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Based on observation, the Critical Access Hospital failed to maintain a safe environment free of potential hazardous situations and/or conditions.

Failure to maintain a safe environment puts patients, staff, and visitors at risk of injury.

Findings:

1. On 6/23/2015 at 11:20 AM, Surveyor #3 noted that florescent light fixtures in the Shipping and Receiving department were not shielded or provided with tube guards to prevent glass from contaminating medical supplies stored beneath the fixtures should the tubes/fixtures be broken.

2. On 6/23/2015 at 2:40 PM Surveyor #3 noted that a chemical dispenser located in the facility laundry lacked a proper means of backflow prevention to protect the domestic water supply. More specifically, the dispenser was outfitted with an E-Gap Eductor, not an Air Gap Eductor as is required.

Item #1: Air Pressure Relationships

Based on observation, the Critical Access Hospital failed to maintain air pressure relationships required for the protection of patients and staff.

Failure to maintain proper air pressure relationships within the facility puts patients and staff at risk of infection.

Finding:

On 6/23/2015 at 12:50 PM, Surveyor #3 used a light weight flutter strip (tissue) to evaluate the air pressure relationships between the Sterile Supply (Room 353), Sterile Processing (Room 352) and the adjacent corridor. As a result it was determined that the Sterile Supply was negative to the adjacent spaces and corridor, not positive as is required.


Item #2: Food Refrigeration

Based on observation, the Critical Access Hospital failed to maintain a food product at the proper temperature.

Failure on the part of the facility to maintain foods at the proper temperature puts patients, staff and visitors of the facility at risk of food borne illness.

Finding:

On 6/24/2015 at 10:25 AM, Surveyor #3 noted that individual service butter packets were not being kept under refrigeration as is required.

Item #1: Food Service Sanitation

Based on observation the Critical Access Hospital failed to adhere to food service requirements of the Washington State Retail Food Code, Chapter 246-215 WAC.

Failure on the part of the facility to adhere to food service requirements and practices puts patients, staff and visitors of the facility at risk of food borne illness.

Findings:

1. On 6/24/2015 at 10:25 AM Surveyor #3 checked the concentration of chemical sanitizer used to sanitize working surfaces of the kitchen. Two of three buckets of sanitizer were found to have less than 100 ppm.

2. On 6/24/2015 at 11:40 AM Surveyor #3 observed a food service worker (Staff Member #9) perform a glove change without benefit of hand hygiene being performed.

Item #2: Infection Control Officer Qualifications

Based on interview the facility failed to assign/designate an individual who has the necessary education and working experience to oversee and be responsible for the Infection Prevention and Control Program.

Failure on the part of the facility to designate an individual with the necessary qualifications to oversee the Infection Prevention and Control Program puts patients, staff and visitors of the facility at risk of hospital acquired infections.

Finding:

On 6/24/2015 between the hours of 1:00 PM and 4:00 PM Surveyor #3 interviewed the person designated by the facility to serve as the Infection Prevention and Control Officer (Staff Member #10). During the interview process the surveyor was informed that the Infection Prevention and Control Officer lacked formal infection control training. It was pointed out that the individual would be sent to the next available Association for Professionals in Infection Control and Epidemiology (APIC) training class.



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ITEM #2: HAND HYGIENE


Based on observation and review of hospital policies and procedures, the hospital failed to ensure staff members followed the hospital policy for hand hygiene.

Failure to perform hand hygiene puts patients and staff at risk for infection.

Findings:

1. The hospital policy and procedure entitled "Hand Hygiene" (Approved 1/7/2015) reads: "All staff shall use the hand hygiene techniques ... Before each patient encounter; before applying gloves; after contact with medical equipment/supplies in patient care areas, always after removing gloves ..."

2. Surveyors #1 and #2 made the following observations during the survey:

a. On 6/25/2015 at 9:45 AM, Staff Member #6 did not perform hand hygiene prior to entering the pre-op room for Patient #1 to examine the patient and review his/her anesthesia plan of care.

b. On 6/25/2015 at 10:17 AM, in the operating room with Patient #1, Staff Member #3 picked up a patient care device from the floor and placed it on the counter with other patient care supplies. Staff Member #3 did not perform hand hygiene after picking up said item from the floor.

c. On 6/25/2015 at 10:18 AM, Staff Member #3 did not perform hand hygiene prior to leaving the operating room as required by policy.

d. On 6/25/2015 at 11:00 AM, Staff Member #6 failed to perform hand hygiene upon removing gloves after disposing Patient #1's emesis bag into a trash container.

e. On 6/25/2015 at 11:10 AM, Staff Member #6 did not perform hand hygiene prior to donning a sterile gown and gloves and performing a spinal injection. Following the procedure, Staff Member #6 failed to perform hand hygiene after glove removal.


ITEM #3: SURGICAL ATTIRE

Based on observation and review of hospital policies and procedures, the hospital failed to ensure staff members followed the hospital policy for surgical attire.

Failure to maintain coverage of facial and neckline hair poses a risk for contamination of the sterile field.

Findings:

1. The hospital policy and procedure entitled "Attire Surgical Services Dept." (Approved 5/14/2013) read: "All head and facial hair is to be covered while in the restricted area ...disposable surgical hat should confine the hair."

2. On 6/25/2015 between 10:12 and 11:00 AM, Surveyors #1 and #2 made the following observations in the operating room:

a. Staff Member #5 set up the sterile table with exposed facial hair.

b. Staff Member #4 entered operating room #1 with exposed neckline hair. In addition, Staff Member #2 entered the same operating room with both facial and neckline hair exposed.

Based on interview and document review, the Critical Access Hospital failed to perform a program evaluation according to the regulatory requirements for Critical Access Hospitals (CAHs).

Failure to perform an annual program evaluation impairs the hospital's ability to improve the quality of healthcare it provides to patients.

Findings:

On 6/25/2015 at 4:00 PM, during an interview with Surveyor #1 and the Chief Nursing Officer (Staff Member #1) revealed that the hospital did not complete a CAH annual program evaluation for two consecutive calendar year periods (2012-2013 and 2013-2014).