Nemaha Valley Community Hospital

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 53828 Based on policy review, document review, observation, and staff interview, the Critical Access Hospital (CAH) failed to implement methods to prevent and control the transmission of infections in accordance with the facility’s policies and nationally recognized infection prevention guidelines. This deficient practice has the potential to increase risk of infection for patients and staff. Findings Include: Review of a hospital policy titled “IV Therapy-Peripheral” last revised on 04/2026, showed the facility’s policy to assure safe intravenous (IV) therapy practices included instructions to scrub the IV hub with alcohol prior to connecting IV tubing or injecting a drug through a luer lock connector. Review of a U.S. Centers for Disease Control and Prevention (CDC) document titled “Preventing Unsafe Injection Practices” dated 03/26/24, showed that “ ...If a multi-dose vial enters an immediate patient treatment area, dedicate it for single patient use only. Examples of immediate patient treatment areas include operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays ...” Review of a CDC document titled “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” dated 04/12/24, listed “ ...Disinfect the access diaphragms of medication vials before inserting a device into the vial ...” and “ ...Dedicate multidose vials to a single patient whenever possible. If multidose vials are used for more than one patient, restrict the medication vials to a centralized medication area and do not bring them into the immediate patient treatment area (e.g., operating room, patient room/cubicle) ...” as a core infection prevention practices. During an observation of Patient 13’s procedure on 05/20/26 at 9:25 AM, Staff O, Registered Nurse (RN) picked up an open vial of injectable medication that had been on an uncovered shelf in the operating room (OR) since the last patient had been in the room, cleaned the top of the vial, and held it while Staff P drew up medication from the vial into a syringe and handed the syringe to the operating physician, who administered it to Patient 13. Staff O returned the vial to the uncovered shelf, where it remained until after Patient 13 was removed from the room. At 9:35 AM, the injectable medication vial that was on the shelf before, during, and after patient 13’s procedure was observed to be a multidose vial (MDV) of Kenalog (injectable steroid medication). The date of 05/20/26 was handwritten on the vial. During an observation of Patient 13’s procedure on 05/20/26 at 9:28 AM, Staff O, RN opened a new vial of injectable medication and held it out while Staff P drew up medication from the vial into a syringe and handed the syringe to the operating physician, who administered it to Patient 13. The vial top was not cleaned prior to drawing up the medication. During an observation on 05/20/26 at 9:45 AM, Staff I, RN, laid down Patient 10’s IV saline lock (a thin, flexible tube placed for IV fluid or medication administration) while performing an IV placement and fluid administration, contaminating the port through skin contact. Staff I failed to scrub Patient 10’s IV port with alcohol before administering IV fluids. During an interview on 05/19/26 at 9:40 AM, Staff G, Pharmacy RN, stated that nurses do not take MDV medications to the patient’s bedside, and that nurses should draw up any MDV medications in the pharmacy area or at the Pyxis (automated medication dispensing system). During an interview on 05/20/26 at 9:35 AM, Staff O, RN reported opening and dating the MDV of Kenalog on that date. Staff O stated that the same MDV would be used on all patients brought into the OR that day, then discarded. During an observation of the inpatient and swing bed unit on 05/18/26 at 1:30 PM, the unit’s dietary area was found to have 5 individual cartons and 1 full case of Peptamen 1.5 tube feeding solution that expired on 1/22/26 and 24 individual cartons of Fibersource HN tube feeding solution that expired on 05/11/25. During an interview on 05/19/26 at 10:30 AM, Staff Q, Registered Dietitian, stated that the facility’s supply of tube feeding solution was stored in the dietary area of the inpatient unit and managed by the kitchen staff, who are responsible for monitoring dietary items for expiration. Staff Q stated that if tube feeding supplies were expired or needed to be ordered, the dietary department would notify the pharmacy department to order them.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 53828 Based on document review, observations, and staff interview, the Critical Access Hospital (CAH) failed to maintain a sanitary environment in accordance with nationally recognized infection prevention guidelines. Failure to maintain a sanitary environment has the potential to increase patients’ risk of infection. Findings Include: No policies or procedures were provided by the facility related to the management of shipping boxes, general waste storage or bottom supply shelf contamination protection. Review of an undated document from the U.S. Centers for Disease Control and Prevention (CDC) and partnering organizations titled “Using the Health Care Physical Environment to Prevent and Control Infection” showed that in areas where sterile (completely free from germs) items may be stored, “ ...The bottom shelves of the storage area should ensure that no contamination occurs during floor care. Solid bottom shelves are preferable ...” This CDC document also showed that “ ...external cardboard shipping containers collect and generate dust and are exposed to dirt and insects in warehouses and in transport vehicles ... supplies should be removed from external cardboard shipping boxes prior to being transported to any patient care area ...” This CDC document also stated that general and medical waste storage in patient care areas must be adequately sized to meet the unit’s needs. During an observation of the inpatient and swing bed unit on 05/18/26 at 1:30 PM, the unit’s dietary area was found to have a refrigerator that contained an open, partially consumed pudding cup that was not dated or labeled with any patient information. The freezer contained an open, partially consumed individual carton of ice cream that was not dated or labeled with patient information, and an open, partially consumed dessert from a fast-food restaurant that had a patient’s name and room number on it, and was not dated. During an observation of the laboratory on 05/19/26 at 9:25 AM, 30 corrugated cardboard boxes were observed stored in the laboratory area, and 3 of these boxes had visible shipping labels. During an observation of the surgical department on 05/20/26 at 10:20 AM, 3 bags of Operating Room trash were stored on the floor at the entrance of the soiled utility area. During an observation of the clean storage room in the surgical department on 05/20/26 at 10:40 AM, 10 metal wire shelving units lacked bottom shelves with either solid bottoms or contamination barriers. Clean and sterile supplies were stored on these metal wire shelves. During an interview on 05/19/26 at 10:30 AM, Staff Q, Registered Dietitian, stated that if personal food is brought to the facility for a patient, it can be stored in the dietary refrigerator, with the patient’s identifier label affixed, and must be dated. Staff Q stated that once a food item has entered a patient’s room, it should not be stored in the dietary refrigerator and that any partially consumed foods should be discarded.”