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Based on observation and interview, the CAH failed to disinfect the shower area in between patients for 1 of 1 (P5) patients to prevent the transmission of infection. Findings include:

P5 was admitted to the hospital on 6/21/10 to a swing bed following a total knee arthroplasty. On 6/22/10 at 8:45 a.m. the patient was assisted with a shower in the shower room located in the left corridor. During the environmental tour at 9:00 a.m. the emergency medical technician (EMT)-A who was providing direct patient care was interviewed regarding the disinfection of the shower stall. He stated there was no procedure to disinfect the shower stall after patient use, and verified the shower stall had not been cleaned/disinfected. He added that the housekeeping staff clean the room once a day. EMT-A stated patients are provided showers either in the shower room in the left corridor or in patient room #70 in the right corridor.

On 6/23/10 at 10:00 a.m. the director of nursing was interviewed regarding the disinfection of the shower area between patients. She verified disinfection should take place between patients. A policy/procedure was requested and none was provided.


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Based on interview and policy review, the CAH failed to designate an individual who is responsible for the operation of the Outpatient Services department. Findings include:

The facility's outpatient departments included Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Infusion Out Patient Surgery, Radiology and Laboratory. Review of the organizational chart indicated it did not delineate that one person was in charge of outpatient services. Review of the policies and procedures and director of nursing job description did not indicate who was in charge of outpatient services.

Interview with the director of nursing at 12 noon on 6/23/10 confirmed the CAH did not have documented information to indicate who was in charge of outpatient services and did not have a description for the coordination of outpatient services.

Based on observation, interview, and record review, the CAH failed to ensure a comprehensive care plan was developed for 3 of 20 (P4, P5, P7) inpatients reviewed. Findings included:

P4 was admitted to the facility on 6/21/2010 after experiencing a fall. P4 was observed on 6/22/2010 at 9:50 a.m. to require extensive assistance with transfers and mobility, had an unsteady gait, cognitive impairment, complained of pain with movement, and had skin abrasions on both knees. Review of P4's care plan revealed the following problem areas: "Pain" with interventions that included, "Administer medications as ordered. Pain management prior to activities. Develop pain management program with patient (Medication regime, Non-med pain reducing techniques-relaxation music) Teach: Relaxation Techniques (Deep Breathing Exercises). Encourage use of Relaxation Techniques (Deep Breathing Exercises). The care plan did not include fall precautions, transfer and mobility considerations, specific pain medication interventions, or care interventions related to the abrasions on P4's lower extremities.

Registered Nurse (RN)-B, interviewed on 6/22/2010, at 1:50 p.m. confirmed that P4's care plan had not been fully developed.


P5 was admitted to the hospital swing bed on 6/21/2010, following a right knee replacement. P5 was observed on 6/22/2010, at 9:15 a.m. at which time there was a dry/intact incision on the right knee, she ambulated with the use of a front wheeled walker, stated she had pain with movement, and had a continuous passive motion (CPM) machine available for use to assist with bending the knee 0-90 degrees. Review of P5's care plan revealed the following problem areas: Achieve optimal BM elimination pattern (Bowel movements at least every 2-3 days, Able to describe components of effective bowel pattern, Explain rationale for lifestyle change). The care plan did not include interventions related to incisional care, transfer and mobility, pain management, or use of the CPM machine.

Registered Nurse (RN)-B, interviewed on 6/22/2010, at 1:50 p.m. confirmed that the patient's care plan had not been fully developed.


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P7 was admitted to the hospital on 6/20/10 with abdominal pain and a partial small bowel obstruction (SBO). The patient was NPO (nothing by mouth) and receiving intravenous fluids. She received packed blood cells due to anemia on 6/21/10. The patient's condition was not improving and was transferred to an acute care hospital in Duluth on 6/23/10.

The care plan only listed "Risk of Infection" with interventions to prevent infections. However, the care plan did not address the primary diagnosis of SBO or interventions to manage pain.

