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The Critical Access Hospital reported a census of 18 inpatient and swing bed patients. Based on observation and interview, the CAH failed to maintain no more than 25 inpatient and/or swing beds for patient care.

Findings included:

- Observation on 5/11/10 at 2 :55pm revealed 27 inpatient and/or swing bed patient beds. Administrative staff F confirmed the CAH maintained more than 25 patient beds, available for patient use.

Based on observation and interview, the Critical Access Hospital (CAH) failed to maintain patient care equipment in safe operating condition.

Findings included:

- Observation on 10/12/10 at 3:00pm revealed a child's crib stored in the surgical suite. The crib evidenced brown, sticky debris and tape on the vertical and horizontal surfaces. The metal frame revealed significant paint chips with metal exposed and rust under the mattress. The paint is chipped on the surfaces a child would contact. Interview with staff M on 5/11/10 at 3:15pm revealed the crib is in storage and ready for patient use. Staff M acknowledged the presence of the debris, rust and chipped paint. The CAH failed to assure the the equipment is maintained in a safe manner.

Based on observation, document review and interview, the governing body of the Critical Access Hospital (CAH) failed to maintain accountability to properly dispense medications, assure expired medications are not available for patient use, failed to identify potential infection control issues and implement the CAH's policies, assure the required group of professional personnel review the patient care policies annually, failed to develop a list of contracted services, failed to assure all clinical records are complete and protected from loss or unauthorized use.

Findings included:

- The CAH failed properly dispense medications, assure expired medications are not available for patient use, failed to identify potential infection control issues and implement the CAH's policies, failed to assure the required group of professional personnel review the patient care policies on annually, failed to designate an individual to coordinate out-patient services, and failed to develop a list of contracted services as evidenced at C270, CFR 485.635.

- The CAH failed to assure all clinical records are complete and protected from possible destruction or or unauthorized use as evidenced at C300, CFR 485.638.

Based on observation, document review and interview, the Critical Access Hospital (CAH) failed properly dispense medications, assure expired medications are not available for patient use, failed to identify potential infection control issues and implement the CAH's policies, failed to assure the required group of professional personnel review the patient care policies on annually, and failed to develop a list of contracted services.

Findings included:


- The CAH failed to properly dispense drugs in accordance with acceptable professional principles and failed to remove expired medications from patient use as evidenced at C-276, CFR 485.635(a)(3)(iv).

- The CAH failed to identify potential infection control issues and implement their policies as evidenced at C-278, CFR 485.635(a)(3)(vii).

- The CAH failed to assure policies were review by a group of professional personnel on an annual basis to assure adequate patient care evidenced at C-291, CFR 485.635(c)(3).

- The CAH failed to develop and maintain a current list of contracted services provided as evidenced at C-291, CFR 485.635(c)(3).

Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to properly dispense drugs in accordance with acceptable professional principles and follow their policy for five of five sampled medications for home use. The CAH failed to follow policies for disposal of open vials of medication in one of one pharmacy refrigerator. This deficient practice had the potential to effect patients receiving medication at the CAH.

Findings included:

- Review on 5/12/10 of the hospital policy titled "Labeling of Medications Pre-packing Procedure", last reviewed on 3/05/07, directed " ...1. Enter the following on the label: A. Drug name. B. Strength and quantity ...C. Lot number. D.Expiration date. 2. Enter the Following in the Pre-pack Log: A. Enter date of pre-pack. B. Enter the manufacturer. C. Enter the manufactures ' lot number. D. Enter the manufactures' and hospitals' expiration date. E. Initials of the person pre-packing. F. Signature of pharmacist checking...".

- During tour of the pharmacy on 5/12/10 at 10:00am staff K revealed the hospital provided after pharmacy hours medications through a Documed system (pre-packaged medications dispensed by the hospital pharmacist). The CAH pharmacy required a written prescription by the provider. The nurse removed the medication from the Documed and filled out a label placed on the prescription with the date, the patient's name, and instruction for taking the medication. The nurse documented the medication dispensed on the Emergency Room (ER) record and filled out a pre-numbered pharmacy log with the date, patient's name, the drug dispensed, the dose, instructions, quantity, and the prescribing provider. The pharmacy retains the provider's written prescription and the prescription number.

- Review on 5/12/10 at 10:00am of the pharmacy log used for the tracking of medications dispensed to ER/outpatients revealed the hospital failed to require staff to document the lot number of the medication or the expiration date of the medication.

