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425 NORTH ELM STREET

SAUK CENTRE, MN 56378

MAINTENANCE

Tag No.: C0914

Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure the dish machine was properly fixed to maintain correct temperatures during the washing and rinsing cycles. This had the potential to affect all patients receiving meals from the kitchen. .

Findings include:

During an observation on 5/13/24 at 11:53 a.m., the digital monitor used to display the wash and rinse cycle temperatures read "Rinse Error Contact Ecolab, wash 162.2 degrees Fahrenheit".

During an interview on 5/13/24 at 11:53 a.m., dietary manager (DM) indicated the digital monitor was hooked up because the temperature gauges on the dish machine did not work properly all the time. DM further indicated it had been over a year since the digital monitor was installed and it continued to have an error reading for the rinse cycle. DM stated the representative from Ecolab continued to come to the facility and say he was going to fix it but it had not been fixed. DM explained staff could use thermal strips as verification if the temperature was adequately hot but the strips could not verify an actual temperature.

On 5/13/24 at 3:28 p.m., contacted Ecolab to speak with facility representative regarding the dish machine. No return call was received.

On 5/14/24 at 3:00 p.m., contacted Ecolab to speak with facility representative regarding the dish machine. No return call was received.

During an interview on 5/14/24 at 4:10 p.m., dietary aid (DA)-A indicated the digital temperature monitor did not always work so the gauges attached to the dish machine would need to be read. DA stated the digital monitor read Contact Ecolab service representative (rinse error, wash 162.0). DA further indicated dietary staff could use a test strip to ensure the temperature got above 170 degrees Fahrenheit when dishes were being washed. DA identified the current test strips being used were called Ecolab Dishwasher Test Strips. The test strips were attached to a piece of silverware and put through the dish machine. If the tip of the strip paper turned bright orange, the dish machine's rinse cycle was within temperature range. DA further indicated "we can use the chlorine test paper too". DA found a bottle of test strips in the storage room and stated she would use the strips to check the concentration of the chlorine. DA dipped the test strip into the chlorine reservoir in the dish machine. DA read the strip by using the color coding on the bottle which identified the chlorine concentration was 100 parts per million (PPM). DA used Chlorine Test Paper lot #203222 and expiration date February 1, 2024. DA confirmed the test strips were expired and new ones would need to be used. DA contacted DM via phone and inquired about new Chlorine Test Paper that were not expired. DM indicated a bottle of Chlorine Test Strips had been given to the state surveyor for review and DA could request those test strips back. DM further indicated that bottle of Chlorine Test Strips were being used earlier in the day. State surveyor provided bottle of Chlorine Test Paper to DA to use during the supper dish machine run. The bottle of Chlorine test strips were labeled with code 4250-BJ and had an expiration date of 4/23, DA was informed and then DA confirmed the strips were expired. DA shared this information with the DM. DM and DA stated they were not aware that bottle of Chlorine Test Paper was also expired. DM indicated she would find new Chlorine Test Paper in the morning when she came into work.

During an interview on 3/15/24 at 2:42 p.m., DM and dietician indicated staff were required to check and record the dishwasher temperatures after every meal. DM and dietician further indicated staff were to use the Ecolab Dishwasher Test Strips during the middle of washing dishes for testing the water temperature and Chlorine Test Paper prior to washing dishes to ensure the concentration was within an acceptable range. DM and dietician confirmed the digital monitor and dish machine gauges were not a reliable at this time. DM further confirmed the dish machine's digital monitor was not working properly and the representative from Ecolab had not fixed the problem. DM stated she received regular service call reports from Ecolab but indicated nothing was reported about the digital monitor for temperature readings being serviced. DM indicated her expectations were staff were temping the dishmachine after every meal. If staff were unable to obtain the correct dishmachine temperature staff would use the Ecolab Dishwasher Test Strip/Chlorine Test Paper to ensure proper cleaning of the dishes. DM further indicated if staff did not know how to complete the process, staff was ask for help. Dietician stated her expectations were staff completed the dishmachine temperature the correct way to be sure sanitation guidelines were being met.

During an interview on 5/15/24 at 4:39 p.m., the facilities president indicated he was not aware the dish machine's temperature gauges and digital monitor were not working. The president further indicated his expectations were staff were to be following and meeting the compliance requirements.

Review of Regular Service Call logs from Ecolab dated 1/24/23 to 1/22/24, on 1/24/23 and 1/22/24 a picture of the digital monitor error was included. Requested Ecolab's response to the pictures however, one was not provided.

Review of facility policy Cleaning Dishes - - Dish Machine and Manual effective date 1/24, dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Prior to use, run the machine until verification of proper temperatures and machine function is made. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures.

LIFE SAFETY FROM FIRE

Tag No.: C0930

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K363 and K918 for additional information.

PATIENT CARE POLICIES

Tag No.: C1006

Based on observation, interview, and document review, the critical access hospital (CAH) failed to properly clean 1 of 1 Nova Statstrip Glucose monitor reviewed for blood glucose monitoring of patients.

