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Based on review of Arkansas Rules and Regulations for Hospitals and Related Institutions, review of Physician Credentialing files and interview, it was determined the facility failed to follow Arkansas State Regulations in that they failed to evaluate the Physician members' professional activities (also referred to as peer review) at the time of reappointment for six of six (#1, #2, #3, #6, #7, and #8) Physicians. By not reviewing the Physician members' professional activities, the facility could not assure that physicians were competent and practiced within the boundaries of professionally accepted norms, which improves the quality and safety of the health care provided. The failed practice had the likelihood to effect all patients that were treated at the hospital. Findings follow:

A. Review of the Rules and Regulations for Critical Access Hospitals in Arkansas, Section 6. MEDICAL STAFF, A.9. showed, an individual file shall be maintained for each physician practicing in the hospital and shall include an evaluation of members' professional activities at the time of reappointment.
B. Review of Physician Credentialing files showed Physicians #1, #2, #3, #6, #7, and #8 did not have an evaluation of members' professional activities at the time of reappointment.
C. During an interview on 11/04/20 at 10:20 AM, the Medical Staff Services Supervisor verified the Facility failed to evaluate the above mentioned six Physician members' professional activities at the time of reappointment.


38994

Based on review of the Arkansas Rules and Regulations for Hospitals and Related Institutions, observation and interview it was determined the facility failed to ensure raw meat was stored in a way to prevent contamination of other food items in that raw meat was found on the middle shelf of the refrigerator and freezer in the facility kitchen. The failed practice did not ensure raw meat was stored on the bottom shelves of the refrigerator and freezer to prevent contamination of other food items in the event of a mechanical failure of the refrigerator and freezer. The failed practice affected all patient receiving food prepared at the facility. Findings follow:
A. Review of the Arkansas Rules and Regulations for Hospitals and Related Institutions 2016 section 17.C.1 showed whole eggs and raw meat shall be stored separately and in a way that prevents contamination of other food items in the refrigerated units.
B. Observation while on tour of the facility kitchen on 11/03/20 at 1:15 PM showed raw meat stored on the middle shelf of the refrigerator and raw frozen meat stored on the middle shelf of the freezer above other food items.
C. The above findings in A and B were verified with the Director of Nursing on 11/03/20 at 1:20 PM.

Based on observation, review of National Fire Protection Association (NFPA) 1 standards and interview, it was determined the facility failed to ensure that the Critical Access Hospital (CAH) was maintained in a manner to ensure the safety and well-being of patients in that one of one fire barrier wall was not sealed in three locations with fire-proof sealant outside of the mechanical room. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:
A. Review of NFPA 1, 12.9.6.2 showed penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, shall be protected by a system or material capable of restricting the transfer of smoke.
B. Observations on 11/04/20 at 9:23 AM outside of the mechanical room showed one of one fire barrier wall with three holes measuring 10"x10" hole with 8" diameter pipe penetrating the wall, 6"x12" hole with a 2" pipe penetrating the wall, 3"x8" hole with a 2" pipe penetrating the wall.
C. The above finding in B was verified 11/4/2020 at 9:30 AM by the Director of Maintenance.


Based on review of the Rules and Regulations for Hospitals and Related Institutions, observation and interview in Exam Room 1, it was determined the Facility failed to follow standards of practice in the organization of building maintenance in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that the exam room did not have a visual mechanism to constantly monitor the pressure status. The failed practice had the potential to affect all patients admitted to the exam room. Findings follow:
A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 44.C.7 requires a visual mechanism to constantly monitor the pressure status in a room occupied by a patient with an airborne infectious disease.
B. The above finding in A was verified by the Director of Maintenance on 11/3/2020 at 10:49 AM.


Based on observation, review of National Fire Protection Association (NFPA) 1 standards and interview, it was determined the facility failed to ensure that the Critical Access Hospital (CAH) was maintained in a manner to ensure the safety well-being of patients in that the kitchen fire extinguisher cabinet consisted of a silver fire extinguisher protruding approximating three inches beyond the front surface of the cabinet had the potential to dislodge, combust and explode. The risk of an explosion had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:
A. Review of NFPA 1, 13.6.8.1.3.6 showed fire extinguishers that are subject to dislodgement shall be installed with a manufacturer's strap-type bracket.
B. Observations on 11/03/20 at 1:00 PM in the kitchen showed fire extinguisher cabinet consisted of a silver fire extinguisher protruding approximating three inches beyond the front surface of the cabinet.
C. The above finding in B was verified 11/03/20 at 1:03 PM by the Director of Maintenance.