The director of nursing was interviewed on 6/23/10 at 10:30 a.m. and verified the plan of care was not complete. She stated that the hospital recently went to electronic medical records the beginning of May and staff are still learning the process. She also verified that staff have had training in the development of care plans.

Based on interview and record review, the CAH failed to ensure medical records were complete for 7 of 25 patient (P1, P2, P3, P6, P9, P10 and P12) medical records which did not include the time of day the physician had written orders and/or the physician signed the orders. Findings include:

P1 was admitted to the facility on 5/31/10 and had four physician's verbal orders for medication from 6/1/10-6/710 that were not signed or dated by the physician.

P2 was admitted to the emergency room on 6/23/10 and had one verbal order that was not signed or dated by the physician.

P3 was admitted to the emergency room on 6/17/10, and it was noted in the patient's record that verbal orders were written that were not signed and dated by the prescribing physician.

During interview with RN-B on 6/25/10 at 1:50 p.m. she confirmed that the verbal orders for P-1, P-2, and P-3, were not signed and dated by the prescribing physician.


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P6 was admitted to the hospital for outpatient surgery on 6/1/10. The surgical consent was signed by the physician (Phy-A) but lacked a date and time next to the signature. The record also contained a Surgical Checklist which is signed by the physician indicating the patient was examined and is an acceptable candidate for the proposed procedure and authorizes anesthesia. The form was signed by the physician but lacked a date and time.


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P9 was admitted to the facility on 02/22/10 and discharged 2/27/10. The medical record had two physician's (Phy-A) orders dated 2/23/10 and 2/25/10 that did not include the time of day the orders were written.

P10 was admitted to the facility on 09/28/09 and discharged on 9/30/10. The medical record had three physician's (Phy-B) orders that did not include the time of day they were written. One order was dated 09/28/09 and two of the orders were dated 09/29/09 and did not include the time of day they were written.

P12 was admitted to the facility on 04/27/10 and discharged on 4/28/10. The medical record had physician's (Phy-B) orders that did not include the time of day it was written. Record review indicated there were six physician orders that did not include the time of day the order was written.

Interview with the compliance officer at 8:40 a.m. on 6/23/10 confirmed that P9, P10, and P12 records did not have times included when physician's orders were written. She further indicated they do not review for times when physician's records are reviewed and indicated they were reviewed for dates and for signatures.

Interview with the Medical Record Director on 6/23/10 at 10:00 a.m. indicated that the medical record department does not flag charts as incomplete for the physician if dates and/or times are lacking.

Based on interview and policy review, the CAH was found not to be in compliance with the Condition of Participation of Surgical Services. The CAH failed to ensure proper sterilization of surgical instruments for 9 of 9 (OPS 1-9) patients who underwent cataract extraction with intraocular lens implant. This potentially could effect most patients provided eye surgery at the CAH. Findings include:

During the tour of the surgical department on 6/22/10 at 2:30 p.m. the Surgical Services Director (SSD) was interviewed regarding the use of flash sterilization. He stated the microsurgical eye instruments are washed between cases and then placed in the flash sterilizer in a tray (not wrapped) and the high speed autoclave cycle is used for 10 minutes. The SSD stated there were 9 eye cases (OPS 1-9) on 6/21/10. The ophthalmologist brings with them two sets of the microsurgical instruments used for cataract extractions and the instruments are sterilized using flash sterilization. The manufacturer recommendations for use of flash sterilization on surgical instruments was requested.

On 6/23/10 at 11:25 a.m. the SSD provided a copy of the recommendations from Bausch & Lomb pertaining to sterilization of microsurgical instruments. He stated that the CAH was using the high speed (flash) autoclave at 270 degrees Farenheit for 10 minutes (unwrapped). However, the recommended procedure indicated to use the Prevacuum high temperature (274 degrees Farenheit for 3 minutes or 270 degrees Farenheit for 4 minutes, wrapped). The SSD verified the instruments are not wrapped prior to placing in the flash sterilizer.