HospitalInspections.org

A. Based on observation and interview, the provider failed to ensure:
*Three of three patient use pillows were stored to protect them from possible contamination in the storage room by the nurses station.
*One of one dirty utility room in the emergency department (ED) did not contain new and cleaned grey positioning mats, clean crutches, and a portable bladder scanner.
*One of one physical therapy department's foam rolls, positioning devices, and foam floating devices used a pool could be disinfected between patient use.
*Four of four patients' water glasses were protected from contamination.
*Ten of ten foam hand sanitizers were not outdated in randomly observed areas.
*One of two boxes of hand scrubs were not outdated at the surgical scrub sink.
*Two of two cloth chairs used by the anesthetists in the operating room (OR) had a cleanable surface.
*One of two head positioning pads in the OR was not cracked and was cleanable.
*One of one in-use PDI (sanitizing wipes) wet wipe containers was not outdated.
*One of one clean room for sterilization did not contain housekeeping equipment and other hospital departments' storage items.
*One of one bottle of Cidex test strips were not outdated and the bottle was labeled with an open date.
*One of one bronchoscope used in the ED was disinfected every five to seven days when not in-use.
Findings include:

1. Observation on 8/26/14 from 2:00 p.m. through 4:30 p.m. and again on 8/28/14 from 10:50 a.m. to 11:30 a.m. revealed:
*Three patient use pillows were stored on the floor in the storage room located by the nurses desk. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She agreed those pillows should have been stored on the shelf to prevent contamination.
*New grey positioning mats, new clean crutches, and a portable bladder scanner were stored in the soiled utility room of the ED. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She agreed those new and clean patient use items should not have been stored in the dirty utility room.
*Two foam rolls, one sliding board with foam, and three pool flotation devices were found in-use in the physical therapy (PT) department. Interview with the director of PT at the time of the observation confirmed that finding. She agreed those foam rolls, foam on the sliding board, and pool flotation devices were not cleanable and should not have been used in-between patients in PT.
*Four uncovered plastic glasses were filled with water and were stored on a wooden shelf in the cardiac rehabilitation therapy department. Interview with the director of that department at the time of the observation confirmed that finding. She stated she had tried to "go green" and not use disposable water cups for the patients. She had the shelf built and each patient received a number, and that was the number on their glass of water. She had not considered the potential for contamination with uncovered glasses of water. She also had not considered possible cross-contamination between patients if they drank out of other patients' glasses of water.
*Ten foam hand sanitizers were found outdated in the following areas:
-Two in the PT department.
-Three in the intensive care unit.
-One in patient room 122.
-One in the endoscopy room.
-Two on the anesthetists' cart.
-One in the dirty side of central sterilization.
Those expirations dates ranged from September 2006 through July 2014.
-Interview with the housekeeping supervisor and head of surgery at the time of the above observations confirmed those findings. They stated the staff responsible for those areas were to check for outdates of supplies.
*One box of hand scrubs in-use at the surgical scrub sink had an expiration date of May 2014.
-Interview with the registered nurse (RN) in charge of surgery at the time of the observation confirmed that finding. She sated she did not realize that box of hand scrubs was outdated. She stated the staff responsible for that area were to check for outdates of supplies.
*A cloth office chair was in-use in the surgical room. Interview with the RN in charge of surgery at the time of the observation confirmed that finding. -She stated there were actually two office chairs used in surgery. She had not realized those chairs were not cleanable nor could they be disinfected and could be a cause of contamination.
*A head positioning pad was found in-use in the surgical room. That pad had several cracks in the vinyl and exposed the foam padding beneath the vinyl.
-Interview with the RN in charge of surgery at the time of the observation confirmed that finding. She stated she did not think the cracks in that pad were that bad and had not removed it from the surgical room.
*A container of PDI disinfecting wet wipes was found in-use at the nurses desk in the recovery area.
-Interview with the RN in charge of surgery at the time of the observation confirmed that finding.
-She stated they used those disinfecting wipes as the patients did not like the smell of the new disinfecting wipes. She had not realized that container of PDI wipes had expired in March 2014.
*A floor buffer, opened packages of patient use items, and other cardboard boxes were stored in the clean room of central sterilization. -Interview with the RN in charge of surgery at the time of the observation confirmed that finding.
-She confirmed that room should be treated as a clean room and not be used for storage of housekeeping equipment or boxes of supplies for other departments.
*A bottle of Cidex test strips used to check the effectiveness of the Cidex solution had expired February 2014. The bottle was not labeled with an opened date. The open date was to ensure it was not used past the effectiveness of the test strips per manufacturer's guidelines.
-Interview with the RN in charge of sterilization at the time of the observation confirmed that finding.
-She was not aware those test strips were outdated.
-She was also not aware the bottle of test strips must be labeled with an open date.
*A bronchoscope hung off of a shelf in the sterilization room. No date was noted on the scope to indicate when it had last been processed.
-Interview with the RN in charge of surgery and the RN in charge of sterilization at the time of the observation confirmed that finding.
-They stated that scope was only used for difficult intubations in the ED.
-They revealed the scope was disinfected after each use.
-They were not aware the scope must be disinfected every five to seven days when not in-use.