Based on policy and procedure review, clinical record review and interview it was determined that 5 (#1, 6, 10, 13, and 18) of 23 (#1-23) patients did not have a signed consent for treatment. Failure to provide patients with consent for treatment on admission did not allow patients or their caregivers to make knowledgeable, informed and clear decisions regarding their care. The failed practice had the likelihood to affect all patients admitted to the Facility. Findings follow:

A. Review of policy and procedure titled "Patient Access Scope of Services" received 11/06/20 at 10:50 AM showed "The clerk will also have the patient/parent/guardian sign the consent to treatment ..."
B. Review of clinical records on 11/4/20 at 1:00 PM showed no consent for treatment for patients #1, 6, 10, 13 and 18.
C. During an interview with the Director of Nursing (DON) 0n 11/06/20 at 10:50 AM she stated the Patient Access Policy is a policy from a sister facility but is what the staff at their facility refer to.
D. The above findings in A and B were verified with the Director of Nursing on 11/04/20 at 2:45 PM.
E. The above finding in C was verified on 11/06/20 at 10:50 AM with the DON.

Based on observation, review of policy and interview, it was determined the facility failed to store medications securely in one (Surgical Services) of two (Surgical Services and Emergency/Med/Surge) medication refrigerators observed. By not securing the medications in the medication refrigerator, the facility could not assure unlicensed personnel did not have access to the medications. The failed practice had the likelihood to affect all the patients treated at the facility: Findings follow:

A. During a tour of the facility on 11/03/20 from 10:03 AM to 11:00 AM, observation showed a Medication Refrigerator in Surgical Services that was unlocked. The refrigerator did not have a locking mechanism on it. The medications in the refrigerator included:
1) #5 vials of Rocuronium Bromide 50mg (milligram)/5ml (milliliter);
2) #5 vials of Succinylcholine 200mg/10ml; and
3) #5 vials of Famotidine 20mg/2ml.
B. Record review of the facility's policy titled, Medication Storage Policy, dated 01/30/2019, showed that medications were to be inaccessible to unauthorized personnel at all times.
C. During an interview on 11/03/20 at 10:07 AM, the Director of Nursing verified the medications in the Medication Refrigerator were not secured, and that unlicensed personnel had access to the unsecured medications.

Based on review of manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for storage of IV (Intravenous) solutions in one of one fluid warmer. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required IV fluids. Findings follow:
A. Review of Manufacturer's storage recommendations for Baxter Lactated Ringers IV solutions showed they could be warmed for a period of no longer than 14 days.
B. During a tour of the facility on 11/03/20 from 10:03 AM to 11:00 AM, observation showed two Baxter Lactated Ringers 1000 milliliter IV solutions in a warmer. Neither of the products were dated to assure they didn't exceed the Manufacturer's recommendation for length of stay in a warmer.
C. During an interview on 11/04/20 at 1:12 PM, the Director of Pharmacy verified the findings at B.

Based on review of policy and procedure, review of the Radiation Safety Division Proper use of Dosimeters, observation and interview, it was determined the facility failed to ensure personal radiation dosimeters were stored with controls, in a radiation free environment, and with dosimeters of the same type and wear date when not in use. The failed practice did not ensure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected all employees in the Radiology department. Findings follow:
A. Review of policy and procedure received 11/03/20 titled "Radiation Safety Policy" showed the radiation monitor shall be worn only at Mercy Hospitals or any of the satellite locations.
B. Review of the Radiation Safety Division Proper Use of Dosimeters showed do not take your dosimeter home and do not store or leave your dosimeter near radioactive material.
C. Observation while on tour of the radiology department on 11/03/20 at 10:00 AM showed no designated storage area for dosimetry badges when not in use.
D. During an interview with the Radiology Manager on 11/03/20 at 10:00 AM she stated that the radiology employees take their dosimetry badges home at the end of each day.
E. The above finding in A, B, C, and were verified with the Director of Nursing on 11/03/20 at 10:30 AM.

Based on policy and procedure review, review of employee files and interview it was determined the Infection Control Program did not employ methods for preventing and controlling transmission of infection in that 2 (#7 and 8) of 10 employees did not receive or refuse the Hepatitis B vaccination series. Failure to ensure employees had the choice of receiving or refusing the Hepatitis B vaccination series did not ensure prevention and control of blood borne pathogen transmission within the healthcare setting. Findings follow:
A. Review of policy and procedure titled "Immunization for Hepatitis B" received 11/05/20 showed "Hepatitis B vaccine is available to personnel considered to be at risk ... Those co-workers who do not want the vaccine must sign "Co-worker Refusal for Hepatitis B Vaccine."
B. Review of employee files on 11/03/20 at 9:30 AM showed employees #7 and 8 had not received the Hepatitis B vaccination or signed a "Co-worker refusal for Hepatitis B Vaccine" form.
C. The above findings in A and B were verified by interview with the Director of Nursing on 11/03/20 at 10:15 AM.




43428

Based on observation and policy review it was determined the facility failed to mitigate the risk of COVID-19 for all patients and visitors entering the facility by not asking the screening questions for signs and symptoms of COVID-19, including, history of a fever, a cough, shortness of breath, fatigue, or exposure to anyone with COVID-19. This failed practice did not allow for screening questions for COVID-19 and had the likelihood to affect all patients and visitors entering the Facility and expose them to potential transmission of COVID-19 virus. Findings follow.
A. Review of facility policy titled "Coronavirus Disease Infection Prevention Guidance COVID-19, Patient Screening" showed, "Entry into the Facility will be limited to be able to actively screen visitors and patients for symptoms of COVID-19. Patient Screening per CDC ( Centers for Disease and Control) guidelines and Mercy's Hospital System infection prevention documentation, should include, checking temperature and signs and symptoms including, cough , shortness of breath, sore throat, chills body aches, headaches, fatigue, new loss of taste or smell, nausea, vomiting or diarrhea."
B. Observation from 11/02/20-11/05/20 showed, during entry to the Facility on four of four days for five of five people the CDC COVID-19 guidelines screening questions were not asked on entry to the hospital.


