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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on July 5 & 6, 2011, 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 C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Recertifcation Survey conducted on July 5 & 6, 2011, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 7/6/2011.

A. Based on review of Critical Access Hospital (CAH) policy, clinical record, and staff interview, it was determined that in 1 of 4 (Pt #14) clinical records reviewed of patients with restraint device usage, the Hospital failed to ensure adherence to restraint usage.

Findings include:

1. The CAH policy entitled, "Emergency Use of Physical or Chemical Restraints." reviewed on 6/14/11 at approximately 1:00 PM required, "...The emergency use of a physical or chemical restraint must be documented in the resident/patient's record, including: 1. The behavior incident that prompted the use of the physical or chemical restraint. 2. The date and times the physical restraint was applied and released...6. The new or revised order is issued by the physician. 7. The effectiveness of the physical or chemical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the patient. 8. Continuous monitoring during the use of restraints is required by the Medical Surgical Unit. A patient wearing a physical restraint shall have it released for a few minutes at least once every two hours, or more often if necessary. During these times, residents shall be assisted with ambulation, as their condition persists, and provided a change in position, skin care and nursing care, as appropriate."

2. The clinical record of Pt #14 was reviewed on 6/15/11 at approximately 9:00 AM. Pt #14 was a 28 year old male admitted on 11/8/10 with diagnoses of Schizophrenia and Drug Overdose. The clinical record contained a physician's order dated 11/8/10 at 5:30 PM that required "Limb restraints as needed" with an order dated 11/09/10 at 8:50 AM to remove the restraints. The clinical record lacked documentation of the time of restraint application, every two hour monitoring, skin care, and time of release. Nursing documentation dated 11/10/10 at 1:48 AM indicated, "restraint placed on patient's right wrist and left ankle." The clinical record lacked a physician's order for the reapplication of restraints for Pt #14 on 11/10/10.

3. The finding was confirmed with the Medical/ Surgical/Emergency Department Charge Nurse during an interview on 6/15/11 at approximately 10:30 AM.

A. Based on review of Critical Access Hospital (CAH) policy, observation, and staff interview, it was determined, that for 3 of approximately 50 freezer items, the CAH failed to ensure open packages of food were properly labeled.

Findings include:

1. On 6/14/11 at 1:15 PM, CAH policy titled, "Storage Guidelines" was reviewed. The policy required, "B. Refrigerated and Frozen Product Storage Guidelines:... i. All opened items (such as refrigerated leftovers) are dated and labeled with a specific label. The label contains the date of preparation or opening, product name, and person who opened or prepared the item."

2. On 6/14/11 between 11:05 AM to 11:30 AM, an observational tour was conducted in the dietary department. Three of approximately 50 open packages (pepperoni, sausage, and hot dogs) were found in the freezer and did not contain labels.

3. These findings were confirmed by the Certified Dietary Manager during an interview on 6/14/11 at 11:20 AM.

B. Based on review of Critical Access Hospital (CAH) policy, observation, and staff interview, it was determined, that for 8 of approximately 30 spice containers, the CAH failed to ensure open spice containers were properly labeled and stored.

Findings include:

1. On 6/14/11 at 1:15 PM, CAH policy titled, "'Storage Guidelines" was reviewed. The policy required, "A. General Guidelines: f. All items are marked with the receiving date on the day of delivery unless they are kept in the original package/box and said box has a dated label."

2. On 6/14/11 between 11:05 AM to 11:30 AM, an observational tour was conducted in the dietary department. Eight of approximately 30 open spice containers did not contain receiving date labels or the receiving date label indicated the container was received over 2 years ago, including:

- Dill Weed no date
- Pumpkin Pie Spice no date
- Fine Ground Sage 5/7/09
- Cream of Tartar 3/26/09
- Celery Salt 2/22/08
- Ground Cloves 8/17/07
- Garlic Salt 12/12/06
- Ground Allspice 4/1/02

3. An interview was conducted with the Certified Dietary Manager on 6/14/11 at 11:20 AM. The Manager stated that spices are used for up to 2 years and then discarded. The Manager confirmed the findings during the interview.

