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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 October 12, 2021, 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 document review, observation and interview, it was determined the Hospital failed to ensure biological's were stored per policy. This has the potential to affect all inpatient and outpatients who receive services by the Laboratory Department.

Findings include:

1. The policy titled "Blood Cultures (Lab-133)" (approved 8/17/21) was reviewed on 10/6/21. The policy noted "Specimen Collection: ... b... The blood culture vials should be prepared by removing the flip-cap and wiping the top of each vial with a 70% isopropyl alcohol pad..." The "BD Bactec Plus Aerobic/F Culture Vials" manufacturer's instructions (dated 7/16) were reviewed on 10/5/21. The instructions noted "... a vial neck may be cracked and the neck may break during removal of the flip-off cap or in handling... a vial may not be sealed sufficiently. In both cases the contents of the vials may leak or spill, especially if the vial is inverted."

2. During an observational tour on 10/5/21 at approximately 1:45 PM with the Laboratory Manager (E#7) and the Regulatory Coordinator (E#1), two lab supply carts were observed to have a drawer that contained blood culture vials labeled BC Bactec Plus Aerobic F Culture Vial. 1 cart was observed to have 3 blood culture vials without flip-off cap and 2 vials were inverted and the other cart was observed to have 2 blood culture vials without flip-off caps and 2 vials were inverted.

3. During an interview during the tour on 10/5/21 at approximately 1:45 PM, the Laboratory Assistant (E#10 ) stated the flip-off caps would come off from the drawers opening and closing. E#10 stated "I just clean them off with alcohol and use them."

4. During an interview on 10/6/2021 at approximately 3:00 PM, E#1 verbally agreed the flip-off caps were not on and should have been and the vials were inverted and should have been removed from patient care.

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 October 12, 2021, 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 October 12, 2021.

Based on document review and interview, it was determined for 2 of 2 (Medical Doctor-MD #1 and MD #2) physicians who have ordered the use of violent and/or non-violent restraints, the Hospital failed to ensure policies were followed for the requirements of restraint training for physicians. This has the potential to affect all patients who are placed in restraints at the Hospital with a current census of 8 patients.

Findings include:

1. The policy titled "Restraint and Seclusion Management (effective 7/5/21)" was reviewed on 10/6/21 at approximately 2:00 PM. The policy noted "...training:1. Physicians...that order and/ or evaluate for restraints...training occurs during orientation, every 2 years..."

2. The educational files of MD#1 and MD#2 were reviewed on 10/6/21 at approximately 2:00 PM. The files of MD#1 and MD#2 lacked documentation the physicians had been trained on restraint usage.
a. MD#1- reappointed 9/1/20. MD #1 ordered restraints for Pt. #7 on 6/15/21 and 6/16/21 Pt. #7 was admitted on 6/14/21 with Diagnosis of Psychiatric Disorder. MD #1 ordered restraints on Pt. #8 on 7/13/21. Pt. #8 was admitted on 7/13/21 with a Diagnosis of Aggressive Behavior.
b. MD#2- reappointed 7/1/20. MD #2 ordered restraints for Pt. #7 on 6/14/21.

3. An interview was conducted with Director of Quality and Safety (E#5) on 10/7/21 at approximately 11:00 AM, E#5 verbally confirmed that MD#1 and #2 lacked restraint training and should have.

A. Based on observation, document review and interview, it was determined the Hospital failed to ensure a sanitary environment. This has the potential to affect all in-patients, out-patients, staff and visitors.

Findings include:

1. During an observational tour on 10/5/21 at approximately 12:00 PM with the Regulatory Coordinator (E#1) and the Imaging Supervisor (E#8), the following was observed:
a) The MRI (Magnetic Resonance Imaging) unit's clean storage area was observed to have a cabinet which contained clean supplies, next to a flower pot filled with dirt;
b) The top of the CT (Computerized Tomography) machine was observed to have a layer of dust;
c) The Fluoroscopy room was observed to have 2 pillows and a positioning wedge on top of a biohazard container and next to an opened linen container.

2. During the tour of the Radiology Department on 10/5/21 at approximately 12:00 PM, E#8 was observed to removed the flower pot with dirt from the clean supply cabinet and stated "I don't know why that's there."

3. During an observational tour of the Medical Surgical Unit on 10/6/21 at approximately 10:45 AM with E#1 and the Director of Inpatient Services (E#3), the Respiratory Therapist (E#9) was observed to exit a COVID isolation room #216 donned with a gown, gloves, mask and face shield, walked down the hall to the PPE supply cart and picked up a new pair of gloves, walked to the nurses station and then entered another COVID isolation room #215 without doffing the PPE or conducting hand hygiene. The Medical Surgical Unit's equipment supply room was observed to have a wheeled walker with soiled tennis balls on the two front legs hanging on the wall above other clean equipment.

4. The policy titled "Personal protective equipment (PPE), removal" (revised 8/20/21) was reviewed on 10/6/21. The policy noted "... remove all PPE at the patient's doorway or in the anteroom... perform hand hygiene."

5. During an interview on 10/6/21 at approximately 3:00 PM, E#1, the Manager of Quality and Safety (E#2) and the Director of Quality and Safety (E #5) verbally confirmed the above findings and agreed the Hospital failed to ensure a clean and sanitary environment and should have been.


B. Based on document review and interview, it was determined the Hospital failed to ensure hand hygiene surveillance was conducted to prevent the transmission of infectious diseases. This has the potential to affect all in-patients, out-patients, staff and visitors.

Findings include:

1. The "Infection Trending Data August 2021" was reviewed on 10/7/21. The "Hand Hygiene per Unit" document lacked documentation hand hygiene was observed monthly in the following units:
a) Emergency Department lacked data for April and May 2021;
b) Operating Room lacked data from November 2020 through May 2021;
c) Kitchen lacked data from October 2020 through May 2020 and August 2021;
d) Rehabilitation lacked data from October 2020 through June 2021;
e) X-ray lacked documentation from October 2020 through August 2021.

2. During an interview on 10/7/21 at approximately 9:00 AM, the Director of Quality and Safety (E#5) verbally agreed hand hygiene had not been monitored.

Based on observation, document review and interview, it was determined the Hospital failed to ensure the Dietary Department's daily cleaning logs were completed and monitored for compliance. This has the potential to affect all in-patients, outpatients, staff and visitors who receive food from the Dietary Department.

Findings include:

1. During an observational tour of the Dietary Department on 10/6/21 at approximately 1:15 PM with the Regulatory Coordinator (E#1) and the Temporary Dietary Supervisor (E#6), the following Daily Cleaning logs were observed to not be completed daily:
a) Daily Cleaning Schedule A- August, 8 out of 30 days; September, 7 out of 30 days; October, 3 out of 6 days
b) Daily Cleaning Schedule B- August, 2 out of 30 days; September, 18 out of 30 days; October, 6 out of 6 days
d) Daily Cleaning Schedule 16- August, 26 out of 30 days; September, 23 out of 30 days; October, 6 out of 6 days

2. During an interview on 10/6/21 at approximately 1:15 PM, E#6 stated cleaning was conducted daily and the logs were not completed due to a turnover in staff and the new hires were not compliant with documentation.

3. During an interview on 10/6/21 at approximately 2:00 PM, E#1 verbally agreed the daily cleaning logs were not completed daily and should have been. E#1 stated "The kitchen is clean. So, they (Dietary staff) obviously are cleaning but there should be some over sight of this (completing the cleaning schedules) since there are quite a few new hires and E#6 is in a temporary position right now. The logs should have been scanned into our shared drive and reviewed for compliance."