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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on November 28, 2017, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on November 28, 2017, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review, policy and procedure and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure complaint resolution was documented, as per facility policy. This has the potential to affect all patients receiving care and services, currently a census of 6.

Findings include:

1. On 11/22/17 at 9:00 AM, the complaint/grievance file for January 2017-present was reviewed. A review of the file indicated the CAH failed to document resolution of the complaints/grievances filed.

2. On 11/27/17 at 9:00 AM, the policy (revision date 2015) titled, "COMPLAINT/GRIEVANCE PROCESS POLICY" was reviewed. The policy under Step 5: A written notice of the hospital's decision to the patient that contains the hospital contact person and the steps taken on behalf of the patient to investigate the grievance as well as the results of the grievance process and the dates of completion, will be mailed or provided to the patient within 48 hours following completion of a thorough investigation by the Grievance Committee.

3. On 11/22/17 at 3:30 PM, an interview was conducted with E#2 (Risk Manager). E#2 reviewed the complaint/grievance file and confirmed the resolutions were not documented per policy.

Based on observation, document review and staff interview, it was determined the CAH failed to ensure expired supplies were unavailable for use, as per facility policy. This has the potential to affect all patients receiving care and services, currently a census of 6.

Findings include :

1. A tour of the medical surgical unit was conducted with E#1 (Chief Nursing Officer) on 11/20/17 at 10:30 AM. During the tour 3 Provon hand sanitizer containers were noted to be expired with dates ranging from 9/17 to 6/13 but available for use by staff and visitors. A tour of the respiratory department with E#4 (Respiratory Therapy Director) was conducted on 11/20/17 at 11:15 AM. One container of Provon hand sanitizer was noted to be expired with a date of 6/2010 but available for staff use. A tour of the therapy department with E#6 (Physical Therapy Director) was conducted on 11/20/17 at 11:45 AM. During the tour one container of Provon hand sanitizer in the occupational therapy room was noted to be expired with a date of 9/2013 but available for staff and patient use.

2. A review of the CAH policy dated 9/2014 titled "Expired Inventory" was completed on 11/27/17 at 10:30 AM. The policy indicates under "Procedure: Any inventory supply/food that is marked with an expiration date by the Manufacturer will be checked monthly to ensure the date has not passed to prevent using expired supplies for patients. If such item is found, it must be destroyed by putting in trash, except if the item has needles... Should the item be liquid and does not contain medicine, it can also be thrown away,..."

3. An interview was conducted with each of the department directors while observing the expired hand sanitizers. Each of the directors (E#1, E#4 and E#6) observed the expiration dates and agreed the sanitizer should have been removed and replaced. During an interview on 11/20/17 at 3:30 PM, E#1 reported it is a housekeeping responsibility to replace them but in the past no continuous check of the sanitizers for expiration dates was conducted.

Based on observation and staff interview it was determined the CAH failed to ensure foods were stored and maintained appropriately. This has the potential to affect all patients receiving nourishment, currently a census of 6.

Findings include:

1. On 11/20/17 at 11:30 AM, a tour of the Emergency Department (ED) was conducted with ED Director (E#3). Approximately 6 containers of prune juice and 10 popsicles in paper wrappers were noted without an expiration date or use by date.

2. On 11/27/17 at 10:00 AM, an interview was conducted with E#5 (Purchasing Director). E#5 was asked to explain the policy on expired prune juice and any other unlabeled food items. E#5 stated, "There is no date (expiration) on the prune juice or popsicles, there is no date on the boxes that they are shipped in either." On 11/27/17 at 10:30 AM, E#5 stated, "I called the company and they told me the expiration for the prune juice and popsicles." E#5 brought a policy written on 11/27/17 with expiration procedures for prune juice and popsicles.

Based on document review, policies and procedures and staff interview, it was determined the CAH failed to ensure all patient care services were included in the quality assurance program and monitored and evaluated by the governing body. This has the potential to affect all patients receiving care and services, currently a census of 6.

Findings include:

1. On 11/21/17 at 9::00 AM, the governing body minutes were reviewed for the past year. The minutes failed to reflect that all patient care services were included in the quality assurance report to the Board of Directors. Therefore, the governing body did not monitor or evaluate the hospital wide performance improvement plan.

2. On 11/21/17 at 11:00 AM, the "PERFORMANCE IMPROVEMENT PLAN HOSPITAL WIDE" dated January 2014 was reviewed. Under "PURPOSE AND OBJECTIVES The purpose and objective of the performance improvement plan....to ensure the Board of Directors, Medical Staff and all employees have a clear direction for the standard of care and use a consistent and systematic approach to continuous performance improvement."

3. On 11/22/17 at 1:00 PM, an interview was conducted with E#3 (Quality Director). E#3 stated "I am also the Emergency Department (ED) supervisor." E#3 was asked to explain the process for providing quality assurance information to the Board of Directors. E#3 verbalized the data and information from Quality is included with Infection Control and Risk. E#3 verbalized the ED reports are reviewed monthly at the Board meetings, but not all departments are included in the report to the Board.