Based on observation, interview and review of , APIC (The Association for Professionals in Infection Control) documentation, it was determined the facility failed to follow acceptable standards of practice in that one of one syringe was found in the drawer of the anesthesia cart, unwrapped from sterile packaging, with needle attached. By not assuring the integrity of the outer package of the syringe the facility failed to prevent and control the transmission of infection for anyone receiving care in the operating room at the facility. This failed practise had the potential to affect anyone receiving care in Operating room 1.
A. Review of APIC position paper titled, "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)" showed to; Avoid having nonsterile contact with sterile areas of devices, such as syringes and to never store needles and syringes unwrapped because sterility cannot be ensured. Keep bulk unwrapped syringes in the original package.
B. During tour of Operating room 1, on 11/03/20 at 10:05AM, showed, on opening the anesthesia cart, one of one unwrapped 5 cm syringe with needle attached.
C. The findings in B were verified during an interview with the Director of Nursing on 11/03/20 at 10:35 AM.

Based on observation and interview it was determined the facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection in that in one of one Decontamination Room in the Operating room Suite for the Facility, there was an overflowing trash can and a medium size sharps container, with was filled to overflowing, with unsanitary contaminated disposable surgical instruments in it. In Operating Room 1 there was also a medium sized sharps container with used disposable instruments in it which were visibly contaminated with bodily fluids, with lid open with instruments sticking out of the top. The failed practice had the potential to affect any patient rendering care within the Operating Suite of the facility, or for potential to exposure to infection for the facility employees. Findings follow.
A. Review of Policy and Procedure titled, "Standard Isolation Precautions" dated, 01/01/20 showed Section H number 3, disposable patient care equipment; a variety of disposable patient care equipment is available and should be considered for all patients. Use of these disposable articles reduces the risk that equipment will serve as a fomite, but they must be disposed of safely and adequately.
B. Review of policy titled, "Infectious Waste Definitions" dated 07/21/20 showed; contaminated items that release blood or body fluids during handling and that contaminated disposable items shall not be washed but treated as a contaminated item and disposed of safely.
C. During tour of operating suite, Operating Room 1 on 11/03/20 at 10:35 AM showed; in Operating Room 1 an overflowing medium sharps container with large disposable operating room instruments that were sticking out of the top of the sharps container and were visibly contaminated with blood.
D. During tour of decontamination room, a trash can was filled to overflowing and there was a medium sized sharps container on the floor open with used disposable instruments that were contaminated with blood.
E. During tour of Facility and interview on 11/03/20 at 10:40AM, with Infection Preventionist and Director of Nursing it was stated that, the trash can and two filled sharps containers had been in the Operating room and the Decontamination room since the prior surgery which was approximately 2 weeks ago.


Based on observation and review it was determined the facility failed to assure the building was clean and sanitary, in that one of one Triage room within the Emergency room, had a vinyl chair, with arm extension for blood drawing accessibility for patients, that had multiple areas of rust on the legs of the chair. The chair seat also had a spillage area on the seat of the chair of an unknown substance and was visibly soiled. There was a vital sign machine that was dusty and unsanitary. There were multiple areas of chipped paint. The floor was also noted to be dirty. Failure to maintain the building in an intact and sanitary environment could not assure that source and transmission of infection could be avoided. This failed practicehad the potential to affect any patient whose care was rendered in the Emergency Room. Findings follow.
A. Review of Policy and Procedure titled, "Standard Isolation Precautions," dated 01/01/2020, showed section G #1, Routine cleaning should be performed, with cleaning and disinfection of all patient care areas and should focus on all surfaces and those most likely to be contaminated with blood and body fluids.
B. Review of Policy and procedure, titled "Infection Prevention, Department Responsibilities," dated 01/01/2020 showed; Environmental services responsibility, that cleanliness depends upon the frequency and thoroughness of cleaning procedure for the total hospital environment.
C. Observation on 11/03/20 at 10:48 AM showed the triage chair in the emergency room with large amount of rust on the legs of the chair. The seat for the chair also had a spillage area in the middle of the seat.
D. Observation on 11/03/20 at 10:49AM, showed the vital sign machine with a large amount of dust.
E. Observation on 11/03/20 at 10:50 AM showed multiple areas on all the walls with chipped paint as follows: one above phone table, one directly above triage chair, one above light switch, one between light switch and triage chair.
F. Observation on 11/03/20 at 10:51 AM showed the floor of the triage room to not be clean and sanitary with generalized areas of old spillage and dust noted.
G. During tour and interview on 11/03/20 at 10:52 AM findings of C, D, E and F were verified with Director of Nursing.