Findings include:

On 5/13/24 at 4:39 p.m., registered nurse (RN)-A was observed using the Statstrip glucose monitor to check P24's blood glucose. RN-A retrieved the monitor from the charging dock at the nursing station, gathered her supplies and went to P 24's room. RN-A checked P24's blood glucose and immediately returned to the nursing station. RN-A applied clean gloves, took a moistened wipe from a container labeled, "Sani-Cloth Prime", with a symbol identifying "disinfects in 1 minute". RN-A held the Statstrip monitor in her left hand and utilized the wipe to wipe over the surface of the meter for 10-15 seconds. She returned the meter to the wall mount charger and removed her gloves. RN-A failed to allow the meter to remain in contact with the sanitizing solution per the manufacturer's recommendation of 1 minute. RN-A confirmed the solution was not in contact with the meter for the recommended time period and the monitor would have been used for the next patient without allowing any additional drying/decontamination time.

Review of the manufacture's written instructions located on the label of the Sani-Cloth Prime canister identified to Disinfect: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for (1) minute. Let air dry.

Interview on 5/13/24 at 4:45 p.m. with RN-A, RN-B, and RN-C reported they also had been following the same procedure for wiping off the Statstrip monitor following use, and had not been aware of the manufacturer's recommendation of allowing the surface to remain wet for 1 minute then allowing it to dry before use.

Interview on 5/13/24 at 4:49 p.m. with the nurse manager voiced her expectation for the Statstip glucose meter to be cleaned/disinfected according to the manufactures recommendations.

Interview on 5/15/24 at 3:00 p.m. with the infection practioner (IP) reported she was not aware staff were not following the manufacture's recommendations for wet surface time using the Sani-Cloth Prime wipes. IP expected staff to use the product in accordance with the label.

Review of the Standard Worksheet Process: Cleaning Glucose Meter (Nova Stat Strip) Desired Goal or Outcome to prevent cross contamination. Clean and disinfect both sides of meter ensuring good contact with the grip. Allow required wet contact time.

Review of the June 2022 CentraCare Sauk Centre Bedside Glucose monitoring policy identified Quality Control, cleaning the meter: Clean the meter with a hospital approved disinfectant wipe. Immediately follow with a water-dampened cloth to remove all cleaning residue. Dry thoroughly with a soft cloth or lint-free tissue. The outside of the meter/tote must be cleaned between each patient, for infection control purposes, using a disinfectant wipe approved by the health system.

NURSING SERVICES

Tag No.: C1049

Based on observation, interview and document review, the critical access hospital (CAH) failed to develop policies/procedure for self-administration of medication for 1 of 2 patients (P24) observed to self-administer a nebulized medication.

Findings include:

P24 had current physician orders for Brovana 15 micrograms (mcg)/ 2 milliliters ml) by nebulizer two times daily (BID) and Pulmacort 0.5 milligrams (mg)/2 ml BID.

Observation on 5/14/24 at 9:06 a.m. with registered nurse (RN)-C as she prepared to administer P24's morning medications. RN-C accessed the Omnicell patient medical record, identified the ordered medications and retrieved them from the unit. She referenced a pharmacy cheat sheet and determined the two nebulized medications were able to be combined in a single administration. RN-C went to P24's room, confirmed the patient identification, administered her oral (PO) medications, and placed both nebulized medications into the mask vial for administration. She connected the mask to the tubing, handed the mask with medication to P24 and turned on the nebulizer unit. RN-C then told R24 she would come back and check on her in 10 minutes and left the room with P24 holding the mask to her face. There was no strap or method to hold the mask in place other than P24 holding it with her hand.

Review of the current physician orders failed to contain an order that P24 was able to self-administer her medications.

During an interview on 5/14/24 at 9:15 a.m. with RN-C reported P24 did not have an order to self-administer her medications and that she usually remained in attendance while P24 had her nebulizer treatment, but had not done so this morning.
RN-C reported she should have remained in attendance in P24's room to supervise as she finished her treatment.

During an interview on 5/15/24 at 2:30 p.m. with the director of nursing (DON) reported her expectation for a patient to have an order on their current physician orders if they were able to self administer a medication/nebulizer treatment, otherwise the nurse was to remain in attendance during the treatment.

Review of the November 2022 Medication Administration Policy identified were to be administered as ordered by the medical provider. The five rights of medication administration were listed and included medication name, dose, route, frequency, and rate. Nursing staff who administered a PO medication were to remain in attendance until the medication was taken. The policy failed to address nebulized medications and if a patient was able to self-administer the medication without the nurse remaining in attendance.

QAPI

Tag No.: C1321

Based on observation, interview, and document review, the critical access hospital (CAH) failed to identify the systematic dish machine sanitation gap and include it in the Quality Assessment and Performance Improvement (QAPI) plan (a creative problem solving to maintain and enhance quality). This had the potential to affect all the patients receiving meals from the kitchen.