A. Based on review of Critical Access Hospital (CAH) policy, medical record, and staff interview, it was determined that in 1 of 1 (Pt #22) medical record reviewed of a patient with an order for isolation, the CAH failed to ensure isolation precautions were initiated and maintained.

Findings include:

1. CAH policy entitled, Clostridium Difficile and Antibiotic Associated Diarrhea (CAD)," reviewed on 6/15/11 at approximately 11:15 AM required, "..Procedure for Prevention and Control:..B. Room assignment: Contact Isolation -..."

2. The medical record of Pt #22 was reviewed on 6/15/11 at approximately 10:00 AM. Pt #22 was an 86 year old female admitted with diagnoses of Severe Dehydration and Acute Diarrhea. The medical record contained a physician's order dated 1/4/11 at 9:00 AM that required, "C diff precautions." The medical record lacked documentation that Contact Isolation had been initiated and maintained for Pt #22 during the course of her hospitalization.

3. The finding was confirmed with the Medical/ Surgical/Emergency Department Charge Nurse during an interview on 6/15/11 at approximately 10:30 AM.


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B. Based on a review of Critical Access Hospital (CAH) policy, medical record, and staff interview, it was determined in 1 of 5 (P#3) medical records reviewed in which the patient received surgical services, the CAH failed to ensure the patient's medications were accurately listed.

Findings include:

1. The CAH policy titled, "Preoperative Teaching and PATS Process (Pre-Admission Teaching)" was reviewed on 6/15/11 at approximately 1:00 PM. The policy required, "POLICY: ...The pre-admission nurse will document on the pre admission testing worksheet all medications."

2. The medical record of Pt #3 was reviewed on 6/14/11 at approximately 1:00 PM. Pt #3 was a 70 year old male admitted on 4/29/11 and scheduled for surgery due to a Left Cataract. On the "Pre-Admission Testing Worksheet", dated 4/26/11 and signed by a RN, it was documented that Pt #3 was taking Simvastatin 40 mg daily, baby Aspirin 81 mg daily, fish oil, Akanasia, and Flutiansone nasal spray. On the "Pre-Operative Assessment Form" under "Nursing Data Elements: Daily Medications (prescription, OTC, vitamins, alternative medication, herbal remedies...)" this section was marked with a zero (meaning the patient was taking no medications.).

3. During an interview with the Director of Surgery, conducted on 6/14/11 at 1:20 PM, the above finding was confirmed.

A. Based on review of the Association of Operating Room Nurses (AORN) 2011 Perioperative Standards and Recommended Practices, observation, and staff interview, it was determined, that for 2 of approximately 50 procedural techniques observed in the OR, the Critical Access Hospital (CAH) failed to ensure the OR staff followed the AORN Standards and Recommended Practices.

Findings include:

1. On 6/15/11 at 11:10 AM, the AORN 2011 Perioperative Standards and Recommended Practices was reviewed and included, "Recommendation V: A sterile field should be maintained and monitored constantly... The OR environment can be breached by other vectors, such as insects, that potentially could come into contact with open sterile fields, unobserved, unless the sterile field is monitored..."

2. "Recommendation IV: All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity... 6. When solutions are dispensed... remaining solutions should be discarded. The edge of the container is considered contaminated after the contents have been poured; therefore, the sterility of the contents cannot be ensured if the cap is replaced..."

3. On 6/15/11 between 7:35 AM and 9:25 AM, an observational tour was conducted in the OR. Between 7:37 AM and 7:43 AM, in OR suite 2, a Certified Scrub Technician (E #1) opened sterile instruments and delivered the instruments to a sterile field. At 7:44 AM, E #1 left OR suite 2, leaving no one to monitor the sterile field. E #1 returned to OR suite 2 at 7:48 AM, leaving the sterile field unmonitored for approximately 4 minutes.

4. An interview was conducted with the OR Manager (E #2) on 6/14/11 at 2:00 PM. E #2 stated that the CAH follows AORN Standards and Recommended Practices.

5. These findings were confirmed by the OR Manager during an interview on 6/15/11 at 11:15 AM.

A. Based on medical record review and staff interview, it was determined that in 1 of 22 (Pt #2) medical records reviewed, the Critical Access Hospital (CAH) failed to ensure all medications were administered in accordance with a physician's orders.

