "Dating of Foods" reviewed on 12/21/11 at 2:00pm directed, "...to make sure foods are utilized within 7 days of being prepared or opened...All containers being opened such as juices...need to be dated with the month and day they were opened...all desserts prepared in advance need to be dated ..."

- Observation on 12/20/11 between 2:10pm and 2:55pm revealed a refrigerator on the east wall identified as the salad and dessert refrigerator with an open pitcher of cranberry juice, an open pitcher of apple juice, and an open bottle of prune juice without a date when opened.

The walk-in refrigerator on the north wall contained three trays with 59 individual bowls of desserts, four 2 ounce containers of pureed prunes without a date when prepared and an open container of sour cream with an outdate of 12/11/11.

Staff N interviewed on 12/20/11 between 2:10pm and 2:55pm acknowledged the opened juices lacked a date when opened, the 59 prepared desserts lacked a date when prepared, and the open container of sour cream was outdated by 10 days. Staff N acknowledged staff failed to follow their policy to date open foods and without a date of opening staff would not know when to discard unused, outdated foods.

The Critical Access Hospital (CAH) provided a list of Medical staff on 12/20/11 at 1:30pm. Based on document review and staff interview, the Governing Body failed to credential/appoint one of one podiatrist providing services to eight of eight of the CAH's patients' who received podiatry services in the last six months (patient #'s 12, 20, 21, 22, 23, 24, 25 and 32)

Findings include:

- The CAH's Medical Staff Bylaws, reviewed on 12/21/11 at 12:05pm, revealed "Qualification of Membership" requires medical staff to have a current, valid license, be a graduate of an accredited school, evidence of ability to provide patient care services, and other required information for consideration for appointment to the medical staff by the CAH's governing board.

- The CAH's Governing Board Policy titled "Review and Approval of Policies and Procedures", reviewed 12/27/11 at 3:15pm, revealed "...Medical Staff applications for appointment, reappointment, privileges...will be submitted and approved by the Board..."

- Patient #12, medical record, reviewed on 12/19/11 at 11:30am, revealed physician G treated the patient in the last six months.

- Patient #20's medical record, reviewed on 12/21/11 at 1:30pm, revealed physician G treated the patient in the last six months.

- Patient #21's medical record, reviewed on 12/20/11 at 10:30am, revealed physician G treated the patient in the last six months.

- The CAH's list of medical staff including active, courtesy and consulting providers lacked physician G's name.

- The CAH's medical staff credentialing files, reviewed on 12/21/11 at 9:10am, revealed the lack of credentialing of physician G.

Administrative staff B, interviewed on 12/21/11 at 9:55am confirmed the governing Board failed to assure physician G held a license to practice medicine and failed to credential physician G to determine scope of practice, insurance other information to be reviewed to appoint physician G to the CAH's medical staff.

The CAH's failure to review physician G credentials and failed to assure a current license before allowing them to treat patients also affected patients #'s 22, 23, 24, 25 and 32.

The Critical Access Hospital (CAH) reported a census of 14 patients. Based on observation, policy review, manufacturer's guidelines, and staff interviews the Critical Access Hospital (CAH) failed to assure the safe, secure storage of drugs in one of two emergency room medication cabinet and one of two crash carts. The CAH failed to ensure outdated drugs and biologicals were not available for patient use in two of two emergency/treatment rooms.

Findings include:

- The CAH's policy "Lock up medication and Biological supplies in the Emergency Room " review on 12/20/11 at 3:30pm directed, "...To ensure personnel, client, family, and visitor safety from accessibility of medications and supplies...The north and east upper cabinets will be locked at all times..."

- Observation on 12/19/11 at 11:30am revealed an unlocked and unattended medication cabinet in the emergency room that contained the following medications:

1. One 25-gram container of Activated Charcoal.
2. One 50-gram container of Activated Charcoal.
3. One bottle Tetracaine Hydrochloride ophthalmic solution (antibiotic eye drops).
4. One bottle Neomycin and Polymyxin B Sulfate and Hydrocortisone ophthalmic suspension (antibiotic eye drops).
5. One Tobramycin ophthalmic solution (antibiotic eye drops).
6. One bottle aspirin 81mg (milligrams) four tablets.
7. Four Duo neb unit dose vials (used for breathing treatments).
8. One bottle Nitro stat 0.4mg 100 tablets (used for chest pain).
9. One 20ml (milliliter) bottle of Albuterol Sulfate 0.3% inhalation solution.
10. One open 30-gram tube of Nitro-bid paste (used topically for chest pain).

