HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to have a certified food protection manager on staff to oversee the dietary needs of the hospital as required by the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12).

Failure to have the required certified food protection employee to manage the dietary services puts patients, staff, and visitors at risk of harm from food borne illnesses.

Findings included:

1. On 05/29/24 at 1:00 PM, Surveyor #4 inspected the hospital's dietary kitchen with the dietary manager (Staff #401). During the inspection, the surveyor asked Staff #401 about his Food Protection Certification. Staff #401 stated that he had not yet completed a certified Food Protection Management course.

2. On 05/31/24 at 8:30 AM, Surveyor #4 reviewed personnel files and training records with the Human Resources Manager (Staff #402). The review showed the hospital's dietary manager has a current food handler permit but is not a certified Food Protection Manager. The surveyor discussed the requirement with Staff #402.

Reference: Washington State Retail Food Code WAC 246-215-02107 Certified food protection manager (2017 FDA Food Code 2-102.12).
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Item #1 - Expired Emergency Supplies

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy.

Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies.

Findings included:

1 Document review of the hospital's policy and procedure titled, "Code Cart and Nurse Servers Outdates - Acute Care and Emergency Room, no policy ID, last reviewed 03/24 showed the following:

a. The purpose of this policy is to ensure that critical emergency response equipment and medications are current and in proper operating order.

b. Code Carts will be unlocked at least monthly and complete contents will be checked for outdates, missing items, and damaged/inoperable equipment.

2. On 05/29/24 between 1:05 PM and 2:00 PM, Surveyor #2 and Surveyor #9 and the Surgery Department Manager (Staff #202) inspected the Operating Room (OR), Procedure Room, and the two Peri-Anesthesia Rooms (PAR Rooms). The inspection of the OR showed a Broselow/Hinkle Pediatric Emergency System Blue intubation module that included two laryngeal blades, one endotracheal tube (ET) , one ET stylet, one suction catheter, one nasogastric tube, one tape, one lubricating jelly, and one gauze pad with a manufacturer's expiration date of 11/20.

3. At the time of the review, Staff #202 verified the outdated emergency supplies and indicated they would obtain a replacement.

Item #2 - Outdated Emergency Resources

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy.

Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies.

Reference: "2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care)." 2020 Guidelines are a comprehensive revision of the AHA's guidelines for adult, pediatric, and neonatal resuscitation education science, and system of care topics. Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Neonatal Resuscitation Provider (NRP) resources were updated in 2020.

Reference: "American Academy of Pediatrics states that 2019 Broselow (Trademark) Reference Tape will be the most compliant with PALS standards."

Findings included:

1. On 05/29/24 between 9:15 AM and 10:05 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Emergency Department Code Cart located between ED beds 1 and 2. Surveyor #2 observed a Broselow Pediatric Antidote for Chemical Warfare tape, 2006 edition.

2. At the time of the observation, Staff #202 verified the outdated resource and stated they would obtain a replacement.

3. On 05/29/24 between 10:10 AM and 11:00 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Emergency Cart and the Drager infant warmer stored at the end of a hallway located in the Acute Care Unit. Surveyor #2 observed a Broselow Pediatric Emergency Reference tape, 2017 edition.

4. At the time of the observation, Staff #202 verified the outdated resource and stated they would obtain a replacement.
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Based on observation, document review, and interview, the Critical Access Hospital failed to prevent the use of patient care supplies that exceeded the manufacturer's recommended use or expiration date.

Failure to monitor the systematic process for ensuring patient care supplies do not exceed their beyond-use or expiration date risks deteriorated, non-sterile, or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Code Cart and Nurse Servers Outdates - Acute Care and Emergency Room," no Policy ID, last reviewed 03/24, showed the following:

a. The purpose of this policy is to ensure that critical emergency response equipment and medications are current and in proper operating order.

b. "Nurse Servers" will be opened and checked monthly.

c. The "Nurse Server" monthly outdate check will be documented and signed on the "Monthly Outdate Inspection" log located in each respective area.

d. The House Supervisor, DNS, and/or Nurse Educator will monitor the logs for compliance.