- Review on 5/17/10 of the hospital policy titled "After hour ER Dispensing Meds" updated 5/13/10 directed " ... Medication to be sent home with ER patient will be dispensed through the documed ... ".

- Review on 5/17/10 at 10:30am of prescription #10580, #10577, #10578, #10579, and #10574 revealed the medications had been removed from the hospital pharmacy.

- Review on 5/17/10 at 10:30am of the pharmacy documentation for dispensed medications revealed patient #32 (prescriptions #'s 10577, 10578, and 10579) received the following medications on 4/26/10: Metformin (used for high blood sugar) 500mg (milligrams), three tablets, Reglan (used to decrease nausea) 10mg, five tablets, and omeprazole (used to decreased stomach acid) 20mg, three tablets. The dispensed medication log indicated the medications came from the CAH pharmacy. The medication log lacked the lot number of the medications or the expiration date of the medications. The emergency room record lacked documentation of the medications sent home with the patient.

- Review on 5/17/10 at 10:30am of the pharmacy documentation for dispensed medications revealed patient #33 (prescription #10580) received the following medication on 4/25/10, Reglan (used to decrease nausea) 10mg, three tablets. The dispensed medication log indicated the medications came from the CAH pharmacy. The medication log lacked the lot number of the medications or the expiration date of the medications.

- Review on 5/17/10 at 10:30am of the pharmacy documentation for dispensed medications revealed patient #34 (prescription #10574) received Alprazolam (an anti-anxiety medication) 0.25mg, four tablets. The pharmacy tracked the medication through the narcotic check out sheet that indicated the medications came from the CAH pharmacy. The narcotic check out sheet lacked the name of the manufacturer, the lot number, the expiration date, dosing instructions, or the provider that prescribed the medication.

- Review on 5/17/10 at 10:30am of the pharmacy documentation for take home medications revealed patient #35 (prescription #10186) received amoxil (an antibiotic) 250mg four tablets. The dispensed medication log revealed the medication came from the Documed. The medication log lacked the lot number of the medication or the expiration date of the medication.

- Review on 5/17/10 at 10:30am of the pharmacy documentation for take home medications revealed patient #36 (prescription #10183) received Lortab (a narcotic pain medication) 7.5mg, six tablets. The medication came from the Documed. The pharmacy tracked the medication through the narcotic check out sheet that lacked the name of the manufacturer, the lot number, the expiration date, dosing instructions, or the provider that prescribed the medication.

- Staff K on 5/17/10 at 10:30am revealed the Documed does not contain all medications prescribed by providers. The nurse would then remove the medication from the CAH pharmacy and filled out a label placed on the prescription with the date, the patient's name, and how to take the medication. The nurse documented the medication dispensed on the ER record and filled out a pre-numbered pharmacy log with the date, patient's name, the drug dispensed, the dose, instructions, quantity, and the prescribing provider. The pharmacy retains the provider's written prescription and the prescription number. Staff K verified the nurses dispensed the multi-dose packaged medication.

- Review of "Kansas State Board of Pharmacy Laws" updated March 2008 K.S.A. 68-7-11 Medical care facility pharmacy mandated " ... (2) Emergency outpatient services. (A) An interim supply of prepackaged drugs shall be supplied to an outpatient only by a designated registered professional nurse or nurse pursuant to a prescriber's medication order when a pharmacist is not on the premises and a prescription cannot be filled. The interim supply shall be labeled with the following information: The name, address, and telephone number of the medical care facility; the name of the prescriber; the full name of the patient; the identification number assigned to the interim supply of the drug or device by the medical facility pharmacy; the date the interim supply was supplied; adequate directions for use of the drug or device; the beyond-use date of the drug or device issued; the brand name or corresponding generic name of the drug or device; the name of the manufacturer or distributor of the drug or device, or an easily identified abbreviation of the manufacturer's or distributor's name; the strength of the drug; the contents in terms of weight, measure or numerical count; and necessary auxiliary labels and storage instruction, if needed. The interim supply shall be limited in quantity to an amount sufficient to supply the outpatient's needed until a prescription can be filled. (3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user ... ".


Based on observation and interview, the Critical Access Hospital (CAH) failed to assure expired medications are removed from potential patient use.