Findings include:

1. The medical record of Pt #2 was reviewed on 6/14/11 at approximately 1:00 PM. It indicated Pt #2 was admitted on 11/20/10 with diagnoses of Dehydration and Intractable Vomiting. Physician's orders, written 11/20/10 at 9:30 PM required, Insulin drip at 8 units/hr Regular and Insulin 8 units Regular IV now. The nursing documentation for the Insulin drip did not indicate the amount of Insulin being delivered per hour and the documentation for the Insulin 8 units IV now did not indicated how the 8 units of Insulin were administered.

2. During an interview with the Medical/Surgical/Emergency Department Director conducted on 6/14/11 at 1:10 PM, the above findings were confirmed.

A. Based on review of Critical Access Hospital (CAH) policy, clinical records, and staff interview, it was determined that in 4 of 21 (Pt #13, 14, 17, and 22) medical records reviewed, the CAH failed to ensure all patient care plans were complete and accurate.

Findings include:

1. CAH policy entitled, "Nursing Care Plan," reviewed on 6/15/11 at approximately 12:00 noon required, "...The Nursing Care Plan for each resident is based on the nature of the illness, treatment prescribed, long or short term goals, and other pertinent information by the interdisciplinary team. The Nursing Care Plan is a personalized daily plan for individual residents. It indicated what nursing care is needed..."

2. The medical record of Pt #13 was reviewed on 6/15/11 at approximately 9:00 AM. Pt #13 was a 21 year old female admitted on 8/22/10 with diagnoses of Drug Overdose and Suicidal Ideations. The medical record contained a physician's order dated 8/22/10 at 9:00 PM that required the use of "Restraints PRN" (as needed). The Patient's Care Plan failed to include the usage of restraints.

3. The medical record of Pt #14 was reviewed on 6/15/11 at approximately 9:00 AM. Pt #14 was a 28 year old male admitted on 11/8/10 with diagnoses of Schizophrenia and Drug Overdose. A physician's order dated 11/8/10 at 5:30 PM required, "Limb restraints as needed. 2 point restraints are needed at this time." The Patient's Care Plan failed to include the usage of restraints.

4. The medical record of Pt #17 was reviewed on 6/15/11 at approximately 9:45 AM. Pt #17 was a 65 year old male admitted on 6/3/11 with diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease. The medical record contained a physician's order dated 6/3/11 at 6:10 PM that required, "Soft Restraints."
The patient's Care Plan failed to include the usage of restraints.

5. The medical record of Pt #22 was reviewed on 6/15/11 at approximately 10:00 AM. Pt #22 was an 86 year old female admitted with diagnoses of Severe Dehydration and Acute Diarrhea. The medical record contained a physician's order dated 1/4/11 at 9:00 AM that required, "C diff precautions." The patient's Plan of Care failed to include isolation.

6. The finding was confirmed with the Medical/Surgical/Emergency Department Charge Nurse during an interview on 6/15/11 at approximately 10:30 AM.

A. Based on review of Critical Access Hospital (CAH) policy, CAH Medical Staff Rules and Regulations, CAH Cobra form, medical records and staff interview, it was determined that in 3 of 6 (Pt #9, 10, and 13) medical records of patients transferred from the CAH, the CAH failed to ensure the medical records were complete.

Findings include:

1. CAH policy entitled, "Transfer of Patient." reviewed on 6/15/11 at approximately 10:00 AM required, "Procedure: 1. When the doctor orders a patient is to be transferred to a higher level of care, the nurse notifies the specialist that the Doctor has requested. ...A Cobra form is filled out by the Doctor and registered nurse."

2. The CAH Medical Staff Rules and Regulations reviewed on 6/15/11 at approximately 1:30 PM required "...C. Medical Records..4. All orders for treatment shall be in writing...and signed by the physician..."

3. The CAH Cobra Form, entitled "Patient Transfer Form" was reviewed on 6/15/11 at approximately 10:00 AM. The second page of this form required "Patient Transfer Form...The potential benefits of such transfer and the potential risks associated with such transfer have been explained to me and I fully understand them...Signature of patient or legally responsible individual signing on patient's behalf..."

