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Based on staff interview, water agreement review and policy review, the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency. This had the potential to affect all patients and staff of the CAH.

Findings include: During review of the CAH's emergency policies it was noted there was an agreement in place for water delivery in case of an interruption in normal water supply with Culligan Water Conditioning of Brown County. However, the policies lacked identification of determination of the need for potable/non-potable water as well as determination of estimated amounts required for use by individual CAH departments. The terms and conditions of the agreement stated; "Culligan Water Conditioning of Brown County will provide the SEMC (Sleepy Eye Medical Center) with the provisions of bottled drinking water as the inventory of the Culligan Water Conditioning of Brown County permits" .

During interview with Maintenance staff- G at 2:00 p.m. on 8/8/11, he indicated he had not been aware of any plan which specified amounts of water required by the individual departments in the CAH, nor of the need to plan for specified amounts of potable versus non-potable water in the event of an emergency. Maintenance staff-G indicated that Culligan Water Conditioning of Brown County would provide potable water and stated that a water tankard could be utilized. He further stated that in the case of a tankard be needed, they had not thought about how to distribute, etc.

During interview with the RN (Registered Nurse)/Infection Control Practitioner (ICP) also at 2:00 p.m. on 8/8/11, she concurred the facility had not developed a plan that included the amount of water required during an interruption of normal water supply nor had a plan that included distribution been included. Both the RN/ICP and Maintenance staff-G confirmed the CAH lacked a written plan /policy for specific amounts of water that may be required for use during an emergency situation. Both staff stated they had been members of the CAH's Emergency Preparedness Program.

During interview with the Administrator at 2:30 p.m. on 8/9/11, he provided no further information.

Based on observation, policy review and staff interview, the hospital failed to ensure that proper cleaning of the common use glucometer was routinely implemented when used for multiple patients. This had the potential to affect all patients who required blood glucose readings at the bedside. In addition, based on employee record review, policy review and interview, the facility failed to ensure that their policies related to Tuberculosis (TB) control were followed and implemented for 2 of 3 newly hired employees.

Findings include: Proper cleaning of the glucometer used for multiple patients had not been implemented as required by hospital policy.

It was observed at 11:00 a.m. on 8/5/11, that a newly hired RN (registered nurse)-A checked the blood glucose level for P1 with the use of a hospital glucometer. RN-A stated the glucometer did not require routine cleaning unless "blood" was evident on the machine. However, RN-A was observed to cleanse the glucometer with an alcohol wipe after measuring the blood sugar for P1.

During interview with the charge RN-B at 11:40 a.m. on 8/5/11, she stated the hospital had "trialed" a bleach solution wipe to clean the glucometer, however she stated the nursing staff had not liked it as it left a film and was "too wet". RN-B checked in the drawer at the nurses' station for the wipes and when there were none available she indicated they have not used the "trial" wipes for a couple of weeks.

During interview with the Director of Nurses (DON) at 9:45 .am. on 8/8/11, she confirmed that there were no Gluco-chlor wipes (bleach solution wipes referenced by RN-B) in the designated drawer at the nurses' station. The DON stated she had not been notified by nursing staff that she needed to order more wipes. Upon further review of the issue, the DON stated there had likely been no wipes available since the weekend of 8/5/11. The DON confirmed that because no wipes had been readily available, the staff would not have been able to ensure proper cleaning of the glucometer between patients. The DON verified the newly hired RN-A may not have been aware of the Gluco-chlor wipes as she had only worked at the CAH for a couple of weeks. However, the DON stated that RN-B had previously been informed of the hospital policy regarding the use of the Gluco-chlor wipes for proper glucometer cleaning.

Interview with the Infection Control Practitioner (ICP)/RN at 10:12 a.m. on 8/8/11, confirmed the protocol for cleaning the glucometer had been discussed at nursing meetings held 11/16/10 and 1/13/11. The ICP/RN stated that two products had been trialed which included Sani-wipes and Gluco-Chlor wipes. She stated the nursing staff had preferred the Gluco-Chlor wipes and not the Sani-wipes because they had complained the Sani-wipes left the glucometer too wet. The ICP/RN stated she too had been unaware that they had run out of the Gluco-chlor wipes. She stated that no nursing staff had reported to her that their supply had run out. The ICP/RN stated that she had developed a policy for 'glucometer cleaning' on 8/8/11 but that it had not yet been presented to the infection control committee for approval and was currently in "draft" form. Review of the draft policy indicated the following: "glucometers used for multiple patients are cleaned and disinfected between patients; cleaning and disinfecting glucometers between patients is designed to prevent transmission of potentially harmful pathogens".

The facility failed to implement their policy related to testing employees for freedom from TB.
Two of three newly hired employees did not receive Tuberculin skin testing per policy guidelines.

A policy titled: "SEMC TB Control Plan" last revised 2/2011, identified the following: "SEMC will have....skin testing program to protect patients, employees and visitors from transmission of TB...The Infection Preventionist....shall manage the program including: Tuberculosis Skin Testing (TST) program for Healthcare Workers." The facility policy specifically identified recommendations for screening of newly hired healthcare workers including: "No previous TST testing- Two-Step baseline TST...Previous documented negative TST results 12 months or less before new employment- Single TST needed for baseline testing; this will be the second step..."

