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Based on observation and interview, the facility failed to have protective coverings on florescent lights in the kitchen. This had the potential to affect all in-patients from the critical access hospital. Findings include:

During an observation on 09/26/17 at 7:16 a.m., all the fluorescent lights of the kitchen ceiling had no coverings over the glass tubes. One set of two fluorescent lights were over the back-wall prep counter, one set of two fluorescent lights were above the three sinks, for washing pots and pans, and three sets of two fluorescent lights were above the main walkway in the kitchen, and one set was above the steam table.

During an interview on 09/25/17 at 7:16 a.m., staff member D stated she was unaware the fluorescent lights needed covers to protect the food from contamination of glass particles if one should burst.

During an interview, on 9/25/17 at 9:10 a.m., staff member D stated maintenance staff was going to order protector covers for the lights.

Based on observation, record review, and interview, the facility failed to securely lock medications and discard expired medications to where staff could not use. This had the potential to affect all critical access hospital patients requiring medication. Findings include:

1. During an observation on 9/25/17 at 1:21 p.m., a metal medication cupboard in the ED, was unlocked. The door to the emergency room was open to anyone, including non- employees, in the critical access hospital. The cupboard contained multiple and various medications including naloxone, metoprolol, amiodarone, marcaine, nitroglycerin, furosemide, phenytoin, and more. Three vials of amidate 20mg/10ml was found to be expired on "1 Jul 2017."

During an interview on 9/25/17 at 1:35 p.m., staff member B said, "The medication cupboard should not be unlocked like it was." The staff member locked the cabinet.


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Review of the facility's Pharmacy Policy, with an effective date of 8/22/06, showed, "Medication in pharmacy for Critical Access Hospital patients will be stored in a locked cabinet in the drug room." "All multi-dose vials should be dated upon initial opening. No opened multi-dose vial should be kept beyond three (3) months of initial opening. This will decrease the chance of vial contamination."

2. During an observation on 9/28/17 at 9:55 a.m., 20 single tabs of Digoxin 0.25 mg were in the pharmacy room on the shelf. The Digoxin had an expiration date of 6/17. An opened bottle of 100 tabs of Digoxin 0.25 mg also had an expiration of 6/17. An open bottle of partially used 100 tabs of Erythromycin delayed release 25 mg, along with 20 single tabs all had expiration dates of 4/17.

A cardboard box with dimensions of 18" wide by 18" long by 24 inches deep was located on the floor, below the open shelves of medication, in the pharmacy room. The box was 3/4 full of outdated medications.

During an interview on 9/27/17 at 10:37 a.m., staff member B stated outdated medications were taken out of the pharmacy room twice a year, by a contracted company that reimbursed the hospital.

Review of the facility's Pharmacy Policy, with an effective date of 8/22/06, showed, "Discontinued and outdated drugs and containers...shall be returned to the pharmacy for proper disposition by the pharmacist." and "Medications no longer in use are disposed of or destroyed in accordance with federal and state laws and regulations. Medications having an expiration date are removed from use and properly disposed of after such date."

Based on record review and interview, the facility did not have informed consent forms or acknowledgement of receiving a copy of the patient rights, signed by the patient or responsible party, for 2 (#14 and 19) of 20 sampled patients.

Review of the facility's policy and procedures for Consent for Care, with no date, showed the patient, the guardian, or the responsible party was to sign a consent to treat form. The signature would be obtained by the attending physician, physician assistant, or the nurse practitioner.

Review of patient #14's admit record showed the patient was in the critical access hospital on 12/11/16. There was no documentation showing the patient had given consent to be treated, or that the patient received and understood the patient rights.

Review of patient #19's admit record showed the patient was in the critical access hospital on 6/6/17. There was no documentation showing the patient had given consent to be treated, or that the patient received and understood patient rights.

During an interview on 9/27/17 at 11:15 a.m., staff member C stated they were unable to find the signed consent forms for treatment or the signed form that the patient received a copy of the patient rights for either patient #14 or #19.

During an interview of 9/28/17 at 9:55 a.m., staff member B stated the registered nurse, the mid-level, or the physician would give paperwork for the patient to review and sign, before treating the patient.

Based on record review and interview, the facility failed to have an abuse policy in place to assure all patients were safe from abuse. Findings include:

Review of the facility's policies, with a review date of 6/20/17, showed no documentation that the facility had an abuse policy for the critical access hospital.

During an interview on 9/28/17 at 8:34 a.m., staff member B stated the critical access hospital did not have an abuse reporting/hiring policy.

Review of the employment files, for staff member B and staff member L, showed no documentation of a criminal background check completed on either staff member.

Based on interview and record review, the facility did not complete criminal background checks or personal reference checks for 9 (B, E, F, G, H, I, J, K, and L) of 11 employees reviewed. This practice had the potential to affect all patients receiving treatment in the facility. Findings include:

Review of the employment files, for staff member B and staff member L, showed no documentation of a criminal background check completed on either staff member.


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Review of the personnel files for employees E, G, H, I, J, and K, showed the facility had not conducted criminal background checks for these employees. Review of the personnel files for employees E, F, G, H, I, J, and K, showed personal reference checks had not been conducted.

During an interview on 9/27/17 at 9:55 a.m., staff member A said he was new to this position and had found a lot of the records were in disarray. He did not feel he would be able to provide the requested information regarding employee screening, or background checks, with the information held in the personnel files on hand.

During an interview on 9/27/17 at 2:40 p.m., staff members A and C, said the county did not conduct criminal background checks on any employees. Staff member A said, "We just started doing background checks with [staff member F]. Staff member A said he had talked with the company that was currently used to contract for agency staff, and the staffing agency would add criminal background checks to the current contract responsibilities. Staff member A said he had requested a copy of a contract from another staffing agency that had been utilized to hire staff member H on a temporary basis. He said the contract needed to be updated to include background checks. Staff member A said he did not have a copy of the contract with that agency now, and he could not tell which agency would have had the responsibility to conduct employee background checks for staff member H.