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Based on random observation during the survey walk-through, staff interview, and document review during the Critical Access Hospital Federal Re-Certification Survey conducted on April 9 - 10, 2013, 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 Critical Access Hospital Federal Re-Certification Survey conducted on April 9 - 10, 2013, 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 CMS Form 2567, dated April 10, 2013.

A. Based on policy and procedure, record review and staff interview it was determined in 1 of 5 (Pt. #9) medical records reviewed with blood transfusions the CAH failed to ensure 2 RN's verified the blood administration according to CAH policy.
Findings include:

1. The revised 11/08 CAH policy titled "Blood/Blood Product Transfusion" was reviewed on 3/5/13. The policy indicates under "V. PROCEDURE 1.0 Preparation 1.8 Upon returning to the patient area the RN administering the blood will verify/complete the identification...with another RN."

2. The medical record of Pt. #9 was reviewed on 3/5/13. Pt. #9 was admitted for Outpatient services on 8/9/12 with diagnosis of Anemia. Documentation indicated Pt. #9 received 2 blood transfusions of PRBCs on 8/9/12. Documentation indicated only one nurse signed the "Transfusion Record" on 8/9/12 to verify the administration of the blood.

3. During an interview with the DON on 3/7/13 at 3:00 PM, the DON confirmed only one nurse had signed the transfusion form and it should have been verified by another RN.

B. Based on policy and procedure, record review and staff interview it was determined in 1 of 1 (Pt. #19) records reviewed in which the patient was restrained, the CAH failed to ensure documentation and orders for restraints were documented according to CAH policy.
Findings include:

1. The CAH policy revised 7/05, titled "Restraints, Use of" was reviewed on 3/7/13. The policy indicated under "V. PROCEDURE 6.0 Physician's Orders: 6.1 Physicians are responsible for ordering the use of restraints based on the identification of clinically justified behaviors. Orders should include: 6.1.1 Reason (clinical justification) 6.1.2 Type of restraint 6.1.3 Location of restraint 6.1.4 Duration of restraint....6.2 Restraint orders should be completed on a Restraint Order Form."

2. The medical record of Pt. #19 was reviewed on 3/7/13. Documentation indicated Pt. #19 was a direct admit to the CAH on 2/25/13 via ambulance with diagnosis of End Stage Alzheimer's with Adult Failure to Thrive. Documentation in the "Patient Care Notes" written by the RN on 2/25/13 at 1400 indicated "Right wrist restraint do to Pt going to remove HL (Heplock) states family." Documentation in the "Progress Note" on 2/26/13 indicated Pt. #19 "will allow her to be restrained as she pulls the needle out as one was started by the ambulance that brought her in." A physician order was written on 2/26/13 at 0852 indicating "may restrain." There was no documentation to indicate a physician order for the reason, type of restraint, location or duration of restraint. There was no documentation on a "Restraint Order Form." There was no documentation in the "Patient Care Notes" after Pt. #19's initial assessment on 2/25/13 regarding restraints or any alternative methods by the RN.

3. During an interview with the DON on 3/7/13 at 3:00 PM, the DON stated the Restraint form has not been used since electronic charting was started in July 2012. The DON stated "we very rarely use restraints." The DON confirmed that the physician should have written a complete order and the RNs should have documented in the patient care notes about the use of restraints according to the policy.

A. Based on observation, CAH policy, and staff interview, it was determined the CAH failed to ensure proper labeling of medications in multi dose vials to ensure safety of medications for administration. This failure has the potential to affect 100% of patients receiving medications from multi dose vials.
Findings include:

1. During a tour of the nursing unit on 3/4/13 at 1:30 PM, it was observed in the refrigerator used for medication storage, several multi-dose vials of insulin were opened with no date of opening or initials of the person opening the vials: Humulin R 1 vial, Humalog 75/25 1 vial and Humulin 70/30 1 vial. During an interview with the Day Shift Supervisor at the time of the observation, the Supervisor reported open vials are to be labeled with date and initials and indicated nurses are aware of this policy.

2. A review of the CAH policies was completed during the survey. The "Fundamental Nursing Skills and Concepts by Lippincott" (undated), indicates under "Withdrawing medications from a vial, If the medication will be used for more than one administration, the preparer writes the date and time on the vial label and initials it."

3. During an interview with the DON on 3/5/13 at 3:30 PM, she indicated there is no written policy regarding the labeling of multi-dose vials but the Lippincott standards are used and nursing staff are knowledgeable of the expectation which requires the multi dose vials to indicate a date of opening and initials. The DON also indicated the multi dose vials are to be destroyed 30 days after opening.

B. Based on observation, CAH policy and staff interview, it was determined the hospital failed to ensure outdated drugs were not available for use in patient care areas. This failure has the potential to affect 100% of patients receiving care.
Findings include:

1. During a tour of the nursing unit on 3/4/13 at 1:30 PM, it was observed in a port access supply kit in the medication room, 6 syringes of Normal Saline 10 ml with an expiration date of 2008.

2. During a tour of the off-site therapy department on 3/5/13 at 8:15 AM, it was observed in the medication cabinet an opened container of Sterile Water had expired 8/2012 and Silver Sulfadiazine cream 1% had expired 12/2012.

3. The CAH policy titled "Outdated Drugs" with a review date of 10/05, indicated "At least once a month a pharmacy representative will make an outdated drug execution of the pharmacy and other areas wherein drugs are stored. Any drug scheduled to expire during the following month will be removed from stock."