Findings included:


- Observation on 5/12/10 at 10:05 of the pharmacy refrigerator revealed the following expired and/or unusable drugs:
1. One 10ml (milliliter) vial of Levemir insulin with an open date of 3/29/10.
2. One 10ml vial of Humalog 50/50 insulin with an open date of 3/29/10.

Staff K on 5/12/10 at 10:05am acknowledged the open vials of insulin and open vials of medications should be removed from use 30 days after opening.


Review on 5/17/10 of the requested policy for storage of open medication vials revealed a policy titled "Medication Administration Responsibilities/Restrictions" revised 5/17/09. Bullet 13 directed " ...When opening a new vial of medicine, date and time the event ...The contents are considered safe for one week after opening".

The Critical Access Hospital reported a census of 18 patients. Based on observation, document review and interview, the CAH failed to identify potential infection control issues and implement their policies.

Findings included:

- Observation in the surgical suite on 5/11/10 at 11:07am revealed provider V completing a procedure. The provider removed their protective gloves and exited the surgical suite without performing hand hygiene. Observation of provider W on 5/11/10 at 11:30am revealed the removal of protective gloves and exiting the surgical suite without performing hand hygiene.

Interview with staff M on 5/11/10 at 12:04pm confirmed hand hygiene is to be performed after removing protective gloves.

- Observation of staff N on 5/12/10 between 1:55pm and 2:55pm revealed the staff member cleaning a patient room following the patient's discharge. The staff member applied protective gloves and removed the shower chair and gait belt to the hallway. The staff member did not clean the shower chair or gait belt prior to removing from the room. The staff member applied protective gloves and bagged and removed the trash from the room. The staff member removed the protective gloves and applied another pair. The staff member used the spray bottle of disinfectant to wet the bathroom door knobs, the toilet and sink. The staff member sprayed disinfectant on the walls and floor of the shower, but did not move the fold-up built-in shower seat to apply disinfectant. The staff member then sprayed the disinfectant on the counter and sink in the room. The staff member stated, "The telephone and nurse call light are not sprayed with disinfectant". The protective gloves were removed and the staff member left the area without performing hand hygiene. The staff member returned to the room, applied protective gloves and resprayed the door knobs. The staff member then removed the right hand glove and applied another glove. The staff member cleaned the toilet, removed the protective gloves and applied another pair of gloves. The staff member rinsed the shower, but did not move the built-in shower seat. The staff member did not remove the shower curtain. The staff member removed the protective gloves and applied another pair. The staff member obtained a yellow cloth and saturated the cloth with disinfectant. The staff member used the cloth to wipe the front and back of the phone book, bedside stand, upper cabinets, a clipboard used by nurses, a cardboard box of gloves, the pop-up style paper towel dispenser, a bottle of liquid hand soap, a bottle of alcohol hand sanitizer and the sink. The staff member then removed the gloves, applied another pair, obtained another yellow cloth, saturated the cloth with disinfectant solution and wiped the lower cabinets, the closet doors and the inside of the closet. The staff member removed the protective gloves, applied another pair of gloves then wiped the pillow, bed rails, intervenous solution hanging pole, the headboard, mattress and footboard. The staff member removed the gloves and applied another pair. The staff member then swept and mopped the floor. The staff member removed the protective gloves and left the room. Each time the staff member removed the gloves; they applied another pair without hand hygiene. The staff member failed to perform hand hygiene after at least 12 glove removals.

Interview with staff X on 5/12/10 at 10:30am revealed each housekeeping cart has a set of "Job Cards" to direct housekeeping staff how to clean each area of the hospital. Review of the "Job Card" for "Patient Room - Discharge" directs staff to "change the shower curtain". Interview with staff Y on 5/17/10 at 3:30pm confirmed the housekeeping staff does not remove the shower curtains when cleaning a patient room upon a patient's discharge unless the curtain is soiled.

Staff O, interviewed on 5/12/10 at 3:00pm, confirmed the patient had been in respiratory isolation. Staff O r stated the isolation precautions were discontinued before the patient's discharge.

Review of the CAH's policy titled "Hand Hygiene" I. directs staff to "decontaminate hands after removing gloves".

Interview with infection control officer N on 5/12/10 at 3:50pm confirmed hand hygiene is to be performed after removal of gloves.

Document review of the CDC (Centers for Disease Control and Prevention) Guidelines for Hand Hygiene in Healthcare Settings- 2002 requires healthcare workers to wash their hands after removing gloves.

