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Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0223, K0324, K0353, K0363, K0901 and K0920.

Based on interview and record review the Critical Access Hospital (CAH) failed to ensure Dietary services and Radiology patient care services were evaluated through the quality assurance program.

Findings include:

Interview and document review on 4/15/24 at 6:30 p.m., with the registered dietitian identified she was aware she was expected to review and develop a Quality Assurance and Performance Improvement (QAPI) project for dietary department however stated she had not had time to do so.

Interview and document review on 4/16/24 at 12:45 p.m. with the director of Radiology services identified he had recently started his position and was not aware of the need to review and develop a QAPI plan to be included in the quarterly meetings.

Interview on 4/17/24 at 12:15 p.m., with the vice president of clinical services, who identified she was also assisting the new QA coordinator identified her expectation for all departments to participate in development of a QAPI project for their departments.

Review of the May 2019 St. Francis Health Quality Assurance/Assessment and Performance Improvement Plan (QAPI) identified the principals drove decision making to promote excellence in all areas of the facility. Departments were to participate in QAPI activities with processes studied and reviewed for 4 months to identify the goal was met and then identify the result of the improvement.

Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient's death was being reviewed.

Findings include:

Review of the facility's Death Report date 3/27/23 to 3/23/24, the facility had 25 deaths.

Review of the facility's Referrals by Hospital Report dated 1/1/23 to 12/31/23, the facility contacted the OPO for 29 facility deaths.

On 4/16/24 at 3:04 p.m., vice president of clinical services (VPOCS) and registered nurse (RN)-A confirmed the above findings. RN-A stated she received a quarterly report from the OPO. RN-A stated she reviewed the report and nothing else was done with the report after review. RN-A stated she reviewed the report for the timely compliance rate. RN-A indicated she provided the information to the nurse manager who shared it during a staff meeting. RN-A stated she had not matched the report with reported facility deaths and had not communicated with the OPO regarding the report. RN-A stated the OPO information and report were not part of the quality assurance and performance improvement (QAPI) plan.

A policy on OPO was requested however was not provided.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the dental services policy included circumstances identifying the process when the loss or damage of dentures occurred for residents residing in the swing bed (SB) unit.

Findings include:

Interview on 4/17/24 at 9:45 a.m., case manager registered nurse (RN)-B indicated the facility provided admission information to SB residents when they were admitted related to dental services. RN-B confirmed the CAH's policies lacked a process when dentures were lost or damaged and who would be responsible for the cost.

Interview on 4/17/24 at 1:00 p.m., vice president of clinical services (VPOCS) confirmed after review of policies, the CAH lacked a policy identifying a process for when dentures were loss or damaged.

Review of CAH's policy titled Oral Health Assessment, reviewed 4/22, identified an oral assessment would be completed by the facility within 14 days after admission. The policy lacked a process for when dentures were broken or lost.

Review of CAH's policy titled Patient Care Service Swing Bed in Acute Care revised 4/23, identified the facility would provide routine and 24 hour emergency dental services for swing bed patients. The policy lacked a process for when dentures were broken or lost.