Dimmit Regional Hospital

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 26870 Based on observation, interview and record review, the facility failed to ensure the crash cart on the med/surg floor, had items available for use that were not expired. Findings include: Observation on 11/20/24 at 12:15 PM of the med/surg crash cart revealed expired supplies. One of the drawers of the crash cart contained 5 (5) Intubating Stylets with expiration dates of 7/23 and 8/24. Record review of the crash cart log revealed the crash cart had been checked on 11/20/24. Interview at the time of the observation with Facility Staff #2 (FS #2) revealed the crash cart is checked every day and the supplies also should have been checked for expiration dates.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 26870 Based on observation and interview, the facility failed to maintain clean and orderly premises. Specifically the facility failed to ensure equipment was stored in proper spaces, not in corridors. The findings were: Observation on 11/20/24 at 11:30 AM during the tour of the facility, in the hallway between the CT Room and the Laboratory room, there was a C-Arm in the hallway, lightly covered in dusty material. Interview at the time of the above observation with Facility Staff #2 (FS #2) revealed the C-arm had not been used in a long time and there was no other place to put the C-arm.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 45179 Based on review of records and interview, the facility governing body failed to ensure that the policies pertaining to a critical access hospital (CAH) were reviewed and subsequently scheduled to be reviewed every two years by members of the hospital’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists on staff. Specifically, review of the restraint policy revealed that the policy had not either been reviewed within the past two years or had a next scheduled review date greater than 2 years. Findings included: Record review of P#22’s medical record revealed the patient was restrained on 10/8/23. Review of the restraint order mentioned “leather” restraints as an option with a date at the bottom corner of the order of 09/15. Interview on 11/20/24 @4:40PM with facility staff #7 (FS #7) revealed that the “policy needs updating. It needs to reflect what we are doing.” Confirming that they do not use leather restraints. FS #7 stated that the facility previously was cited for restraints and had been a focus of the facility since that time. FS #7 confirmed the policy was out of date. Interview on 11/20/2024 @5:30PM with the facility CEO confirmed that facility does not use leather restraints and has not in a “long time.” Record review of the policy titled “Restraint and Seclusion-Staff Training and Competency” was last effective 7/9/2020. Further review of the policy revealed blank spaces to show training requirements for physicians and other LIPs and staff training on page 3 of 6 to reveal an incomplete policy.”

“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: 26870 Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following: 1.) In CT room, the the frame of the CT scam machine had deep scratches, exposing the metal and unsafe in order to avoid the transmission of infection and communicable diseases. 2.) In the Lab, the chairs in the waiting area had the under lining hanging down and unsafe in order to avoid the transmission of infection and communicable diseases. 3.) The vital sign machines in the Emergency Department were unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 4.) The med/surg floor was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. Findings included: Observations on 11/20/24 at 11:00 AM of the facility with facility staff #2 (fs #2) revealed the following: 1.) In CT room, the the frame of the CT scam machine had deep scratches, exposing the metal and making the frame an unwipeable surface which could breed bacteria. 2.) In the Lab area, the chairs in the waiting area had the under lining hanging down and unsafe in order to avoid the transmission of infection and communicable diseases. 3). There were two vital sign machines in the Emergency Department that were unsanitary with dusty bases. This provided a source for bacteria, the trasmission of infection and communicable disease. 4.) The med/surg floor had three vital sign machines in the Emergency Department that were unsanitary with dusty bases. This provided a source for bacteria, the trasmission of infection and communicable disease. Interview on 11/20/24 at 11:40 AM with facility staff #7 (FS#7) confirmed the vital sign machines bases were covered in dust. FS #7 further revealed that it is the nurses responsibility to clean equipment on the nursing floor. Interview on 11/2024 at 12:00PM with facility staff #2 (FS #2) confirmed the above findings. Record review of the facility policy titled, Sanitary Environment Policy, revised July 29, 2022, states in part...Shall provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. ....All areas of the hospital must be clean and sanitary.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 26870 Based on record review and interviews the facility failed to ensure written policies and procedures regarding the use of restraint and seclusion were consistent with current standards of practice. 45179 The findings include: Record review of P#22’s medical record revealed the patient was restrained on 10/8/23. Review of the restraint order mentioned “leather” restraints as an option with a date at the bottom corner of the order of 09/15. Interview on 11/20/24 at 4:40PM with facility staff #7 (FS #7) revealed that the “policy needs updating. It needs to reflect what we are doing.” Confirming that they do not use leather restraints. FS #7 stated that the facility previously was cited for restraints over a year ago and had been a focus of the facility since that time. FS #7 confirmed the policy was out of date. Interview on 11/20/2024 at 5:30PM with the facility CEO confirmed that facility does not use leather restraints and has not in a “long time.” Record review of the policy titled “Restraint and Seclusion-Staff Training and Competency” was last effective 7/9/2020. Further review of the policy revealed blank spaces to show training requirements for physicians and other LIP’s and staff training on page 3 of 6 to reveal an incomplete policy.”