- Observation of the operating room (OR) on 5/11/10 between 10:30am and 12:20pm and on 5/12/10 at 2:50pm revealed an infant warmer ready for a newborn including a mattress cover, blanket, hat and diaper. The warmer sat behind the provider during an invasive, non-surgical procedure. Interview with staff M on 5/11/10 at 12:05pm confirmed the warmer is ready in case of cesarean section birth is performed. Staff M confirmed the bedding and supplies are not removed with the cleaning of the room following use of the surgical area. Staff M further confirmed the warmer is potentially contaminated during the surgical and non-surgical procedures performed in the room and is not cleaned between cases.

Review of the CAH's policy titled "Cleaning of the Operating Room- Cleaning between cases:" #7 directs staff "All equipment and horizontal surfaces in the OR are cleaned with disinfectant".

Based on document review and interview the Critical Access Hospital (CAH) failed to ensure policies were reviewed by a group of professional personnel on an annual basis to ensure adequate patient care. This deficient practice had the potential to affect patient care provided at the CAH.

Findings included:

- Review of the policy and procedure manuals provided during the survey between 5/10/10 and 5/17/10 revealed a lack of evidence the documents were reviewed annually by a group of professional personnel that included at least one doctor of medicine or osteopathy, at least one midlevel practitioner (Advanced Registered Nurse Practitioner or Physician Assistant) and at least one member that is not on staff at the CAH.

Staff P, identified as the person responsible for the CAH's annual program evaluation, on 5/13/10 at 9:15am acknowledged the CAH failed to include policies in the annual program evaluation.

Administrative staff B on 5/13/10 at 9:30am acknowledged policy and procedure manuals lacked annual review by a group of professionals.

Review of the policy and procedure manuals provided during the survey between 5/10/10 and 5/17/10 lacked evidence of Medical Staff or Governing Body approval.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to designate an individual to coordinate the overall operation of outpatient services provided by the CAH.

Findings included:

- The "Hospital Information Sheet" (a roster of key CAH staff requested by the surveyor), completed by the CAH on 5/10/10, lacked the name of a staff member in charge of the outpatient services.

Administrative staff A and B on 5/10/10 at 1:30pm confirmed the CAH failed to appoint an out-patient coordinator to be responsible for all outpatient services.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and maintain a current list of contracted services provided. This deficient practice had the potential to effect patient services provided through contract by the CAH.

Findings included:

- Review of documentation provided during the survey between 5/10/10 and 5/17/10 revealed a lack of a contract services roster or list with the nature and scope of services provided to the CAH patients.

Administrative staff B on 5/13/10 at 9:30am acknowledged administration failed to develop and maintain a list of contract services.

Based on document review and interview, the Critical Access Hospital (CAH) failed to assure all clinical records are complete and failed to assure all clinical records are protected from possible destruction or or unauthorized use.

Findings included:

- The CAH failed to assure complete medical records as evidenced at C302, CFR 485.538(b)(1).

- The CAH failed to secure all patients' clinical records from possible destruction or unauthorized use as evidenced at C308, CFR-485.638(b).

Based on document review and interview, the CAH failed to assure complete medical records for three of ten emergency room clinical records reviewed (#22, 24 and 27).

Findings included:

Review of the clinical record for patient #27 revealed an emergency room visit on 1/30/10. the patient received epinephrine (to stimulate the heart) and atropine (to increase heart function). The patient had a urinary catheter placed and laboratory studies completed. The clinical record lacked evidence of a provider's order for the medications and other treatments and tests. Interview with Adminsitrative staff B on 5/13/10 at 9:37am acknowledged the record lacked evidence of provider's orders for the care provided.

- Review of the emergency room record for patient #22 revealed a visit on 11/17/09. The CAH failed to obtain informed consent to treat the patient or document the patient could not sign the consent.

- Review of the clinical record for patient #24 revealed the patient died during an emergency room visit on 3/29/10. The patient remained at the hospital until the next day, when the patient was released to the funeral home. The CAH failed to document the release of the body to the funeral home and the disposition of the belongings the patient may have had.

Interview with staff E on 5/11/10 at 4:50pm confirmed the CAH failed to complete medical records.

- Review on 5/17/10 of the pharmacy documentation for dispensed medications revealed patient #32 received the following medications on 4/26/10: Metformin (used for high blood sugar) 500mg (milligrams), three tablets, Reglan (used to decrease nausea) 10mg, five tablets, and omeprazole (used to decreased stomach acid) 20mg, three tablets. Medical record review on 5/17/10 for patient #32 revealed the patient received services in the Emergency Room (ER) on 4/26/10. The emergency room record lacked documentation of the medications sent home with the patient.

