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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on January 27-28, 2020, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on January 27-28, 2020, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated January 28, 2020.

Based on document review and staff interview, it was determined in 1 of 4 (Pt #16) blood transfusion medical records reviewed, the registered nurse failed to conduct vital signs per critical access hospital (CAH) blood transfusion policy. This failure has the potential to affect all inpatients and outpatients receiving blood transfusions.

Findings include:

1. On 1/6/20, the CAH policy (effective by the facility, 12/2019), titled, "Blood/Blood Product Transfusion & Suspected Adverse Reaction, SY-NG-017 was reviewed. The policy under "VI. DOCUMENTATION 1. Document on the Blood Component Transfusion Form all pertinent information: ...B. Baseline, at 15 minutes, 30 minutes, 60 minutes, 120 minutes, 180 minutes, and post-transfusion vital signs."

2. On 1/15/20 at 3:00 PM, the medical record of Pt #16 was reviewed. Pt #16 was admitted on 9/18/19 with diagnoses of chronic obstructive pulmonary disease exacerbation and anemia. Pt #16 received a unit of blood beginning on 9/19/19 at 2:28 PM. At 2:28 PM, blood pressure (BP) was 95/48. At 3:00 PM, the BP was 103/43. Documentation indicated the blood pressure was not taken at the 15 minutes time per policy.

3. On 1/15/20 at 3:30 PM, an interview was conducted with the quality manager (E#1). E#1 reviewed the medical record of Pt #16 and confirmed the BP was not documented at the first 15 minute time per policy.

Based on document review and staff interview, it was determined for 2 of 2 patients receiving same day surgical procedures (Pt # 2 and #13) the nurse failed to document patient discharge occurred with a responsible adult. This failure has the potential to affect all same day surgical patients, currently an average of 25 daily.

Findings include:

1. A review of the medical record of Pt #2 was completed on 1/14/2020. Pt #2 was admitted for same day surgery with diagnosis of malignant neoplasm of bladder to have a cystoscopy with bladder biopsy. The medical record indicated Pt #2 received monitored anesthesia during the procedure. There was no documentation to indicate Pt #2 was discharged with a responsible adult.

2. A review of the medical record of Pt #13 was completed on 1/15/2020. Pt #13 was admitted for same day surgery for a circumcision with diagnoses of phimosis and dysuria. The medical record indicated Pt #13 received monitored anesthesia during the procedure. There was no documentation to indicate Pt #13 was discharged with a responsible adult.

3. A review of the policy titled "Discharge from Anesthesia & Surgical Services" (revised by the facility 6/3/2017), was completed on 1/16/2020. The policy indicates on page 5, under 8. "All patient who receive general anesthesia, monitored anesthesia (MAC) or sedation: Must have a driver to accompany them home: It is recommended for a responsible adult to remain with them for 24 hours after discharge; The driver and responsible adult may be the same person"

4. An interview with E# 3 (Information Technology Services/Trainer) was conducted on 1/16/2020 at 12:15 PM. E#3 reviewed the record of Pt #13 and viewed the discharge field in the electronic record. E#3 indicated there was no documentation to indicate the patient was discharged with a responsible adult. E#3 confirmed none of the recent surgical charts have the complete discharge documentation.