Staff A interview on 12/19/11 at 12:00pm acknowledged the unlocked unattended medication cabinet, which is across the hall from patient rooms. Staff A verified unauthorized persons could access the area without hospital staff knowledge.

- The manufacturer's information sheet for Hospira Sodium Chloride and Sterile Water irrigation solutions reviewed on 12/20/11 at 11:30am directed "... irrigation contains on bacteriostat, antimicrobial agent or added buffer and is intended for use only as a single-dose ...unused portions should be discarded..."

- Observation on 12/19/11 at 11:00am in the treatment room revealed one open partially used bottle of Sodium Chloride 500cc (cubic centimeter) irrigation solution and one open partially used bottle of Sterile Water 500cc irrigation solution.

- Observation on 12/19/11 at 11:30am in the emergency room revealed one open partially used bottle of Sodium Chloride 500cc (cubic centimeter) irrigation solution and one open partially used bottle of Sterile Water 1000cc irrigation solution.

Staff A interview on 12/19/11 at 12:00pm acknowledged the open partially used bottle of irrigation solution and verified they were available for patient use.

The Critical Access Hospital (CAH) reported a census of 14 patients. Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of one dressing change, two of two soiled utility rooms, two of two laundry areas observation and one of one observed cleaning of a discharged patient room.

Findings include:

- The CAH's Infection Control Policies reviewed on 12/27/11 at 2:35pm directed "...Establish and implement the policies and procedures related to control of infections within the hospital..."

- Staff C interviewed on 12/21/11 at 3:30pm verified they were responsible for the management of the infection control program. The CAH's infection control committee reviews policies and procedures and approves hospital wide cleaning products. Staff C acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control. Staff C's infection control surveillance is based on patient assessment, antibiotic use, and lab reports to track patient infections.

- The CAH's soiled utility room on the Transitional Care Unit, observed on 12/20/11 at 2:15pm revealed a flush rim sink and sprayer. Observation in the rooms revealed the lack of cover gowns (personal protective equipment) available to protect staff and their clothing from the spread of germs while using the flush-rim sink and sprayer.

- The CAH's soiled utility room by the nurses station, observed on 12/20/11 at 2:30pm revealed a flush rim sink and sprayer. Further observation revealed a large plastic container with lid, approximately 2/3 full with a clear, colorless fluid. The container has a spigot at the bottom. A sign on the lid of the plastic container directed staff to place soiled underpads in this container. Observation in the rooms revealed the lack of cover gowns (personal protective equipment) available to protect staff and their clothing from the spread of germs while using the flush-rim sink and sprayer or handling soiled linens.

Staff E, interviewed on 12/20/11 at 2:15pm, explained staff rinse heavily soiled items using the flush rim sink and sprayer to remove debris, places the soiled item in a plastic bag if it is a personal item or in the fluid-filled plastic container to soak if it is an underpad.

- Staff Q, observed on 12/21/11 at 10:30am, collected soiled laundry from the nursing units Staff Q, wearing protective gloves, obtained soiled laundry from the Transitional Care Unit soiled utility room, opening the door with their gloved hands. Staff Q, wearing the same gloves, pushed the laundry cart to the soiled utility room of long-term care department and opened the door to obtain the items to be transported to laundry. Staff Q continued to wear the same protective gloves, opened the door and entered the soiled utility room at the nurses station to obtain items to be laundered. Staff Q continued to pushed the linen cart to the laundry area wearing the same gloves. Staff Q touched at least six door handles to enter and exit the utility rooms with the potentially contaminated gloves.

- Observation In the laundry area on 12/21/11 at 10:40am, revealed staff E put on a pair of protective gloves without performing hand hygiene. Staff E removed linens from plastic bags and placed the linens into a bin on the scale. Staff E removed the linen from the scale bin and sorted the linens for washing. Staff E failed to protect their uniform with an apron. Staff E removed their gloves, sprayed themselves with Lysol, and used hand sanitizer.

The CAH's policy titled "Laundry Safety", reviewed on 12/21/11 at 2:00pm, revealed "...5. You must wear gowns and gloves when sorting laundry..." The CAH's policy titled "Washing Machine loading and Unloading", reviewed on 12/21/11 at 2:05pm, revealed " ...Procedure- Loading Gloves, aprons and other appropriate personal protective equipment will be worn when handing soiled linens..."

- The Transitional Care Unit, observed on 12/21/11 at 12:00pm revealed a washing machine and dryer. Staff P stated they placed patient's clothing in the washing machine. Staff P explained staff use "Tide" laundry detergent on patient's clothing.

Staff A, interviewed on 12/21/11 at 1:30pm, acknowledged the CAH lacked policies and procedures for the use of the washing machine and dryer on the Transitional Care Unit including how to use the equipment and infection control practices.