Staff K on 5/17/10 at 12:35pm acknowledged patient #32's ER record lacked documentation of the medications sent home with the patient.





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- Review on 5/17/10 of the pharmacy documentation for dispensed medications revealed patient #32 received the following medications on 4/26/10: Metformin (used for high blood sugar) 500mg (milligrams), three tablets, Reglan (used to decrease nausea) 10mg, five tablets, and omeprazole (used to decreased stomach acid) 20mg, three tablets. Medical record review on 5/17/10 for patient #32 revealed the patient received services in the Emergency Room (ER) on 4/26/10. The emergency room record lacked documentation of the medications sent home with the patient.

Staff K on 5/17/10 at 12:35pm acknowledged patient #32's ER record lacked documentation of the medications sent home with the patient.

Based on observation and interview, the Critical Access Hospital (CAH) failed to secure all patient's clinical records from loss or unauthorized use for all patients treated and discharged from the hospital between 1998 to present.

Findings included:

- Interview with staff E and P on 5/11/10 at 10:30am revealed all patient records from 1998 to present were stored in the medical records office. Interview with administrative staff F on 5/11/10 at 5:00pm confirmed some medical records were stored on the second floor. Interview with staff E and P on 5/12/10 confirmed the clinical records of some patients who died are stored upstairs, and stated they have not observed the storage area. Observation on 5/12/10 between 9:05am and 9:15am of the upstairs storage area with staff E and P present revealed the stored clinical records. Observation of the medical records office, during the time of the tour of the upstairs storage area with staff E and P, revealed the door to the room stood open and unattended, with no staff members present. Observation of the computer screens, at this time, revealed patient information viewable on the monitors. The CAH failed to assure the clinical records remained secure while the staff members were out of the office.

The CAH failed to assure all clinical records are protected from loss, destruction or unauthorized use.

Based on document review and interview, the Critical Access Hospital (CAH) failed to report one of three deaths that occurred at the CAH to the organ retrieval organization.

Findings included:

- Review of the clinical record for patient #24 revealed they arrived at the CAH as a "Code Blue" (requires emergency care) on 3/29/10. The provider, after assessing the patient, stopped the emergency treatment and pronounced the patient dead. The clinical record lacked evidence of the death notification to the Midwest Organ Bank (MOB) .

Review of the CAH's policy titled "Organ, Tissue and Eye Donation" directs staff to "contact the Midwest Transplant Network...to notify of all patient deaths...".

Review of the contract between the CAH and MOB "1.a.To notify MOB in a timely manner of all individuals whose death is imminent or who have died in the hospital".

Staff C, interviewed on 5/11/10 at 5:50pm, confirmed the CAH failed to notify the organ retrieval organization of the patient's death.

Based on record review and interview the Critical Access Hospital (CAH) failed to provide a patient or their representative a transfer notice that included required federal requirements for one of one transfer swing-bed patients (#14).

Findings included:

- Interview on 5/12/10 at 11:30am with staff J revealed the CAH initiated the transfer/discharge of patient #14 to another facility. Staff J provided a letter of notice given to patient #14 on 3/26/10. Review of the transfer/discharge notification revealed the CAH failed to include the location of the transfer or discharge, the right to appeal the action, and the name, address, and telephone number of the state long term care ombudsman.

The CAH failed to have a policy for the contents of a transfer/discharge notice.

The CAH failed to provide swing-bed residents with the right to appeal a transfer or discharge.

Based on observation, document review and interview, the Critical Access Hospital (CAH)failed to post signs regarding the patient's right to receive emergency medical care.

Findings included:

- Review of a map of the CAH building confirmed three entrances that might be used by patients seeking emergency care or waiting for examination or treatment. The entrances are the ambulance entrance, the entrance next to the ambulance entrance and the main hospital entrance. Observation in the ambulance entrance and walk-in emergency entrance on 5/10/10 at 11:40am revealed the CAH failed to post the required information. Observation of the main CAH entrance during the survey revealed the CAH failed to post the required information.

Interview with administrative staff B on 5/10/10 at 11:40am confirmed the CAH failed to post the required information at entrances and areas where individuals wait for examination or treatment.