Findings include:

Review of Dishmachine Temperature Log - CentraCare Health Sauk Centre dated May 2023 through May 2024 revealed the following:
-5/23, 4 days of missing recorded temperatures and chlorine tests for 1-2 meals.
-6/23, 18 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals.
-7/23, 20 days of missing recorded temperatures and chorine tests for 1-2 meals.
-8/23, 13 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals.
-9/23, 10 days of missing recorded temperatures and chorine tests for 1-2 meals and 4 full days of missing recorded temperatures and chlorine tests for all meals-June 2023 18 days of missing recorded temperatures and chorine tests for 1-2 meals and 1 full day of missing recorded temperatures and chlorine tests for all meals.
-10/23, no temperature log was provided.
-11/23, 22 days of missing recorded temperatures and chorine tests for 1-2 meals and 7 full days of missing recorded temperatures and chlorine tests for all meals.
-12/23, 9 days of missing recorded temperatures and chorine tests for 1-2 meals and 6 full days of missing recorded temperatures and chlorine tests for all meals.
-1/24, 19 days of missing recorded temperatures and chorine tests for 1-2 meals and 9 full days of missing recorded temperatures and chlorine tests for all meals.
-2/24, 16 days of missing recorded temperatures and chorine tests for 1-2 meals and 7 full days of missing recorded temperatures and chlorine tests for all meals.
-3/24, 17 days of missing recorded temperatures and chorine tests for 1-2 meals and 11 full days of missing recorded temperatures and chlorine tests for all meals.
-4/24, 11 days of missing recorded temperatures and chorine tests for 1-2 meals and 9 full days of missing recorded temperatures and chlorine tests for all meals.
-5/1/24 to 5/12/24, 4 full days of missing recorded temperatures and chlorine tests for all meals.

During an observation on 5/13/24 at 11:53 a.m., the digital monitor used to display the wash and rinse cycle temperatures read "Rinse Error Contact Ecolab, wash 162.2 degrees Fahrenheit".

During an interview on 5/13/24 at 11:53 a.m., dietary manager (DM) indicated the digital monitor was hooked up because the temperature gauges on the dish machine did not work properly all the time. DM further indicated it had been over a year since the digital monitor was installed and it continued to have an error reading for the rinse cycle. DM stated the representative from Ecolab continued to come to the facility and say he was going to fix it but it had not been fixed. DM explained staff could use thermal strips as verification if the temperature was adequately hot but the strips could not verify an actual temperature.

During an interview on 5/15/24 at 2:42 p.m., DM and dietician confirmed the above findings and indicated they were aware of the the days that staff did not record temperatures or test strip readings following every meal. DM and dietician further indicated they were aware of the days staff did not record temperatures or test strips for the entire day. DM stated changes have taken place in the dietary services and different staff had been responsible for washing dishes in the dishmachine. DM further stated the new staff may not have been aware of the policy or how often temperatures and test strip readings needed to be completed. Dietician indicated the department was aware of the issue but was not/has not been a QAPI project, however, they were going to be working on the dishmachine gap going forward. Dietician further indicated the current QAPI projects were Press Ganey Scores (determining how hospitals are dedicated to enhancing a patient's experience of food during their stay) food temps, and food quality.

During an interview on 5/15/24 at 3:15 p.m., registered nurse infection preventionist (RNIP) indicated she was not aware of any sanitation concerns in the dietary department and nothing had been discussed during QAPI meetings. RNIP further indicated her expectations were staff must be following the temperature guidelines and policies on a daily basis for the safety of patients, family, and staff.

During an interview on 5/15/24 at 4:39 p.m., the facilities president indicated he was not aware the dish machine's temperature gauges and digital monitor were not working. The president further indicated his expectations were staff were to be following and meeting the compliance requirements.

Review of manufactures documentation on Sodium Hypochlorite Solution/Dishmachine Sanitizer (current chlorine solution being used in the facilities dish machine) not dated, dishmachine sanitizer kills bacteria on contact in as little as 50 PPM. Can be used in high-temp machines when booster heater fails to reach 180 degree final rinse temperature.

Review of the facility policy titled Kitchen/Food Service Observation dated 10/22, manual water temperature solution shall be maintained at no less than 110 degrees Fahrenheit. After washing and rinsing, dishes are sanitized by immersion in either: how water (at least 171 degrees Fahrenheit) for 30 seconds; or a chemical sanitizing solution. If explicit manufacture instructions are not provided, the recommended sanitation concentrations are as follows: chlorine: 50 - 100 parts per million (PPM) 10 second contact time.

Review of facility policy titled Cleaning Dishes - - Dish Machine and Manual effective date 1/24, dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Prior to use, run the machine until verification of proper temperatures and machine function is made. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures.

Review of facility policy titled Quality Assurance/Performance Improvement - Nutrition Services effective date 1/24, each year, the food service and nutrition departments should set goals based upon desired outcomes or identified gaps. Steps will be taken to assure quality and safety of foods served, and adequacy of nutrition services and documentation. The QA/PI surveys may include sanitation audits. The sanitation audit form is intended to be open-ended. Use the guidelines in the infection control and sanitation section when evaluating the sanitation status of the food service department.

Hospital CAH and LTC Emergency Power

Tag No.: E0041

Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2, and 8.4.9.7. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.