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Based on personnel record review, policy review and staff interviews, the facility failed to ensure 1 of 3 contracted employees, selected for review, received the mandatory 2 hour dependent adult abuse training within six months of their hire date (Staff B).

235 B16.5b. A person required to report cases of dependent adult abuse pursuant to sections 235B.3 and 235E.2, ... shall complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment or self-employment which involves the examination, attending, counseling, or treatment of adults on a regular basis.

Failure to ensure all staff, attending CAH patients, receive dependent adult abuse training may result in failure to report potential abusive situations placing patients at risk.

Findings include:

Review of a policy titled, "Mandatory Reporter: Dependent Adult & Child Abuse Certification", dated 4/2016, revealed in part "... It is the policy of CRHC [Clarinda Regional Health Center] that all employees obtain and maintain current Mandatory Reporter certificate according to state guidelines ... Employees who lack a current certificate upon hire will be required to complete the full curriculum within 90 days.

Review of Staff B's, Sleep Study Tech, education and training information revealed a lack of documented evidence for the completion of the required 2 hour dependent adult abuse training.

Review of the CAH's sleep services contract, and related emails, revealed Staff B began providing services to CAH patients 7/2/2013.

During an interview on 4/5/17, at 1:35 PM, Staff E, Education and Corporate Compliance, confirmed Staff B had not completed the required 2 hour dependent adult abuse training and would have him complete it that evening when he arrived for work.

During a follow-up interview on 4/6/17, at 9:45 AM, Staff E reported the CAH did not have a separate policy to cover education requirements for contracted staff, but would be expected to complete the same basic training requirements expected of employed staff.

Based o observation and staff interview, the critical access hospital (CAH) failed to ensure one of four CAH owned ambulances took measures to secure two of two oxygen cylinders lying loose in the storage area found under the bench seat in the patient care area inside the ambulance.

On 4/5/17 at 8:20 a.m., during an observation of one of the CAH's four ambulances, two oxygen cylinders were under the bench seat of the ambulance unsecured.

Staff F, EMT (Emergency Medical Technician) Manager stated during the observation there were no brackets available to secure the tanks because there was no place in the ambulance to put brackets where they would not in the crew's way, and the cylinders were too tall to be secured upright under the bench seat.

Staff G, Respiratory Treatment Manager, stated in an interview on 4/10/17 at 10:53 a.m. she was not in charge of the oxygen tanks for the Emergency Department. Staff F would be in charge of the oxygen tank storage in the ambulances. Staff G stated she expected all oxygen tanks she is responsible for to be secured. She stated she used to be on a flight crew and all the oxygen was secured because of safety factors.

Staff H, interviewed on 4/10/17 at 11:02 a.m. stated he is working under a contract as the Interim EMT Manager until Staff F gets acclimated to the job. He stated it would not be safe to have the oxygen tanks unsecured in the ambulance. The tanks are under pressure and if a valve got knocked off somehow, it would be "like a rocket" and could also be a fire hazard. Se stated the risk was low but the tanks should be secured. Staff H looked for a policy but could not find one for the ambulance oxygen storage.

on 4/10/17 at 3:50 PM Staff H reported the oxygen cylinders were secured under the bench seat. He stated maintenance had some brackets and fashioned makeshift brackets securing the cylinders lying on their sides.

Review of the Policy and Procedure titled Compressed Gas and Oxygen Use dated 05/14 indicated under policy all personnel concerned with the use and transport (handling) of compressed gas shall be trained in the proper handling of cylinders, and supports and cylinder-protection caps.

The procedure of the policy indicated the cylinders shall be transported, stored and used in an upright position. The procedure also indicated oxygen and other gases are potentially dangerous. Special safety precautions shall be followed at all times while using or storing oxygen. The procedure continued to indicate storing oxygen cylinders upright and secured.

On 4/12/17 at 10:35 a.m. Staff F stated in an interview prior to becoming the EMT Manager he had been a PRN (as needed) employee for three years. Staff F checked his training transcript and he did not have the training in the proper handling of cylinder, and supports, and cylinder-valve protection caps.

Failure to properly secure the oxygen tanks for storage posed a danger to the crew, patients and others.





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I. Based on document review, observation, and interview, the administrative staff failed to ensure the clinic staff correctly dated the shortened outdate time for 1 of 1 bottle of Cidex OPA test strips in the clinic. The clinic administrative staff identified an average of 8 procedures requiring the clinic staff to test the Cidex OPA solution per month.

Failure to document the shortened expiration date could potentially result in the staff failing to detect the Cidex OPA solution contained the minimum effective concentration of disinfectant, potentially resulting in the solution failing to fully kill all the bacteria and viruses, potentially spreading infection between patients.

Findings include:

1. Observations during a tour of the Outpatient Clinic on 4/4/17 at 7:45 AM revealed 1 of 1 bottle of Cidex OPA test strips (strips used to test a solution used to kill bacteria and viruses on medical equipment) in the gynecologic clinic room. The bottle of test strips contained 51 test strips out of 60 original test strips. The staff had documented a shortened expiration date 6 months after they initially opened the bottle.

2. Review of the manufacturer's directions for the Cidex OPA solution test strips, copyright 2015, revealed in part "Do not use any remaining strips 90 days after opening the bottle."

3. During an interview with the Clinic Manager at the time of the tour, the Clinic Manager acknowledged the manufacturer's directions required the staff to discard the test strips after 3 months instead of 6 months.


