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Based on document review and staff interview the governing body and the designated administrator failed to ensure the Critical Access Hospital (CAH) complied with, the development of an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed surgical patient (#28) and one of one observed terminal cleaning of a patient room. The CAH failed to ensure supervision of dietary services to assess and evaluate the nutritional needs for 5 of 20 sampled patients requiring a dietary consult/nutritional assessment/diet teaching, (patients
#12, 15, 19, 25 and 30). The CAH failed to follow policies and procedures, failed to follow physician orders for 3 of 3 sampled patients with dietary orders (patients #15, 25 and 30), and failed to assure safety of food stored in two of four refrigerators.

Findings included:

- Document review of the Bylaws of the Board of Trustees revealed under Article 1 - Organization 1.2 Authorization of Board of Trustees " ...the hospital Board of Trustees has been lawfully created to act as the governing Body of the Hospital, having rights, duties, responsibilities, power and authority ... " . Article 5 - Administrator directs " ...The Administrator shall be delegated the responsibility for overall management of the Hospital ...Organize the function of the Hospital, delegate duties and establish formal means of accountability on the part of subordinates ... " .

- The governing body and the designated administrator failed to ensure an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed surgical patient (#28) and one of one observed terminal cleaning of a patient room. See further evidence at CFR 485.635(a)(3)(vi), C-0278.

- The governing body and designated administrator failed to ensure dietary services supervised, assessed and evaluated the nutritional needs for 5 of 20 sampled patients requiring a dietary consult/nutritional assessment/diet teaching (#'s 12, 15, 19, 25 and 30), to follow policies and procedures, to follow physician orders for 3 of 3 sampled patients with dietary orders (#'s15, 25 and 30), and failed to assure safety of food stored in two of four refrigerators. See further evidence at CFR 485.635(a)(3)(vii), C-0279.

Based on observation, record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of service for infection control were met due to the failure to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed surgical patient (#28) and one of one observed terminal cleaning of a patient room. The CAH failed to ensure the provision of dietary services supervised, assessed and evaluated the nutritional needs for 5 of 20 sampled patients requiring a dietary consult/nutritional assessment/diet teaching (patients
#12, 15, 19, 25 and 30), to follow policies and procedures, to follow physician orders for 3 of 3 sampled patients with dietary orders (patients #15, 25 and 30), and failed to assure safety of food stored in two of four refrigerators.

Findings included:

- The CAH failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed surgical patient (#28) and one of one observed terminal cleaning of a patient room. See further evidence at CFR 485.635(a)(3)(vi), C-0278.


- The CAH failed to ensure dietary services supervised, assessed and evaluated the nutritional needs for 5 of 20 sampled patients requiring a dietary consult/nutritional assessment/diet teaching (patients #12, 15, 19, 25 and 30), to follow policies and procedures, to follow physician orders for 3 of 3 sampled patients with dietary orders (patients # 15, 25 and 30), and failed to assure safety of food stored in two of four refrigerators. See further evidence at CFR 485.635(a)(3)(vii), C-0279.

Based on observation, record review and staff interview, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed surgical patient (#28) and one of one observed terminal cleaning of a patient room.

Findings included:

- The hospital admitted patient #28 on 3/31/10 for an outpatient esophagogastroscopy (a procedure to view the inside on the esophagus and stomach by inserting a tube through the esophagus into the stomach) and colonoscopy (a procedure to view the inside of the colon by inserting a tube through the rectum into the colon). The patient was prepared for surgery and taken to procedure room at 3:05pm. Staff completed the surgical procedure and transported the patient to the recovery room at 3:35pm.

Observation on 3/31/10 at 3:35pm revealed staff F cleaned the gross contamination (body fluids) off the scope in the procedure room, suctioned enzymatic cleaner (a cleaning product that removes microscopic particles) through the ports and submerged the gastroscope in the container of enzymatic cleaner. Staff transported the container with the cleaner and gastroscope to the cleaning room in central supply. At 5:05pm Staff F filled the sink with water and enzymatic cleaner then removed the gastroscope from the container and placed it in the sink in central supply. Staff F cleaned all areas of the gastroscope. The ports of the gastroscope were cleaned with the enzymatic solution and a brush. Staff F suctioned the enzymatic solution through the ports. Staff F using the second sink rinsed the gastroscope and flushed water through the ports with flush tubing and a syringe. Staff F then places the gastroscope in OPA (a high disinfecting solution) for the required 12 minutes.