Staff C interviewed on 12/27/11 at 10:30am acknowledged the CAH lacked monitoring of the laundry process in the Transitional Care Unit.

- The Transitional Care Unit washing machine, observed on 12/27/11 at 1:35pm, revealed cold and warm water wash and rinse cycles. The cupboard above the washer contained "Tide" and "Wool-ite" detergents. The labels of Tide and Wool-ite lack disinfecting properties.

- Staff K, observed on 12/21/11 at 11:30am performed patient 18's dressing changes. Patient #18's dressings covered three surgical sites. Staff K performed hand hygiene, applied gloves and cleaned wound #1. Staff K then removed the gloves, applied another pair of gloves and cleaned wound #2. Staff K removed the gloves, applied another pair of gloves and cleaned wound #3. Staff K removed the gloves, put on another pair of gloves and applied the dressing to wound #1. Staff K removed the gloves, put on another pair and applied the dressing to wound #2. Staff K removed the gloves, put on another pair of gloves and applied the dressing to wound #3. Staff K removed the gloves six times and applied another pair of gloves without performing hand hygiene.

- Staff A, interviewed on 12/22/11 at 8:10am, confirmed the CAH lacked policies and procedures directing staff when to perform hand hygiene including before and after wearing gloves.

Staff D, the quality assurance officer, interviewed on 12/27/11 at 9:55am confirmed the CAH failed to develop and implement a plan to identify report, investigate and control the potential spread of infections including handling potentially infectious materials, disinfecting items and hand hygiene.

- The Infection Control Committee Minutes, reviewed on 12/27/11 at 12:35pm, lacked evidence of surveillance of CAH practices including laundry, housekeeping, nursing procedures, and hand hygiene.

- Review of the manufacturer's guidelines for the use of the Virex 256 One-Step Disinfectant cleaner on 12/27/11 at 3:00pm directed, " ...To disinfect hard, non-porous surfaces, treated surfaces must remain wet for 10 minutes..."

- Review of the manufacturer's guidelines for the use of the Clorox bleach on 12/27/11 at 3:00pm directed, "...Do not mix or use with other chemicals..."

- Review of the manufacturer's guidelines for use of Crew Bowl and Bathroom disinfectant cleaner on 12/27/11 at 3:00pm directed, "...Empty toilet bowl or urinal and apply solution to exposed surfaces...treated surfaces must remain wet for 10 minutes...prepare fresh solution daily..."

- Observation of staff H and staff I on 12/27/11 between 1:35pm and 1:55pm cleaning room 113, a discharged patient room revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation, hand hygiene and cleaning from dirty areas to a less dirty area. For example:

Staff H confirmed the CAH's cleaning products included Virex 256 for general cleaning and a combination of Soft Scrub with bleach added for sinks. Staff L explained they placed an unmeasured amount of Soft Scrub in a plastic container and poured in an unmeasured amount of bleach. Staff L failed to have a ratio of Soft Scrub to bleach for disinfection.

Staff H placed a cleaning caddy with cleaning supplies on the counter in room 113.

Staff H, wearing gloves, cleaned the sink with the mixture of Soft Scrub and bleach, rinsed out the sink with water, and dried the surface with a cloth.

Staff I, wearing gloves, applied Virex 256 disinfection cleaner to the bedside cabinet, IV pole, chair, and over the bed table. The surfaces remained wet between one to six minutes not the required 10 minutes for total disinfection.

Staff H applied Virex 256 disinfecting cleaner to the cabinets, drawers, and closet then wiped the surfaces with a cloth. The surfaces remained wet less than one minute not the required 10 minutes for total disinfection.

Staff H picked up the cleaning caddy went to the bathroom and placed the caddy on the floor. Staff H, using Crew Bowl and Bathroom cleaner, poured an unmeasured amount in the toilet bowl without removing the water from the bowl or measuring the solution. Staff L cleaned the inside of the toilet bowl with a toilet bowl brush then cleaned the outside of the toilet then recleaned the inside of the toilet bowl. Staff H failed to allow the Crew toilet bowl cleaner to sit on the surface 10 minutes. Staff H sprayed Virex 256 to a cloth and wiped the outside of the toilet bowl. Staff H reapplied Virex 256 to the cloth and wiped down the walls of the bathroom. Staff H moved from dirty to a less dirty area with the toilet bowl brush and cleaning cloth. The surfaces remained wet less than one minute not the required 10 minutes for total disinfection. When Staff H left the bathroom they picked up the cleaning caddy and sat the caddy on the floor in the patient room.

