HospitalInspections.org

Based on observations and interviews, the facility failed to ensure that health care services are furnished in accordance with appropriate written policies (Cross Reference C0271 and maintain an infection control program to prevent the transmission of disease (Cross Reference C0278).

Based on observation, policy and procedure review, and interview, it was identified that not all staff were familiar with the policy and procedure relating to cleaning the Hospital glucose meter.

Findings include:

During the initial tour of the emergency department on 4/12/16 it was identified that staff were not familiar with the policy and procedure for cleaning the hospital glucose meter.

Review of the facility's policy and procedure entitled "Blood Glucose Testing Monitoring: Nova StatStrip ... ", revealed the following instructions on page 3 under the section entitled "Cleaning the Meter: 1. Clean the outside of the meter with an Oxavir TB wipe after each use (between every patient)..."

Interview with Staff A (RN Emergency Department) confirmed the above findings.

Based on observations, record review, policy and procedure review and interview the facility failed to ensure that appropriate infection control practices that meet professional standards were implemented at all times.

Findings include:

During the initial tour of the main nursing unit on 4/12/2016 at approximately 10 A.M. it was observed by this surveyor that in room 217 a nurse was sitting on the side of the patient bed placing an IV catheter. The nurse was observed to be wearing only one protective glove. The other hand was making direct patient contact with no protective equipment. Also during this observation it was identified that the room was set up for precaution measures.

Interview with Staff H (Unit Manager) revealed that the patient in room 217 was being treated for C-Difficile (Clostridium Difficile Colitis) and that the nurse was an Emergency Department nurse and Staff H would need to "speak with her".

Review of the facility's Policy and Procedure entitled, "Clostridium Difficile Policy" #IC-IP203 with a last revision date of 3/15, page 1 of 2 under the heading "Suspect Cases" #1 bullet 2 revealed the following: "Gloves are to be used for all patient contact and hands should be washed after removing gloves."

During the initial tour of the main nursing unit on 4/12/16 at approximately 10:15 a.m. it was observed by this surveyor that there were 3 consecutive rooms, #217, #218 and #219 that were identified with patient's diagnosed with C-Difficile.

Outside each precaution room there was a precaution cart with all the necessary PPE (Personal Protective Equipment) for use in that room. On the cart outside room #218 there was a container with non-bleach wipes which are not effective on C-Difficile.

Interview with Staff H revealed, "these are not the correct wipes for this precaution cart" and Staff H immediately removed these wipes from the precaution cart.

During the initial tour of the emergency department on 4/12/16, it was identified that staff were not familiar with the policy for cleaning the glucose hospital meter.

Interview with Staff A (RN Emergency Department) and Staff C (Tech) both Staff indicated they use alcohol wipes to clean the glucose meters.

Review of the facility's policy and procedure entitled, "Blood Glucose Testing Monitoring: Nova StatStrip ... ", revealed the following instructions on page 3 under the section entitled "Cleaning the Meter: 1. Clean the outside of the meter with an Oxavir TB wipe after each use (between every patient)..."

Interview with Staff A (RN Emergency Department) confirmed the above findings.

During the initial tour on the OB (Obstetrics) department on 4/13/16 with Staff B (RN OB) it was determined that 1 of 2 hospital glucose meters on the OB unit had a brown substance on the back of the meter.



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Interview with Staff D (Registered Nurse) from the coumadin clinic on 4/13/16 at 10:30 a.m. revealed that Staff D cleaned the exterior coagucheck XS used for INR (International Normalized Ratio) testing once at the end of each day of testing. It was also revealed Staff D tested approximately 15 patients a day.

Interview with Staff E (Register Nurse) from the coumadin clinic on 4/13/16 at 10:40 a.m. revealed that Staff E cleaned the exterior coagucheck XS used for INR testing once at the end of each day of testing. It was also revealed Staff E tested approximately 20 patients a day.

Tour of the radiology department on 4/12/16 at 11:00 a.m. revealed that there were no cleaning wipes available in the bone density room.

Interview with the Staff F (Director of Radiology) on 4/12/16 at 12:30 revealed that the bone density table pad was cleaned with soap and water from the hallway between patients. Staff F further revealed it was not disinfected because it was against manufacturer's instructions.

Review of manufacturer's instructions for the Discovery QDR Series Bone Densitometer revealed cleaning the table pad with soap and water and disinfecting the table pad with a phenolic or quaternary type disinfectant.

Based on record review and interview, the facility failed to ensure that agreements for services provided in the Critical Access Hospital (CAH) were kept current.

Findings include:

Record review on 4/12/16 of this facility's agreement for credentialing and quality assurance signed by the facility and by the qualified entity in 2013, revealed an expiration date of 12/31/13.

Interview on 4/12/16 with Staff G, (Chief Nursing Officer), established that there is no updated contract but the entity has been providing services since 12/31/13 without a contact, and they are getting a new contract today. The facility subsequently provided for review, a copy of the CAH's Agreement for Regulatory Compliance Support in Meeting Requirements Contained in the CMS (Centers for Medicare and Medicaid) Critical Access Hospital Conditions of Participation which is signed by both parties, and has an effective date of 4/13/16.

Record review of the CAH's Patient Referral and Transfer Agreement with an area hospital revealed that this agreement commenced on 3/1/08 and "shall continue for a period of two (2) years unless sooner terminated as herein provided...." The facility provided documentation dated 4/13/16 that indicated the area hospital thought it was auto renewal, however it's not reflected in the contract.

Based on record review and interview it was determined that the Critical Access Hospital failed to maintain complete patient medical records. (Patient identifiers are #3, #4, #5, #8 and #25.)

Findings include:

Record review on 4/12/16 and 4/14/16 4 of ten emergency room patient records revealed four emergency room patient's (#3, #4, #5 and #8) were transferred to another hospital with incomplete documentation on the required transfer certificate.


Record review of record Patient #25 on 4/14/16 revealed that Patient #25 was 3 months old and was pronounced dead on 1/8/16 in the emergency room. Review of the Physician's narrative revealed that Patient#25 was a "38 month old child... and pronouned dead at on12/8/2015..".

During interview with Staff A (Registered Nurse) on 4/12/16 at approximately 2:00 p.m., after Staff A reviewed the above listed patient records, Staff A verbally confirmed that the emergency room transfer certificates for Patient's #3, #4, #5 and #8 were not complete.


Interview with Staff A on 4/14/16 verbally confirmed that Patient#25 medical record was incorrect and needed to be corrected with the correct information.