Staff F, on 3/31/10 at 5:35pm, returned to the cleaning room in central supply and began the post disinfection phase of the gastroscope used on patient #28. Staff F returned to the same sink used for decontamination of the gastroscope. Staff F stated, after placing the scope in OPA, they had rinsed the sink out with water. Staff F filled the sink with water and removed the gastroscope from the OPA solution and placed the gastroscope in the sink. Staff F acknowledged they were using the same sink used for the decontamination of the gastroscope. Staff F flushed the gastroscope and ports with water three times using both sinks used to clean the gastroscope. Staff F and staff G acknowledged the potential for cross-contamination of the gastroscope when they failed to disinfect the sinks between cleaning the gastroscope and disinfecting the gastroscope.

The CAH's policy for cleaning of endoscopes (gastroscope and colonoscope) failed address techniques for separation of a clean process from a dirty process to limit the potential of the spread of infections.


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- Observation of staff H on 3/30/10 between 1:40pm and 2:40pm revealed staff H put on protective gloves to remove trash then removed the gloves. Staff H then put on another pair of protective gloves to clean the bedside stand. Staff H put on protective gloves to clean the recliner. Staff H then removed the protective gloves and put on another pair to clean the bed headboard. Staff H then removed the protective gloves and put on another pair to clean the mattress and bed frame. Staff H then removed the gloves and put on another pair to clean the television and intravenous pump pole. Staff H then removed the gloves and put on another pair of gloves to clean the mirror and sink. Each time the staff member removed the gloves, they put on another pair without hand hygiene. The staff member failed to perform hand hygiene after at least eight glove removals.

Interview with administrative staff B on 3/30/10 at 4:00pm confirmed the CAH's policy
for hand washing after removal of gloves.

Document review of the CDC (Centers for Disease Control and Prevention) Guidelines
for Hand Hygiene in Healthcare Settings- 2002 requires healthcare workers to wash their
hands after removing gloves.

The infection control officer failed to develop an active infection control system to identify, report, investigate, monitor and implement infection control practices.

Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure dietary services supervised, assessed and evaluated the nutritional needs for 5 of 20 sampled patients requiring a dietary consult/nutritional assessment/diet teaching (patients #12, 15, 19, 25 and 30), to follow policies and procedures, to follow physician orders for 3 of 3 sampled patients with dietary orders (patients #15, 25 and 30), and failed to assure safety of food stored in two of four refrigerators.

Findings included:

- Review of the policy titled " Hospital and Manor Dietary: Nutritional assessments " review on 10/1/09 directed staff " ...Residents will be fully assessed upon admission by the Certified dietary Manager (CDM). New admissions will be reviewed and assessed by the Registered Dietician (RD) ... " .

- Patient #25's record review on 3/29/10 revealed an admission date of 3/20/10 with a diagnosis of Diabetes Mellitus type I uncontrolled, left foot pain and elevated temperature. Admission physician orders included a dietary consult, an 1800 calorie diabetic carbohydrate count diet and directed nursing to give one unit of humalog insulin per 8 carbohydrates. Through out the patient's hospital stay the patient's diet change frequently due to their changing health care status. On 3/23/10 the physician reordered the 1800-calorie diabetic diet. On 3/29/10 the physician placed an order to restart Humalog insulin one unit per 8 carbohydrates with meals. The medical record lacked an assessment of the patient's nutritional needs from the RD or CDM. The medical record included a four by five piece of paper with a room number and listed foods with calculated carbohydrate counts, which read " 3/29/10-carb count for lunch " . The carbohydrate count equaled 231 and noted 4 units. Interview with staff B at that time revealed the unsigned paper came from the dietary department.

Administrative staff B interviewed on 3/29/10 at 4:30pm acknowledged the paper in patient #25's chart came from the dietary department. Staff B indicated at first the dietary department calculated the calories instead of the carbohydrates. Staff B added, "I don't trust the kitchen" and did not want nurses administering insulin based on a carbohydrate count totaled by unlicensed staff. Staff B acknowledged the importance of a dietary consult for patient #25.

