HospitalInspections.org

Based on observations, record reviews, and interviews, the facility was found to be not in substantial compliance with the Condition of Participation §485.640 Infection Prevention & Control & Antibiotic Stewardship Program, by failing to have active hospital-wide programs for the surveillance, prevention, and control of Hospital Acquired Infections (HAIs) and other infectious diseases; and not addressing issues identified by the programs in coordination with the facility-wide quality assessment and performance improvement (QAPI) program.

The facility failed to:

1. Ensure a clean and sanitary environment to avoid sources and transmission of infection. Cross-refer to C1208.

2. Ensure the infection prevention and control professional communicated and collaborated with the Critical Access Hospital's (CAH's) QAPI program about infection prevention and control issues. Cross-refer to C1237.

3. Ensure the infection prevention and control professional audited CAH personnel's adherence to infection prevention and control policies and procedures. Cross-refer to C1240.

Based on observations, record reviews, and interview, the facility failed to avoid potential sources of infection by not maintaining a clean and sanitary environment.

Findings were:

During a facility tour on the afternoon of 3/11/25, dust was observed on horizontal surfaces throughout the radiology department and in central supply.

A review of Infection Control Minutes and Documents reflected that during environmental rounds in Quarters, 1, 3, and 4, 2024, dust to horizontal surfaces was observed in the radiology department.

During an interview, on the afternoon of 3/12/25, Staff #4 (Chief Nursing Officer(CNO)) verified the findings from the facility tour on the afternoon of 3/11/25.

Based on a review of facility documents, observations, and interviews, the infection prevention and control professional failed to communicate and collaborate with the CAH's QAPI program on infection prevention and control issues.

Findings were:

The facility policy # IC 027 titled "Infection Control Responsibilities" effective 4/19/2020, last reviewed 4/25/2022, reflected:

"The Infection Control Nurse ... is responsible for, but not limited to, the following:
2. Implementing policies governing asepsis and infection control.
3. Developing a system for identifying, investigating, reporting, and preventing the spread of infections and communicable diseases among patient and personnel ...
...7. Cooperating with other departments and services in the performance of quality assurance and performance improvement (QAPI) activities. ..."

During facility tours with Staff #3 (Director of Quality), and Staff #4 (CNO), on 3/10/25 and 3/11/25, the following was observed:

*Expired supplies throughout the facility including physical/occupational/speech therapy (PT/OT/ST), emergency, medical surgical (Med-Surg), radiology, respiratory, surgery, and laboratory departments. These expired supplies included: Intravenous (IV) start kits, gloves, masks, acupuncture needles, extension tubing, chlorhexidine swabs, cleaning wipes, and wound care cleaning solutions.

*Opened and unlabeled containers included:

-Radiology - opened, single-use package of foam positioning blocks, bulk lots of oxygen extension tubing separated by central supply into individual Ziploc bags dated 11/2024 with no indication what this date is, syringes stored in a cardboard box.

-Emergency Department (ED) - open electrode packages in drawers in ED rooms, glucometer control solutions and test trips with no open or discard dates, overfilled sharps container.

-Surgery - discolored and degraded pressure infuser bag dated 2016, open Burrette Set package, and an unpackaged single use Pressure Bag on shelf with sterile supplies.

-PT/OT/ST - three containers of wound care cleaning solutions on the top of the wound care cart with no open/discard date (two of three were expired), and tube of Medi-honey with patient label in top drawer of wound care cart with no open/discard date.

During these facility tours on 3/10/25 and 3/11/25, Staff # 3 (Director of Quality) and Staff #4 (CNO) witnessed and confirmed the above findings.

Review of the Infection Control Meeting notes from Q1, Q2, Q3, and Q4 of 2024, reflected that expired supplies had been identified during environmental rounds in all four quarters of 2024.

Review of the QAPI minutes notes from Q1, Q2, Q3, and Q4 of 2024 reflected that no Infection Control Meeting findings for 2024 were reported.