4. During an interview with the Day Shift Supervisor on 3/4/13 at 2:00 PM, the Supervisor reported the port kit is used very rarely so it had likely been missed with other medication checks. The Supervisor agreed the syringes of Normal Saline were expired and disposed of them.

5. During an interview with the Therapy Manager on 3/5/13 at 8:30 AM, it was confirmed the pharmacy at the hospital supplies medications for the clinic and the outdates should have been disposed.

C. Based on observation and staff interview, it was determined the hospital failed to ensure the safe preparation and labeling of all medications for use in patient care areas. This failure has the potential to affect 100% of patients receiving nuclear medical or surgical services.
Findings include:

1. During a tour of the Radiology Department on 3/5/13 at 2:00 PM, it was observed in the Nuclear Medical procedure room in a storage cabinet, 2 syringes with a clear solution, one with a needle attached. The syringes had no labeling of the solution in the syringes, a date of preparation, or initials of the preparer. At the time of the tour the Radiology Manager indicated the syringes should be labeled and disposed of them.

2. During an interview with the DON on 3/6/13 at 3:30 PM, she was asked if the hospital has a written policy for labeling of syringes when medications are prepared. The Director reported there is no written policy, but through education it is a known expectation to label any medication drawn into a syringe and to include a date and initials of the person who has prepared the medication.

3. During a tour of the Surgical Department on 3/6/13 at 11:00 AM, this surveyor was given a lab coat to wear over surgical attire to go to the preoperative area. This surveyor found 2 syringes in the top pocket of the lab coat. One was labeled Normal Saline and the other did not have a label. This surveyor showed the Surgical Nurse Manager the syringes. The Nurse Manager laughed and stated "those must be ..." who was later identified as a CRNA.

4. During an interview with the DON on 3/6/13 at 4:00 PM, she agreed the syringes should have been labeled with the name of the medication, dated and initialed. The DON confirmed the syringes should not have been in the lab coat.

Based on a review CAH policy and staff interview, it was determined the CAH failed to ensure medical records were completed within 15 days, as per the CAH's policy, for 10 records as of 3/5/13. This has the potential to affect 100% of the patients who receive services at the CAH.
Findings include:

1. The CAH policy titled "Medical Staff Rules and Regulations" revised 11/05, was reviewed on 3/5/13. The policy indicated under "MEDICAL RECORDS... All medical records are to be completed within fifteen (15) days of discharge."

2. During a staff interview a request for delinquent records was made on 3/5/13 at 8:30 AM, the DON stated there were 10 records that had not been completed within 15 days.

Based on policy, record review and staff interview, it was determined in 3 of 20 records reviewed (Pts #9, 11, 12) the CAH failed to ensure all physician orders are authenticated, dated and timed by the ordering physician.
Findings include:

1. The CAH policy titled "Authentication" with a revision date of 2/07 indicated under "POLICY" paragraph 3, "To be in compliance with CMS Hospital Conditions of Participation and Illinois Rules and Regulations, verbal orders other than telephone orders should be authenticated before staff member leaves the patient care area and telephone orders should be authenticated within 48 hours. All orders should be dated, timed and authenticated by the individual who made or authorized the entry."

2. The medical record of Pt. #9 was reviewed on 3/5/13. Documentation indicated Pt. #9 was admitted for Outpatient services on 8/9/12 with diagnosis of Anemia. Documentation indicated a telephone physician order was written on 8/9/12 for type and cross match 2 units packed red blood cells (PRBC). The physician telephone order was signed on 11/8/12, over the 48 hour policy requirement.

3. The medical record of Pt #11 was reviewed on 3/5/13. Documentation indicated Pt #11 was admitted to the CAH on 1/2/12 with diagnoses of Possible Pneumonia and Leukopenia. Documentation in the physician orders indicated multiple telephone orders written on 1/2/12 and 1/3/12 with physician signatures dated 4/14/12, over the 48 hour hospital policy requirement.

4. The medical record of Pt. #12 was reviewed on 3/5/13. Documentation in the ED record indicated Pt. #12 arrived via ambulance Unresponsive on 8/18/12 at 1157. Pt. #12 was pronounced dead at 1202. Documentation indicated the physician orders as of this survey date have not been signed by the physician.

5. During an interview with the DON on 3/5/13 at 3:30 PM, she agreed the physician signatures were late. The DON indicated since implementing the computerized records the physicians have the option to sign electronically which has helped in meeting the policy.

Based on internal documentation review and staff interview it was determined the CAH failed to ensure an annual program evaluation was completed, potentially affecting all patients receiving services.
Findings include:

1. A request was made for the CAH annual program evaluation on 3/4/13. Documentation indicated the last program evaluation was completed on 11/29/11. Documentation indicated an Agenda for the meeting on December 13, 2012, but the meeting was cancelled. The Agenda included required components for an annual evaluation.

2. During an interview with the Executive Secretary on 3/4/13 at 3:00 PM, the Secretary stated that the meeting was scheduled on 12/13/12, but the Administrator left abruptly and the meeting was cancelled. The new Administrator started the first part of January 2013 and the meeting has not been rescheduled. The Secretary reviewed with this surveyor the utilization of services, clinical record audits, policies and procedures, and evaluation of program for 2012. The Secretary stated "everything was ready for the meeting in December."