Staff I retrieved a broom from the hallway, sweep the room, returned to the hallway, retrieved a mop and mopped the floor. Staff I failed to remove their gloves and perform hand hygiene when leaving the room.

Staff H picked up the cleaning caddy from the floor, left the room, walked down the hallway, and placed the cleaning caddy on a cleaning cart. Staff H failed to remove their gloves, perform hand hygiene, and clean the cleaning caddy that sat on the floor in the bathroom and patient room.

Staff H and staff I interviewed on 12/27/11 at 2:10pm acknowledged they moved from dirty to a less dirty area with the toilet bowl brush, the cleaned surfaces failed to remain wet 10 minutes, the cleaning caddy sat on a dirty floor without cleaning before placing on a cleaning cart, they failed to change gloves and perform hand hygiene when leaving the room and failed to perform hand hygiene when they completed the cleaning of room 113.

Staff J observed on 12/27/11 at 2:10pm cleaned the bed in room 113 with Virex 256 disinfection cleaner. Areas of the bed remained wet for two to eight minutes, not the required 10 minutes for disinfection.

Following the cleaning of room 113 observation of two electric razors, an IV (intravenous) bag and tubing, under pad, and washcloth from the discharged patient remained in the room.

Staff J interviewed on 12/27/11 at 2:30pm acknowledged staff failed to remove two razors, the IV bag with tubing, and all linens in room 113 after cleaning of the room and confirmed the discharge patient used those items.

Supervisory staff E interviewed on 12/27/11 at 3:00pm acknowledged the facility used Soft Scrub and bleach mixture for sinks and lacked knowledge of its disinfecting property. Staff E failed to have a policy for cleaning of patient rooms and failed to present a housekeeping policy manual as requested.

Based on policy and procedure manual review and staff interview the Critical Access Hospital (CAH) failed to ensure a group of professional personnel reviewed patient care policies on an annual basis for six of nine policy and procedure manuals reviewed.

Findings include:

- The CAH's policy "Policy and Procedure Review" reviewed on 12/27/11 at 9:30am directed "...Each policy and procedure manual will be reviewed annually...Each manual will keep a log of review dates and signatures...Each manual dealing with clinical services will be reviewed by the following three persons: Physician, Department Head, and non-staff person ..."

- Policy and procedure manuals provided during the survey reviewed between 12/19/11 and 12/27/11 lacked evidence of an annual review by a group of professional personnel that included at least one doctor of medicine or osteopathy and a non-staff member.

Staff A interviewed on 12/21/11 at 4:05pm acknowledged the CAH lacked evidence of an annual review of the patient care policy and procedure manuals by a group of professional personnel.

The Critical Access Hospital (CAH) reported a census of 14 patients. Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure staff signed, dated and/or timed all entries in the medical record for 11 of 21 sampled medical records (#'s 11, 12, 17, 19, 20, 23, 25, 26, 28, 29, and 30).

Findings include:

- Patient #11's medical record, reviewed on 12/19/11 at 11:00am, revealed an admission date of 3/4/11. The medical record included a "Morse Scale", used to determine a patient's risk for falls. The document lacked the date it was completed.

- Patient #17's medical record, reviewed on 12/20/11 at 1:20pm, revealed the patient an admission date of 9/11/11 and discharged 11/6/11. The medical record contained a signed discharge summary which lacked the date and time signed, a signed history and physical which lacked the date and time signed, and signed physician orders which lacked the date and time signed.

- Patient #19's medical record, reviewed on 12/21/11 at 1:10pm, revealed an admission date of 5/16/10. The medical record contained a physical therapy evaluation completed "5/", but lacks the date, time and signature of the therapist.

- Patient #26's medical record reviewed on 12/22/11 at 7:30am revealed an admission date of 8/10/11 with a diagnosis of Alcohol Withdrawal and discharged on 8/13/11. Record review revealed the history and physical and discharge summary lacked the date and/or time the practitioner authenticated (signed) the documents.

- Patient #28's medical record reviewed on 12/22/11 at 8:40am revealed an admission date of 6/6/11 with a diagnosis of Pneumonia and discharged on 6/10/11. Record review revealed the history and physical and discharge summary lacked the date and/or time the practitioner authenticated the documents.

- Patient #29's medical record reviewed on 12/22/11 at 9:30am revealed an admission date of 11/16/11 with a diagnosis of Upper Gastrointestinal Bleed and discharged on 11/18/11. Record review revealed the history and physical and discharge summary lacked the date and/or time the practitioner authenticated the documents.

- Patient #30's medical record reviewed on 12/22/11 at 11:15am revealed an admission date of 10/5/11 with a diagnosis of Acute MI (heart attack) and discharged on 10/6/11. Record review revealed the discharge summary lacked the date and/or time the practitioner authenticated the documents.