4. The medical record for Pt #9 was reviewed on 6/14/11 at approximately 10:15 AM. Pt #9 was a 2 year old boy admitted for observation on 1/12/11 with diagnoses of Gastroenteritis and Dehydration. Pt #9 was admitted at 8:37 PM and then transferred to another Hospital at 10:23 PM. The medical record contained transfer orders and page one (1) and page three (3) of the Cobra form that included Pt #9 was in stable condition and transferred via private car with his mother to the receiving Facility. The medical record lacked the second page of the Cobra form, and therefore lacked documentation of mother's signed, informed consent including risks of the transfer.

5. The medical record for Pt #10 was reviewed on 6/14/11 at approximately 10:30 AM. Pt #10 was a new born boy delivered at 6:19 AM on 11/18/10 at the CAH's Emergency Department (ED). The medical record contained a physician's ED order that required Pt #10 be transferred to another Facility, which lacked a physician's signature and date. Pt #10 was transferred at 8:15 AM on 11/18/10. The medical record lacked a Cobra form for transfer.

6. The medical record of Pt #13 was reviewed on 6/15/11 at approximately 9:00 AM. Pt #13 was a 21 year old female admitted on 8/22/10 with diagnoses of Drug Overdose and Suicidal Ideations. The medical record contained a physician's order dated 8/24/10 at 1:45 PM that required Pt #13 be transferred to Robert Young Psychiatry. The clinical record lacked a copy of the required Cobra Forms.

7. The above findings were confirmed with the Medical/Surgical/Emergency Department Charge Nurse during an interview on 6/15/11 at approximately 10:30 AM.


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B. Based on medical record review and staff interview, it was determined that in 1 of 4 (Pt #3) clinical records reviewed of patients that required surgery, the CAH failed to ensure that the report of operation was accurate.

Findings include:

1. The medical record of Pt #3 was reviewed on 6/14/11. It indicated Pt #3 was admitted for outpatient surgery on 4/29/11 with a diagnosis of Left Cataract. The document titled, "Anesthesia Record", dated 4/29/11 indicated Pt #3 received MAC anesthesia with Versed 1.5 mg and 0.5 mg having been administered. However, on the "Report of Operation", dated 4/29/11, the physician failed to include the fact that Pt #3 had been sedated with MAC anesthesia and only documented "Anesthesia: Topical/intracameral".

2. During an interview with the Director of Surgery, conducted on 6/15/11 at 1:20 PM, the above finding was confirmed and the Director stated that Pt #3 had received both topical and MAC anesthesia.

A. Based on a review of Critical Access Hospital (CAH) policy, medical record, and staff interview, it was determined that in 1 of 4 (Pt #4) medical records reviewed in which the patient received surgical services, the CAH failed to ensure all patient's allergies were accurately documented on the Preanesthesia Evaluation.

Findings include:

1. The CAH policy and procedure titled, "Anesthesia Department Responsibilities and Service" reviewed on 6/15/11 at approximately 1:00 PM required, "POLICY: ...The medical record should reflect the following in the pre-anesthesia exam: 6. Allergies...".

2. The medical record of Pt #4 was reviewed on 6/14/11. It included Pt #4 was admitted for outpatient surgery on 2/28/11 with a diagnosis of Tonsillectomy. Documentation on the "Nursing Data Elements" included "Allergies verified...Food...Shrimp." The document titled, "Preanesthesia Evaluation", dated and timed 2/28/11 at 9:35" it included "Allergies: NKA (no known allergies)".

3. During an interview with the Director of Surgery, conducted on 6/15/11 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Critical Access Hospital (CAH) policy, medical record, and staff interview, it was determined that in 1 of 4 (Pt #3) medical records reviewed in which the patient received surgical services, the CAH failed to ensure the patient received a proper post-anesthesia evaluation.

Findings include:

1. The CAH policy and procedure titled, "Anesthesia Department Responsibilities and Service" reviewed on 6/15/11 at approximately 1:00 PM required, "POLICY: ...Postoperative visits must be made before the patient is discharged from the Phase II Recovery and or the Medical/Surgical Unit...Documentation of preoperative and postoperative anesthesia visits must be done on the anesthesia post-op evaluation sheet..."