Staff E, the CDM, acknowledged during interview on 3/30/10 at 9:15am the physician's order for a dietary consult for patient #25 did not occur. Staff E indicated they received the consult order but because it was a pediatric diabetic with special needs the consult was out of the scope of a CDM's practice and required the service of the Registered Dietician. Staff E communicated the need for the consult and scheduled the dietary consult on 3/23/10. The RD had other commitments on 3/23/10 and rescheduled the dietary consult on 3/25/10. Staff E, on 3/30/10, indicated they were unaware why the nutritional assessment had not been completed by the RD.

The mother of patient #25 confirmed on 3/30/10 at 9:40am the Registered Dietician failed to conduct a dietary consult of the patient. The mother of patient #25 reported her 10 year old had been diagnosis with diabetes 2 ? years ago. The patient had been following a diet of 60 carbohydrates per meal and received 1 unit of humalog insulin per eight carbohydrates with meals.

Staff B on 3/30/10 at 10:20am while reviewing patient #25's medical record revealed a small piece of paper with a room number and foods with a calculation of carbohydrates. Staff B acknowledged the carbohydrate calculations were incorrect. Staff B stated nursing staff identified the incorrect carbohydrate calculation and notified the physician for insulin orders. The physician discontinued the insulin dosing based on calculations of the carbohydrate count.

Interview on 3/30/10 at 10:30am with staff E and staff I revealed staff I used the food labels and a computer web site to figured the carbohydrate count for patient #25's evening meal on 3/29/10. Staff I reported they miscalculated the carbohydrate count for the bread. The information on the bread label based the calculation for carbohydrates for a serving of bread on two slices instead of the single slice the patient received. Dietary carbohydrate calculations provided to nursing for the bread were doubled. Staff I reported they did not call the RD for advice or consultation to help determine accurate carbohydrate count because they did not know how to reach the RD.

The RD on 3/30/10 at 4:40pm verified they worked for the CAH as a contracted service and worked on-site one day a month. The RD acknowledged the CDM provided day-to-day supervision and could do dietary consults on patients. The RD verified they were contacted on 3/22/10 for a dietary consult on patient #25 and had scheduled the visit for 3/23/10. The CDM informed the RD the patient would probably be transferred. On 3/23/10 the RD rescheduled their visit to the CAH to 3/25/10. The RD stated they " assumed " patient #25 had been transferred and failed to complete the order dietary consult. The RD reported the CAH staff could reach them by telephone or fax when they need advice on patients nutritional needs.

The RD completed a dietary consult on patient #25, whose medical condition could be adversely affected by their nutritional intake, on 3/30/10 ten days after the physician ordered a dietary consult.

- Patient #30's medical record review on 3/31/10 revealed an admission date for observation on 11/06/09 with a diagnosis of abdominal pain, weight loss, and nausea followed by an acute admission on 11/08/10. The physician ordered a dietary consult on 11/06/09 and again on 11/08/10. The physician's history and physical indicated the patient had loss ten pounds over the last two months. Review of the medical record on 3/31/10 revealed the CAH failed to provide the dietary consult.

During review of patient #30's medical record on 3/31/10 at 12:45pm administrative staff B acknowledged the record lacked a dietary consult and failed to explain why the medical record lacked a nutritional consult.

- The CAH's policy for nutritional assessment directed staff to complete a nutritional evaluation within 72 hours after admission to the swing bed.

- Review of the clinical record for patient #12 revealed an swing bed admission date of 3/18/10 with diagnoses including congestive heart failure (an abnormal condition that reflects impaired cardiac pumping) and pleural effusion (an abnormal accumulation of fluid in the intrapleural spaces of the lungs.) Admission orders included a low salt diet. The nutritional evaluation, completed by the Certified Dietary Manager (CDM), dated 3/24/10 (completed 7 days after admission), revealed "Food Allergies: No oatmeal or eggs". The evaluation documentation failed to address the patient's diet order for no added salt diet.

Observation and interview with patient #12 on 3/30/10 at 8:20am revealed eggs and oatmeal on their breakfast tray. The patient stated the empty glass contained a milkshake since she/he would not eat the eggs and oatmeal. The patient stated the food is bland and " I add Cajun-style seasoning " to the food. The seasoning container listed salt as the primary ingredient.

The swing bed coordinator, staff N acknowledged on 3/30/10 at 8:45am that patient #12 completed their list of food likes/dislikes on 3/15/10. Staff E interviewed on 3/30/10 at 9:00am indicated they were aware of patient #12's preferences but failed to notify the dietary department.