2. On 05/29/24 between 10:10 AM and 11:00 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Respiratory Closet and Drager Infant Warmer in the Acute Care Unit. The inspection showed the following:

In the Respiratory closet

a. One Glidescope GVL2 stat laryngoscope, with a manufacturer's expiration date of 07/23.

b. Two Glidescope GVL1 stat laryngoscope, with a manufacturer's expiration date of 09/23.

c. Two Glidescope GVL0 stat laryngoscope, with a manufacturer's expiration date of 07/23.

d. One intubation stylet, with a manufacturer's expiration date of 09/21.

In the Drager Infant Warmer

a One Drager temperature sensor on the OB delivery cart, with a manufacturer's expiration date of 07/22.

3. At the time of the review, Staff #201 verified the expired supplies and removed them from use.
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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell 3YDY21.
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Based on interview and document review, the Critical Access Hospital's Governing Body failed to ensure the medical staff periodically reviewed bylaws, rules, and regulations.

Failure to periodically review bylaws, rules, and regulations risks inappropriate oversight and outdated practice.

Findings included:

1. Document review of the hospital document titled, "Medical Staff Bylaws," last approved May 2003, showed that that the medical staff shall periodically, at least every two years, review and revise its rules and regulations to comply with current practice.

2. On 05/30/24, Surveyor #9 interviewed Chief Clinical Officer (Staff #903) regarding the "Medical Staff Bylaws" and "Medical Staff Policies Rules and Regulations" which were both approved in May 2003. Staff #903 stated 2003 was the most current version of the documents.
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Item #1 - Emergency Department Standards of Care

Based on record review and interview, the Critical Access Hospital failed to develop and implement policies and procedures to define standards of care for Emergency Services.

Failure to develop and implement policies and procedures risks inappropriate and/or ineffective patient care and poor patient outcomes.

Findings included:

1. On 05/29/24 at 9:00 AM, Surveyor #9 and the Director of Nursing Services (Staff #901) reviewed medical records of Emergency Department patients. Surveyor #9 requested a policy for standards of care for the Emergency Department.

2. On 05/29/24 at 4:00 PM, Surveyor #9 interviewed the Director of Nursing Services (Staff #901), Chief of Clinical Services (Staff #903) and Nurse Educator (Staff #904) regarding standards of care for the Emergency Department such as frequency of assessment and reassessment, vital sign frequency, required screenings, and discharge criteria. Staff #901 verified that they did not have a complete standard of care policy for the Emergency Department.


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Item #2 - Kiwi® vacuum policy

Based on record review and interview, the Critical Access Hospital failed to develop and implement policies and procedures to define standards of care for the use of a Kiwi® vacuum assisted delivery system.

Failure to develop and implement policies and procedures risks inappropriate use of equipment and potential serious injury or death.

Reference Instructions for Use: The Clinical Innovations' Kiwi® is a disposable vacuum assisted fetal delivery system. It is a sterile, single-patient-use device designed to provide assistance in childbirth under the following conditions: 1) Term pregnancy, 2) Ruptured amniotic membranes, 3) Engaged head, 4) Complete cervical dilation, and 5) Adequately trained or supervised operator. Adverse events for the fetus include cephalohematoma, subgaleal hemorrhage, intraventricular or parenchymal hematoma, subconjunctival, intracranial, or retinal hemorrhage, nerve injuries, subjective jaundice, elevated bilirubin, bruises, contusions, lacerations, fractures. Maternal Injuries: Vaginal, cervical, uterine, bladder, rectal.

Findings included:

1. On 05/29/24 at 9:00 AM, Surveyor #2 and Surveyor #9 and the Nurse Educator (Staff #904) inspected the hospital's acute care area. In a drawer in an obstetrical emergency cart was a Kiwi® vacuum (a device to assist childbirth). Surveyor #9 requested a policy for the use of the device.

2. On 05/29/24 at 4:30 PM, Surveyor #9 interviewed the Chief Clinical Officer (Staff #903) regarding a policy for the use of the Kiwi®. Staff #903 stated that there was not a policy for the use of that device.

Item #3 - Restraint Order

Based on record review, interview, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff followed policies and procedures for restraint orders for 3 of 3 patients with non-violent restraint orders reviewed (Patient #202 and #203).

Failure to ensure that staff limit the use of restraints to the least restrictive intervention risks serious physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint: Physical and Chemical Restraint," no policy ID, last approved 03/24, showed the following:

For violent or self-harm patients:

a. The Provider must be notified at the time of restraint initiation.

b. Provider orders will include clinical justification for the type of restraint used.