II. Based on document review, observation, and interview, the administrative staff failed to ensure the clinic staff followed the manufacturer's directions to test the Cidex OPA solution for 1 of 1 active Cidex OPA disinfectant solution. The clinic administrative staff identified an average of 8 procedures requiring the clinic staff to test the Cidex OPA solution per month.

Failure to test the Cidex OPA solution prior to each use could potentially result in the staff failing to detect the Cidex OPA solution lacked the minimum effective concentration, potentially resulting in the solution failing to fully kill all the bacteria and viruses, potentially spreading infection between patients.

Findings include:

1. Observations during tour of the Outpatient Clinic on 4/4/17 at 7:45 AM revealed 1 of 1 container of active Cidex OPA solution.

2. Review of the manufacturer's directions on the bottle of the Cidex OPA solution, copyright 2015, revealed in part, "use Cidex OPA solution test strips to monitor ... before each use ...."

3. During an interview at the time of the tour, the Nursing Supervisor of the Specialty Clinics stated the clinic staff only tested the Cidex OPA solution once a day instead of before each use. The Nursing Supervisor of the Specialty Clinics acknowledged the manufacturer's directions required her to test the solution prior to each use.

I. Based on observation, document review, and interview, the administrative staff failed to ensure the staff cleansed the top of medication vials prior to removing the medication from the vial with a needle. The staff failed to cleanse the vial during 1 of 1 observation of intravenous medication handling in the emergency department and observations of 3 of 3 intravenous medications being withdrawn from vials in the operating rooms (OR). The hospital's administrative staff identified an average of 3.8 patients per month.

Failure to cleanse the stopper prior to removing the medication from the vial could potentially result in the patient developing an infection in their blood.

Findings include:

1. Review of the policy "Multi-dose Vials/Single-dose Vials/Solutions," revised 7/2012, revealed in part, "the rubber stopper of containers should be wiped or sprayed with 70% alcohol before each [time withdrawing medication from the container]."

2. Observations during a tour of the Emergency Department on 4/5/17 at 8:41 AM revealed Registered Nurse (RN K) removed vials of dexamethasone (a steroid) and Zantac (a medication to control nausea) from the medication cabinet. RN K removed the plastic top on the vials of the medications. RN K pierced the medication vials with a needle to remove the medication from the vials. RN K failed to cleanse the stopper on the top of the vial with alcohol prior to withdrawing the medication.

3. Observations during a tour of the operating room on 4/5/17 at 10:26 AM revealed Certified Registered Nurse Anesthetist (CRNA) L removed vials of fentanyl (a potent pain killing medication), Versed (a medication to relax patients), Lidocaine (a numbing medication), and propofol (a medication to put patients to sleep) from the anesthesia cart. CRNA L removed the plastic top on the vials of the medications prior to removing the medication from the vial with a needle. CRNA L failed to cleanse the stopper on the top of the vial with alcohol prior to withdrawing the medication.

4. During an interview on 4/5/17 at 1:35 PM, Infection Prevention Nurse J stated the critical access hospital's policy required the staff to cleanse the stoppers with alcohol prior to withdrawing the medication from the vial.


II. Based on observation and staff interview, the administrative staff failed to ensure 1 of 1 CRNA (CRNA L) did not contaminate the needle while removing needles from the package. The administrative staff identified an average of 3.8 patients per month.

Failure to prevent the contamination of the needle could potentially result in the patient developing a life threatening infection in their blood.

Findings include:

1. Observations during a tour of the operating room on 4/5/17 at 10:26 AM revealed CRNA L removed the needle from the manufacturer's package. When CRNA L removed the needle from the package, CRNA L pushed the needle through the paper in the package.

2. During an interview on 4/5/17 at 1:35 PM, Infection Prevention Nurse J stated CRNA L should have opened the needle package by peeling apart the two sides of the package, instead of pushing the needle through the paper. Infection Prevention Nurse J stated CRNA L could have contaminated the inside of the needle with material from the packaging, which could result in the patient developing an infection in their blood.



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III. Based on document review, policy review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure health exams were regularly completed as part of their system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 1 of 3 volunteers selected for review (Staff A) and 2 of 3 contracted staff. (Staff B and C)

Failure to identify infections and communicable diseases among employees and volunteers could potentially result in the transmission of a communicable disease to patients.

Findings include:

Review of a CAH policy titled "Employee Health Statement", revised 2/2017, revealed in part "... Prospective employees/volunteers ... and current employees/active volunteers will update the Health Statement Information ... as mandated by state regulations ... Volunteer's health information will be updated every four years during the employee health fair..."

Review of the health information for Staff A, Volunteer, revealed documented evidence of the most recent health exam dated on 4/10/2007.

Review of the health information for Staff B, Contracted Sleep Study tech, revealed a lack of documented evidence of a health exam.

Review of the health information for Staff C, Contracted Occupational Therapist (OT), revealed documented evidence of the most recent health exam dated on 11/2/12.

During an interview on 4/5/17, at 11:00 AM, Staff D, Employee Health and Wellness, confirmed the CAH lacked documented evidence of a health exam within the past 4 years for Staff A, B and Staff C. She acknowledged Staff A and C should have had a more recent health exam and had been missed. Staff D reported she doesn't have contact with sleep study staff and did not track their health exams.

During an interview on 4/6/17, at 9:45 AM, Staff E acknowledged the CAH needed a better system for contracted staff to ensure the required training and health requirements are completed.






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