2. The medical record of Pt #3 was reviewed on 6/14/11 at approximately 1:00 PM. Pt #3 was a 70 year old male admitted on 4/29/11 and scheduled for surgery due to a Left Cataract. The Anesthesia Record, dated 4/29/11, indicated Pt #3 was in surgery at 9:30 AM. The "OR Record" indicated anesthesia was started at 9:12 AM and finished at 9:45 AM. The document titled, "Post Anesthesia Evaluation" was completed by the CRNA and dated 4/29/11 at "09" (while the patient was still in surgery).

3. During an interview with the Director of Surgery, conducted on 6/14/11 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Critical Access Hospital (CAH) policy, medical record, and staff interview, it was determined that in 1 of 4 (Pt #1)medical records reviewed, in which the patient received surgical services, the CAH failed to ensure the patient was discharged to a responsible adult or exempted by the practitioner performing the procedure.

Findings include:

1. The CAH policy titled, "Discharge Instructions" reviewed on 6/14/11 at approximately 1:00 PM required, "PROCEDURE: ...The patient must have a responsible adult to provide transportation home. No patient will be allowed to drive himself/herself home."

2. The medical record of Pt #1 was reviewed on 6/14/11 at approximately 1:00 PM. Pt #1 was an 86 year old female admitted on 4/29/11 for outpatient surgery with a diagnosis of YAG Laser Capsulotomy. There was no documentation in the medical record that indicated Pt #1 was discharged into the care of a responsible adult or was exempted by the practitioner that performed the procedure.

3. During an interview with the Director of Surgery, conducted on 6/14/11 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Critical Access Hospital (CAH) policy, medical records, and staff interview, it was determined 1 of 4 (Pt # 1) medical records reviewed in which the patient received surgical services, the CAH failed to ensure a time out was performed prior to the procedure.

Findings include:

1. The CAH policy titled, "Surgical Site Identification" reviewed on 6/15/11 at approximately 1:00 PM required,"PROCEDURE: Verification of Site/Side: ...Before induction, the surgeon, anesthesiologist and the Circulating RN as a team, will again review the medical record, surgical checklist, and preoperative assessment to verify all pertinent information, including correct surgical site, patient, procedure...This process is referred to as a "time out", with the intent of the process being a double-check verification of the correctness of the surgical procedure to be performed, the correctness of the site/side of surgery and that the correct patient is involved."

2. The medical record of Pt #1 was reviewed on 6/14/11 at approximately 1:00 PM. Pt #1 was an 86 year old female admitted on 4/29/11 for outpatient surgery with a diagnosis of YAG Laser Capsulotomy. The form titled, "OR Record", dated 4/29/11, under the section titled, "Patient/Procedure/Site/Side verified before incision?(Time-Out)" there was no documentation that indicated a time out procedure was done prior to the procedure.

3. During an interview with the Director of Surgery, conducted on 6/14/11 at 1:20 PM, the above finding was confirmed.

A. Based on a Critical Access Hospital (CAH) agreement, attestation letter, and staff interview, it was determined that the CAH failed to ensure medical records were sent for peer review to determined if diagnoses and treatment were appropriate.

Findings include:

1. The CAH agreement with the ICAN (Illinois Critical Access Hospital Network) was reviewed on 6/15/11 at approximately 1:00 PM. The Agreement required, "External Peer Review Agreement Purpose: The objective of the External Peer Review Program ("EPRP") is to provide, to committees of licensed or accredited rural hospitals or their medical staffs, confidential third party assessments of the professional competence of health care practitioners, for use in the course of internal quality control..."

2. On 6/16/11 at approximately 10:00 AM the Director of Quality presented an attestation letter dated 6/15/11 from ICAN that indicated, "I have reviewed Morrison Community Hospital's external peer review activity within ICAHN's External Peer Review Network (EPRN) Program over the last three years. I have no record of any peer review requests within this time frame by your facility."

3. During an interview with the Director of Quality, conducted on 6/16/11 at 10:30 AM, the above finding was confirmed.