For chemical restraints

d. Chemical restraint orders will contain specific medication doses, frequency, and duration of use and rationale for use and re-order every 24 hours.

2. On 05/30/24 between 3:15 PM and 4:30 PM, Surveyor #2 and the Director of Nursing Services (Staff #203), reviewed the medical records of 3 restraint patients. The review showed the following:

a. Patient #202 who was an 88-year-old male admitted to the Acute Care Unit (ACU) on 12/12/23 with a diagnosis of endocarditis (inflammation of the inside lining of the heart chambers and valves). On 12/23/23 at 1:00 AM, Patient #202 had a nursing note stating patient's combative behaviors continue and alternative interventions attempted were not successful, patient continues to kick, punch, attempts to bite, and has verbal threats of harm to staff. On 12/23/23 at 1:05 AM Patient #202 had a provider order for Haldol (an antipsychotic medication) 5 milligrams to be given intramuscularly. On 12/23/23 at 1:35 AM a verbal order for restraint for non-violent behavior was placed in Patient #202's medical record. On 12/23/23 at 1:35 AM Patient #202 had a nursing note stating patient was placed in bilateral wrist and bilateral ankle soft restraints. Surveyor #2 found no evidence of an order for physical restraints for violent or self-harm patients in the medical record.

b. Patient #203 who was an 86-year-old female admitted to the ACU on 05/09/24 for failure to thrive. Patient #203 had a nursing note on 05/10/24 at 1:38 PM stating the patient was very drowsy this morning, very confused, became very agitated, making threats to staff, multiple attempts to pull IV out, unsteady on her feet, and impulsive. Patient #204 had a provider order for restraint for non-violent behvior and an order for Haldol 2 milligrams to be given intravenously. Surveyor #2 found no evidence of an order for restraint for violent or self-harm patients in the medical record.

3. At the time of the review, Staff #203 verified the missing order for violent restraints.

Item #4 - Violent Restraint Face-to-Face Evaluation

Based on record review, interview, and document review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff performed a face-to-face evaluation for patients with restraint orders for 2 of 3 patients reviewed (Patient #202 and #204).

Failure to follow approved policies and procedures for restraint or seclusion use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint: Physical and Chemical Restraint," no policy ID, last approved 03/24, showed restraints used for violent self-harm patients will have a face to face evaluation, with the provider, within one hour of the initiation of the restraint.

2. On 05/30/24 between 3:15 PM and 4:30 PM, Surveyor #2 and the Director of Nursing Services (Staff #203), reviewed the medical records of 3 restraint patients. The review showed the following:

a. Patient #202 who was an 88-year-old male admitted to the Acute Care Unit on 12/12/23 with a diagnosis of endocarditis. On 12/23/23 at 1:35 AM Patient #202 had a nursing note stating patient was placed in bilateral wrist and bilateral ankle soft restraints. Surveyor #2 found no evidence of a face to face evaluation by the provider within one hour of initiation of 4-point physical restraints.

b. Patient #204 who was an 86-year-old female admitted to the ACU on 05/09/24 for failure to thrive. Patient #204 had a provider order for Haldol 2 milligrams IV on 05/10/24 at 12:56 PM. Surveyor #2 found no evidence of a face to face evaluation by the provider within one hour of the medication administration.

3. At the time of the review, Staff #203 verified the missing face to face evaluation within one hour.
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Item #1 Pain Assessment/Reassessment

Based on interview, record review, and review of policy and procedure, the Critical Access Hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 4 of 9 patients reviewed (Patient #201, #905, #906, and #907).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pain Management", no policy ID, last reviewed 03/24, showed all patients will be assessed for pain using a pain scale appropriate for the patient's age and clinical condition and pain reassessments will occur within 30-60 minutes following any pain management intervention.

2. On 05/30/24 at 9:15 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #905 who was evaluated in the Emergency Department on 05/04/24 for a fractured clavicle. The review showed on 05/04/24 at 10:33 PM, 2 tablets of Hydrocodone (an opioid narcotic pain medication) 325 milligrams was administered orally for a pain score of 6-7 out of 10. The Surveyor found no documentation of pain reassessment after the medication administration.