- The "Rules and Regulations of the Medical Staff" reviewed on 12/21/11 at 12:05pm, directs providers to sign their orders. The CAH lacks policies and procedures directing staff to sign, date and/or time all entries in the medical record.

Administrative Staff D interviewed on 12/22/11 at 10:10am acknowledged the facility identified staff failed to date and time all entries into the medical record.

The deficient practice also affected patient #'s 20, 23 and 25.

Based on Quality Improvement Plan review and Quality Assurance Calendar review the Critical Access Hospital (CAH) failed to monitor staff and environmental infection control issues and/or problems and failed to include those in their Quality Assurance/Performance Improvement (QA/PI) program. Although hospital staff documented a concern with infection control practices in the laundry the CAH quality assurance and performance improvement program failed to follow-up and monitor for continued compliance to ensure safe care for future patients.

Findings include:

- The CAH's Quality Improvement Plan reviewed on 12/22/11 at 9:15pm stated "...it is important to have a program that generates the right mix of quality improvement activities that will demonstrate a "change-ready organization"; being proactive to improve systems and processes and foster a constructive organization-wide commitment to quality improvement..."

Administrative staff C and Administrative staff D interviewed on 12/22/11 at 10:10am acknowledged the facility had identified infection control issues in the laundry, had monitored this, and thought the laundry staff knew of proper techniques for infection prevention.

- Review of the Quality Improvement Activity Report with staff C on 12/27/11 at 10:00am revealed the CAH had identified infection control issues in the laundry in January 2008. Following education of laundry staff through January and February the QAPI officer monitored laundry practices on 3/18/08, 6/08/08, and 7/23/08. The documented monitoring on 7/23/08 indicated a continued infection control problem in the laundry. The CAH lacked documentation of continued monitoring for infection control practices in the laundry.

- Review of the Quality Assurance Calendar 2011 on 12/27/11 at 10:00am for environmental services indicated a check mark each month from January to September for PPE (personnel protective equipment) as needed to handle dirty laundry. The months of October to December the department failed to monitor the use of PPE. The calendar indicated a check mark each month from January to September for Ensure dirty to clean traffic flow in the laundry. The months of October to December the department failed to monitor dirty to clean traffic flow in the laundry. The calendar lacked evidence environmental services monitored housekeeping staff on appropriate cleaning products or cleaning of rooms.

- Review of the Quality Assurance Calendar 2011 on 12/27/11 at 10:00am for infection control revealed the Infection Control Officer failed to include monitoring the laundry for infection control practices.

Staff C interviewed on 12/27/11 at 9:45am acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control.

Staff D interviewed on 12/27/11 at 10:00am, explained the check marks on the Quality Assurance Calendar indicate the department completed the activity and the document lacked criteria used doing observation.

The Critical Access Hospital (CAH) reported eight patient deaths in the last three months. Based on document review and interview, the CAH failed to develop and implement policies and procedures to assure all deaths are reported to the Organ Procurement Organization (OPO).

Findings include:

- Patient #17's medical record, reviewed on 12/20/11 at 1:20pm, revealed a death date of 11/6/11. The medical record lacked evidence the OPO was notified of the patient's death.

- Patient #32, who died on 10/22/11, was selected from the CAH's list of deaths that have occurred in the last six months.

- A representative from Midwest Transplant Network (MTN), the OPO, interviewed on 12/20/11 at 1:20pm by telephone, confirmed the CAH failed to report the deaths of patient
#17 and 32.

- The CAH's policy titled "Organ/Tissue Donation", reviewed on 12/20/11 at 6:30pm, revealed the CAH lacks a policy directing staff to report all hospital deaths to the OPO.

- The CAH's contract with Midwest Transplant Network (MTN), reviewed on 12/21/11 at 7:45am, revealed "... Hospital shall notify MTN in a timely manner of every death that occurs at the Hospital..."

- Staff A, interviewed on 12/20/11 at 3:30pm, confirmed the CAH failed to report all deaths to the OPO.

The Critical Access Hospital (CAH) reported a census of 14 swing bed patients. Based on document review and staff interview the CAH's Swing Bed Patient Rights provided to all swing bed patients failed to include the right for the resident to choose a personal attending physician.

Findings include:

- The CAH's Swing Bed Patient's Rights reviewed on 12/20/11 at 7:30am lacked the patient's right information that the resident had the right to choose a personal attending physician.

Administrative staff A, interviewed on 12/21/11 at 9:00am acknowledged the patient's rights information given to swing bed patients lacked the patient's right to be informed of their right to choose a personal attending physician.