Staff N interviewed on 3/30/10 at 2:18pm stated nursing failed to provide education to the patient regarding the order for a "no added salt" diet. Staff N then went directly to the patient's room. The patient was seated in a wheelchair with family present and ready for discharge. Staff N presented patient information regarding the "no added salt" diet. The nurse discharged the patient.

- Review of the clinical record for patient #15 revealed a swing bed admission date of 12/11/09 with diagnoses including congestive heart failure (an abnormal condition that reflects impaired cardiac pumping), bronchitis (acute or chronic inflammation of the mucous membranes of the tracheobronchial tree, most commonly presents as a dry, hacking cough that produces thick mucus) and diabetes (a complex disorder where the pancreas is deficient or lacks secretion of insulin). The Certified Dietary Manager completed the "Nutrition Evaluation on 12/16/09, five days after the patient's admission instead of within the required 72 hours.

- Review of the clinical record for patient #19 revealed an acute care admission date of 1/28/10 with a diagnosis of gastrointestinal complaints and discharged 1/31/10. The provider ordered the patient to receive a gluten-free diet on 1/29/10. On 1/31/10, the provider wrote "instruction about gluten-free diet" and "home today". Review of documentation provided by the CAH failed to provide the patient information regarding a gluten-free diet prior to or at discharge. Interview with administrative staff B on 4/1/10 at 11:30am confirmed the CAH failed to provide diet teaching.


- Observation on 3/29/10 at 1:45pm of the refrigerator in the snack room on the nursing floor revealed the following outdated products:
1. Three 4-ounce containers of orange juice with an expiration date of 12/25/09.
2. Two 8-ounce cartons of 2% milk with an expiration date of 3/27/10.
3. Two 8-ounce cartons of skim milk with an expiration date of 3/27/10.
4. A half bottle of Redi-Cat (a barium used for CT scans) without a date of opening.
5. A small bowl of cooked shrimp with sauce lacked a date when placed in the
refrigerator.
6. An open 33.8 ounce bottle of pediatric electrolyte drink with an open date of 3/16/10.
The label directed refrigerate after opening and use within 48 hours.

An ice machine in the snack room contained an uncovered plastic box with three ice scoops and a towel with 2 silver pitchers turned upside down.

Administrative staff B on 3/29/10 at 1:45pm acknowledged the juice, milk, Redi-cat, shrimp and pediatric electrolyte drink were outdated and available for patient use. Staff B acknowledged the ice scoops should be covered.

- Observation on 3/29/10 at 2:15pm of the silver refrigerator in the kitchen revealed ten 4-ounce containers of orange juice with an expiration date of 12/25/10.

Staff E on 3/29/10 at 2:15pm acknowledged the juice containers were outdated and available for patient use.

The dietary policy and procedure manual lacked a policy directing staff when to dispose of leftovers or outdated foods.

- Document review on 3/31/10 of the Registered Dietitian's contract revealed, " ...Contractor shall provide registered dietician services to inpatients, outpatients, and residents .... Such services shall consist of routine assessments, nutrition consults, and patient education. Contractor also shall be responsible for consulting with and advising employees ...concerning compliance with government regulations concerning food safety and sanitation ... " .

- Document review on 3/31/10 of the job description of the Dietary Manager revealed " ...Coordinates and administers the function of food production, services, purchasing, and quality control for the hospital ...Maintains and implements established department policies and procedures, objectives, risk management/quality assurance programs, safety and infection control standards ...Plans and directs the operation of the dietary department."

Review on 4/1/10 of the requested three-month time sheets for the Registered Dietitian revealed the following on-site activity in the CAH:
January 27, 2010---2.58 hours.
February 25, 2010---2 hours.

Review of the past three months time sheets for the CDM on 4/1/10 revealed the on-site time spent " coordinating and managing " the operation of the CAH's dietary department are as follows:

12/27/10-1/09/10---17.89 hours
1/11/10-1/23/10---11.18 hours
1/24/10-2/06/10---9.43 hours
2/08/10-2/19/10---11.72 hours
2/22/10-3/05/10---4.44 hours
3/08/10-3/19/10---0 hours

The Certified Dietary Manager, identified as the person responsible for the day-to-day activities in dietary, spent a total of 53.68 hours on-site over the last twelve-week period.