Staff 1, with a hire date of 2/14/11, had a previously documented negative TST result from 8/5/10. Although the facility policy indicated she should have received a single TST baseline test at the time of hire, staff 1 did not receive any TST upon hire.

Staff 3, with a hire date of 10/12/10, had no documented previous TST. Per facility policy guidelines, staff 3 required a two-step baseline TST. Staff 3's employee record revealed she had received only a single step mantoux when hired.

During interview with the RN (registered nurse) Infection Control Practioner at 10:00 a.m. on 8/9/11, she verified that staff 1 should have received a TST upon hire, and that staff 3 should have had a second step mantoux within 3 weeks following her first step TST.

Based on interview and record review, the CAH (Critical Access Hospital) failed to ensure the governing body received reports evaluating provision of care by anesthesia services which were provided by arrangement. This had the potential to affect any patients who received anesthesia services.

The findings include: The CAH failed to ensure that all services affecting patient care, including anesthesia services, were evaluated with findings reported to the governing body.

Review of the CAH's CQI (Continuous Quality Improvement) plan revealed that although anesthesia services had been scheduled to present QI results in 1/11, 4/11 and 7/11, they had conducted no projects, so had nothing to present.

The hospital's quality director confirmed at 2:05 p.m. on 8/9/11, that contracted services for anesthesia had not been evaluated as a part of the hospital's CQI program since 12/10. Although the anesthesia services had not been evaluated in accordance with the QI program, the governing body had been not taken any action to ensure their compliance.

Based on observation, record review and staff interview, the facility failed to ensure that 5 of 5 surgical in-patients (S1, S2, S3, S4 and S5), and 3 of 3 surgical out-patients (S6, S7 and S8) were evaluated for proper anesthesia recovery following surgery.

Findings include: Eight surgical patients' records lacked documentation to support the patients had been evaluated for proper anesthesia recovery.

S1 had a surgical procedure under general anesthesia on 7/24/11. The CRNA (certified registered nurse anesthetist) documented his post-anesthesia note at 1:56 p.m. However, the anesthesia was documented to have been administered from 10:30 a.m. to 1:55 p.m.

S2 had a surgical procedure under general anesthesia on 7/8/11. The CRNA documented the post-anesthesia note at 10:35 a.m., the same time documented for the end of administration of anesthesia.

S3 had a surgical procedure under general anesthesia on 5/26/11. The CRNA documented the post-anesthesia evaluation at 7:00 p.m. however, the anesthesia was documented to have been administered from 5:40 p.m. to 7:05 p.m.

S4 had a surgical procedure under spinal anesthesia on 4/18/11. The post-anesthesia evaluation was documented at 8:25 a.m. however, the anesthesia was documented to have been administered from 7:21 a.m. to 8:39 a.m.

S5 had a surgical procedure under local with IV (Intravenous) sedation on 6/6/11. The CRNA documented a post-anesthesia evaluation without noting an identified time or date.

S6 had a surgical procedure under local with IV sedation on 7/18/11. The CRNA documented the post-anesthesia note at the same time documented for the end of administration of anesthesia.

S7 had a surgical procedure under IV sedation on 7/25/11. The CRNA documented the post-anesthesia note at 1:13 p.m. however, the anesthesia was documented to have been administered from 12:20 p.m. to 1:15 p.m.

S8 had a surgical procedure under IV sedation on 7/13/11. The CRNA documented the post-anesthesia note at 2:40 p.m., the same time documented for the end of administration of anesthesia.

There was a section on the Anesthesia Record titled "Post Anesthesia Comment". There had been no entries made in that section of the Anesthesia Record documented for any of the above patients.

During observations of the CRNA following a surgical proceedure at 9:35 a.m. on 8/5/11, the CRNA was observed to complete the post anesthesia comment section as he wheeled the patient to the recovery room.

The CRNA was interviewed at 9:45 a.m. on 8/5/11. He stated that he forgets to make a post anesthesia comment following some of the procedures. When asked whether any other staff would see the patient post-operatively and make a comment in the post anesthesia record, he replied "no".

The DON (Director of Nursing) verified during interview at 2:45 p.m. on 8/8/11, that the facility currently does not have a policy for Post Anesthesia Visits.

Based on review of quality assurance information and staff interview, the CAH (Critical Access Hospital) failed to evaluate all services provided by agreement, including anesthesia services, as part of the overall quality improvement program. This had the potential to affect any patients receiving anethesia services from the CAH.

The findings include: The CAH failed to ensure that all services affecting patient care, including anesthesia services, were evaluated.

Review of the CAH's CQI (Continuous Quality Improvement) plan revealed that although anesthesia services had been scheduled to present QI results in 1/11, 4/11 and 7/11, they had conducted no projects, so had nothing to present.

The hospital's quality director confirmed at 2:05 p.m. on 8/9/11, that contracted services for anesthesia had not been evaluated as a part of the hospital's CQI program since 12/10.