During an interview, on the afternoon of 3/12/25, Staff #3 (Director of Quality) reported that Infection Control findings have not been reviewed in the QAPI meetings resulting in no action plan being developed to address these findings.

Based on observations, interviews, and record reviews the infection prevention and control professional failed to ensure the prevention and control of HAI's, including adherence to infection prevention and control policies and procedures by CAH personnel.

Findings were:

During a tour of the therapy department on the afternoon of 3/11/25, the wound care cart was observed in the therapy room where outpatient wound care is performed.

During an interview, on the afternoon of 3/12/25, Staff # 7 (Director of Therapy) reported that wound care is performed in this room and the cart is taken to inpatient rooms for wound care. When asked if the cart is taken into all patient rooms regardless of isolation status, he reported that "yes, it is".

Review of facility policy # IC 018 Titled "Non-Critical Medical Equipment, Cleaning of", effective 4/19/2020, last reviewed 5/6/2022, reflected the following:

1. "Non-critical medical equipment used at... hospital will be maintained in a safe and effective manner to help prevent transmission of infections.
2. It is the responsibility of all healthcare staff using multi-patient equipment e.g., workstations on wheels, vital sign monitors, etc.) to manage, the cleaning and disinfection of these devices...
3. Shared equipment... that is shared between patients will be cleaned before and after every patient, and as needed by the staff using said item...
6. ... At a minimum, non-critical patient care equipment is disinfected when visibly soiled and on a regular basis (between patients or once daily ...)."

Review of facility policy # IC 009 Titled "Isolation Precautions, Guidelines for", Effective 4/9/2020, last revised 10/25/2019, reflected the following:

"... 9. Equipment used in the isolation room should remain in the room.
10. Equipment removed from the room should be disinfected with an approved germicidal solution or spray prior to reuse..."

During an interview, on the afternoon of 3/12/25, Staff # 3 (Director of Quality) verified these findings.

Based on record reviews and interview the facility failed to have a multidisciplinary comprehensive care plan for 4 out of 4 (#1, 2, 3, and 14) swing bed patients reviewed.

Findings were:

Review of the interdisciplinary team plan documents for patients #1, 2, 3, and 14 reflected that there were no therapy notes related to wound care included in these Interdisciplinary Team (IDT) plans.

During an interview on the afternoon of 3/12/25, Staff #4 (CNO) confirmed that all members of the IDT must document their progress on the IDT care plans.

Based on record review and interviews, the facility failed to have physician's orders for physical therapy-provided wound care, on 4 of 4 swing bed patients (#1, 2, 3, and 14) reviewed.

Findings were:

Review of the facility policy # Rehab 00001, titled "Rehabilitation Department", Effective date 5/1/2017, last revised 4/26/2022, reflected the following:

"Policy/Criteria:
1. Physical Therapy, Occupational Therapy and Speech Therapy evaluation and treatment services are considered medically necessary when all of the following critera are met...
b. The treatment is ordered by an examining physician or appropriate health care provider. ..."

Review of swing bed patient charts for patients #1, 2, 3, and 14 revealed that there were no physician orders for wound care.

During an interview, on the afternoon of 3/12/25, staff #7 (Director of Therapy) stated that he did not obtain physician orders for wound care that he and other physical therapists provided. He also reported that when he gets an order "to evaluate and treat" he was not required to have additional orders.

During an interview, on the afternoon of 3/12/25, staff #4 (CNO) confirmed that prior to providing wound care to patients, physical therapy staff must submit their wound care plan to the provider or physician for approval and orders.

Based on record review and interview the facility failed to develop a QAPI Program that included all departments of the CAH.

Findings were:

Review of the QAPI minutes for 2024 reflected that no findings were reported from Infection Control Meetings for Quarters 1, 2, 3, and 4 of 2024.

During an interview, on the afternoon of 3/12/25, Staff #3 (Director of Quality) reported that Infection Control findings have not been reviewed in the QAPI meetings. Therefore, no action plan was developed to address these findings.