26632

B. Based on observation, interview, and policy review, the provider failed to ensure one of one physician (A) had performed hand hygiene before and after a colonoscopy procedure for one of one patient (44). Findings include:

1. Observation on 8/28/14 from 8:30 a.m. through 9:45 a.m. revealed physician A:
*Entered the surgery hall from the family room.
*Immediately came into the endoscopy room and put on a surgical gown and clean gloves.
*He did not perform any type of hand hygiene before he put on the clean gloves and clean gown.
*He completed the colonoscopy for patient 44.
*He removed the surgical gown and his gloves.
*He left the endoscopy room, went into the surgery hall, and then went into the family room.
*He was observed to shake patient 44's husband's hand.
*He had not performed any hand hygiene after he had completed the colonoscopy.

Interview on 8/28/14 at 10:00 a.m. with registered nurse (RN) B revealed she was aware physician A had not performed any hand hygiene before or after the coloscopy for patient 44.

Interview on 8/28/14 at 11:00 a.m. with RN C revealed she was the infection control nurse for the hospital. She stated hand hygiene audits had been performed, but not in the surgery areas. She agreed physician A should have performed hand hygiene before and after the colonoscopy.

Review of the provider's revised March 2014 Hand Hygiene policy revealed decontamination of hands would have taken place:
*Before having direct contact with patients.
*After removing gloves.
*There was no direction for hand hygiene to have been done before putting on clean gloves.
*There was no policy for hand hygiene in the surgical setting.

Based on observation, interview, and policy review, the provider failed to comply with proper food handling practices as evidenced by the following items/areas were found dirty and/or in need of repair:
*Main kitchen:
-The baking area drawers and shelves.
-The plastic plunger for the food chopper.
-The louvered filters in the range hood.
-Three of three ovens.
-The splash area of the ice machine.
-The janitor's closet.
-The wall behind the dish rack storage area was gouged and scraped.
*Undated ham salad and egg salad sandwiches, two dessert crepes, and four pieces of pie were found in the cafeteria.
*Nutrition room:
-The inside of the refrigerator.
-The inside of the microwave.
-All drawers and cabinets.
-The bottom shelf under the sink drain line.
-The splash area of the ice machine.
-The front edge of the coffee cart.
*A large vessel in the visitor dining room and a small container in the nutrition room of brewed ice tea was not cleaned daily.
Findings include:

1. Observation on 8/26/14 from 9:30 a.m. to 10:45 a.m. revealed the following in the kitchen and cafeteria:
*The baking area had drawers and shelves that had dried and spilled food and liquid debris in them and on them.
-Interview with the dietary manager (DM) at the time of the observation confirmed that finding.
-She stated she had a regular cleaning schedule for the kitchen.
-The baking area was to have been cleaned on a quarterly calendar basis or more often as needed.
*The plastic plunger for the food chopper had rolled and folded edges and appeared to have been melted. The edges of that plunger also had cracks and chips in the plastic.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated she was not aware of the condition of that plunger.
*All the louvered filters in the range hood had layers of liquid and baked on grease. The stainless steel filters appeared brown and tan from the grease.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated the filters were to have been cleaned monthly.
-She stated staff were busy last month, so the hood and filters had not been cleaned for almost two months.
*All four ovens had bubbled, caked, dried, and liquid black debris that adhered to the wire shelves and laid on the bottoms of the ovens.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated the ovens were to have been cleaned monthly.
-She stated staff were busy last month, so the ovens had not been cleaned for almost two months.
*The splash area of the ice machine had dried and spotted liquid debris around and inside the ice chute.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated the ice machines were to have been cleaned weekly or more often as needed.
*The janitor's closet for the kitchen had imbedded grime and unidentified matter on the floor around the caulk of the floor sink.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated the closet was to have been cleaned twice a month, but agreed the closet should have been deep cleaned and maintenance should replace the caulk.
*The wall behind the dish rack storage area under the window had gouges, scrapes, and damaged areas in the gypsum board.
-Interview with the DM at the time of the observation confirmed that finding.
-She stated that wall was repeatedly damaged by the dish racks.
-She stated the walls were to have been cleaned monthly, but the staff had not reported the wall needed to be repaired.
*Ham salad and egg salad sandwiches, two dessert crepes, and four pieces of pie were on the cafeteria line. Those prepared items had no preparation date or pull date on the plates or clear food wrap.
-Interview with the DM at the time of the observation confirmed that finding. She stated all food was to be marked with a pull date.

2. Observation on 8/28/14 at 11:15 a.m. revealed the following in the nutrition room of the hospital:
*The refrigerator had pooled milk on the bottom of the unit. The inside had old dried food and liquid debris on the shelves and needed to be cleaned.
*The inside of the microwave had dried food and liquid debris on the inside surfaces.
*All drawers and cabinet shelves had spilled and/or dried food and/or liquid debris on them.
*The bottom shelf under the drain line of the sink had spilled liquid debris that had pooled and covered a third of the shelf.
*The splash area of the ice machine had dried and spotted liquid debris around and inside the ice chute.
*The front edge of the laminate covered coffee cart was damaged, and the particle board was visible for about four inches which made that surface uncleanable.

Interview at the time of the observation with the social service designee confirmed those findings. She stated she thought nursing staff were responsible for the cleanliness and order of the nutrition room. She was not aware if it was on a cleaning schedule.

3. Observation on 8/26/14 at 2:00 p.m. in the staff and visitor dining room and at 4:15 p.m. in the nutrition room revealed:
*A large ice tea machine and holding container that held approximately two gallons of brewed tea sat on the counter. The tea appeared cloudy and foamy and the container was not labeled with a date or time.
*An small pot of brewed ice tea sat under the machine in the nutrition room. The pot sat at room temperature and had not date or time.

Interview on 8/27/14 at 10:30 a.m. with the DM revealed:
*She was not aware the FDA 2009 Food Code required ice tea dispensers to be cleaned every 24 hours.
*She stated staff were to have cleaned and sanitized the ice tea machine every day in the staff and visitor dining room.
*On Friday they would have cleaned the spigot of the machine.
*She confirmed the ice tea machine, spigot, and its holding container were not on the regular food service cleaning schedule.
*She could not ensure or account for the cleanliness of the ice tea machine, spigot, and holding container.
*She stated the nursing staff were responsible for the cleanliness of the ice tea brewer in the nutrition area.
*She was not aware of any cleaning schedule for the nutrition area or any food service equipment in the area.
*She revealed the hospital's food service followed the 2009 food code adopted by the state.

Review of the provider's 3/7/14 General Sanitation of the Kitchen policy revealed:
*The staff would maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.
*Tasks would be addressed as to the frequency of cleaning.

Review of the provider's 3/7/14 Production, Storage, and Dispensing of Ice policy revealed the ice dispenser was to have been cleaned and sanitized at least monthly and/or as needed. Inside and outside of the machine were to have been cleaned.

Based on interview, document review, and policy review, the provider failed to ensure all aspects and departments of the critical access hospital (CAH) operations were part of the comprehensive quality assurance performance improvement (QAPI) program for the following:
*A complete annual utilization review of its total program.
*A review of patients' active and closed records.
*A review of the CAH's policies and procedures (P/P).
*A review of physicians' services.
*A review of provider acquired infections and medical therapy.
*Evaluations of mid-level practitioners (such as physician assistants and nurse practitioners) by a medical doctor (MD)/doctor of osteopathy (DO).
*Evaluations of MD/DO diagnosis/treatment apart from those who worked at the facility.
*Reviews and evaluations of all contracted services.
*Direction, recommendations, and actions for each aspect of all hospital departments' performance improvement (PI) plans.
Findings include:

1. Interview on 8/27/14 at 2:30 p.m. with the performance improvement (PI) coordinator revealed:
*The PI committee met every other month.
*The PI committee promoted focusing on high risk, high-volume, and problem prone areas, but it did not create the projects.
*The department or area of review was not driven by the PI committee.
*The department or area of review was responsible to create their own projects, set their own goals and timelines, and monitor and set their own thresholds. The department or area of review was also responsible for reporting to the PI committee.
*The PI committee gave no recommendations or actions to the departments or areas of review.
*The bi-monthly reports were sent to the governing board for review. The board devised their own quality indicator quarterly report. That report provided a comparison worksheet for all their licensed facilities in common with one another. The board gave no feedback to the provider on their reports.
*Credentialing reviews (such as MDs, DOs, certified nurse anesthetists, physician assistants, and nurse practitioners) were not part of the PI committee.
*The director of nursing (DON) completed a review of active and closed patient records but did not report the findings to the PI committee.
*The DON evaluated the MDs' and DOs' diagnoses and treatments but did not report the findings to the PI committee.
*The provider's healthcare P/Ps were evaluated and reviewed by the administration but were not part of the PI committee.
*The provider's contracted services were not reviewed by the PI committee.
*Other programs monitored infection control, patient safety, and MD/DO credentialing and evaluations. Those areas did not report to the PI committee.
*She agreed there was no indicator the following projects had improved the health outcomes of the CAH patients:
-The plant operations project for assurance of correct identifier labels of electrical panels.
-The environmental services project for reduction in trash can liners.
-The environmental services project of labeling of long term care residents' laundry.
-The dietary meal start times for long term care residents.
-Health information management project for physician visits to long term care residents.
*She agreed there was no distinction for QAPI projects between long term care and acute care.

Interview on 8/28/14 at 8:20 a.m. with the chief executive officer (CEO) revealed:
*He agreed there might not have been enough information in the PI committee meeting minutes to reflect each department's and/or area's QAPI part for the hospital.
*He stated there were always recommendations and discussion of actions for the PI projects for the department and/or areas. But he agreed the PI minutes did not reflect those findings.
*He reviewed the contracted services when their contract was up for review. He did not report any information regarding the review to the PI committee.
*The PI meeting encompassed reports for both the long term care facility and the CAH. Some of those departments and/or areas overlapped both facilities and did not differentiate between the long term care and the CAH.

Review of the provider's December 2013 PI Plan policy revealed:
*Goals:
-The clinical quality and safety of care.
-Patent health outcomes consistent with current professional knowledge.
-The needs and expectations of customers.
*Priorities for measurement and improvement would have been selected on:
-Problem prone, high risk, and high volume areas.
-Patient safety.
-Areas identified by employees, staff, medical staff, or board members.
*Organization/Authority:
-Providing the framework for planning, directing, coordinating, providing, and improving health services that were responsive to patient needs and improving patient outcomes.
-Setting priorities of the program to include patient safety and improvement in the quality of care.
*Department responsibility:
-Due to coordination of efforts the department project first required submission of the AIM and Project Plan to the PI Coordinator and PI committee.
*PI committee:
-Provide input into Performance Improvement Activities.
*Performance improvement coordinator:
-Responsible to maintain the appropriate documentation of the PI program.
*Chief executive officer:
-The CEO was responsible and accountable for the PI program.

Based on interview and policy review, the provider failed to ensure activities were provided under the supervision of a qualified activity coordinator for all swing bed patients. Findings include:

1. Interview on 8/28/14 at 10:30 a.m. with the director of nursing regarding the acute care activity coordinator revealed:*That coordinator was a certified nursing assistant.
*She was supervised by the assistant director of nursing.
*She completed the activities assessments for the swing bed patients.
*A qualified activity coordinator was not involved with the swing bed patients' assessments nor the provision of their activities.

Review of the provider's revised August 2013 Swing Bed Assessment policy revealed an activities assessment would have been completed by the nursing department staff.

Review of the provider's revised August 2014 Swing Bed Services policy revealed:
*On admission an initial activities assessment would have been completed by the activities coordinator or designee.
*Activities would have been provided by the acute care activities coordinator, nursing staff, and care coordination staff.