3. At the time of the review, Staff #901 verified the missing reassessment documentation.

4. On 05/30/21 between 1:15 PM and 3:15 PM, Surveyor #2 and the Director of Nursing Services (Staff #203) reviewed the medical record of Patient #201 who was admitted on 05/17/24 as a swing bed patient for therapy services following a surgical repair of a left femur fracture. Patient #201 had a provider order for oxycodone (a narcotic medication used to treat pain) 5-10 milligrams orally every 4 hours as needed for pain. Patient #201 received oxycodone 10 milligrams on 05/29/24 at 4:22 AM. Surveyor #2 found no evidence of pain assessment prior to pain medication administration.

5. At the time of the review, Staff #203 verified the missing pain assessment documentation.

6. On 05/31/24 at 10:00 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #906 who was admitted on 05/29/24 for treatment of cellulitis (a skin infection). The review showed the following:

a. On 05/29/24 at 3:53 PM, Hydrocodone 325 milligrams orally was administered for a pain score of 5 out of 10 at 3:31 PM. The Surveyor found no documentation of pain reassessment after the medication administration.

b. On 05/30/24 at 10:15 AM, Hydrocodone 325 milligrams was administered orally. The Surveyor found no documentation of a pain assessment prior to the medication administration.

c. On 05/31/24 at 8:47 AM, Hydrocodone 325 milligrams was administered orally. The Surveyor found no documentation of a pain assessment prior to the medication administration.

7. At the time of the review, Staff #901 verified the missing pain assessment/reassessment documentation.

8. On 05/31/24 at 10:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #907 who was admitted on 05/27/24 for treatment of neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves). The review showed the following:

a. On 05/27/24 at 7:59 AM, Oxycodone (an opioid narcotic pain medication) 15 milligrams orally was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration.

b. On 05/28/24 at 2:28 PM, Hydromorphone (an opioid narcotic pain medication) 0.8 milligrams intravenously was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration.

c. On 05/28/24 at 6:14 PM, Oxycodone 15 milligrams orally was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration or a reassessment after the medication administration.

d. On 05/28/24 at 10:09 PM, Hydromorphone 0.8 milligrams intravenously was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration.

9. At the time of the review, Staff #901 verified the missing pain assessment/reassessment documentation.

Item #2 Insulin Administration

Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff implemented provider orders for sliding scale insulin administration in accordance with acceptable standards of practice as demonstrated by 1 of 2 insulin administration records reviewed (Patient #907).

Failure to implement provider orders for medication administration risks patient harm from unsafe or inappropriate medication administration.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Management High Risk Medications," no policy number, last revised 04/10/24, showed the following:

a. High risk medications at Lincoln Hospital include insulin, infusion, and subcutaneous doses.

b. Insulin is administered based on provider orders.

c. Double checks are required for pediatric subcutaneous insulin and concentrations greater than 100 units/milliliter.

2. On 05/31/24 at 10:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #907 who was admitted on 05/27/24 for treatment of neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves) and diabetes. The review showed the following:

a. On 05/27/24 at 11:34 AM, the patient's blood glucose was 262 milligrams/deciliter and was to receive 6 units of insulin lispro as per the provider order. A review of the medication administration record showed that 4 units were administered.

b. On 05/28/24 at 10:06 PM, the patient's blood glucose was 162 milligrams/deciliter and was to receive no insulin as per the provider order. A review of the medication administration record showed that 2 units were administered.

3. At the time of the review, Staff #901 verified that the incorrect amount of insulin had been administered and documented at the times above.

Item #3 Suicide screening/assessment

Based on interview, record review, and review of policy and procedure, the Critical Access Hospital failed to ensure that patients receiving care in the Emergency Room received a suicide risk assessment as directed by hospital policy and procedure for 2 of 3 medical records reviewed (Patient #903 and #904).

Failure to perform a suicide risk assessment, risks that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Prevention Crisis Protocol," no policy number, last revised 03/24, showed that all patients are screened/assessed for suicide risk upon admission to the Emergency Department or inpatient.

2. On 05/30/24 between 8:50 AM and 10:00 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical records of 3 patients who were evaluated in the Emergency Department. The review showed the following:

a. Patient #903 was a 48 year old who was evaluated on 04/29/24 for a laceration. The Surveyor found no evidence of a suicide screening/assessment documented in the medical record.

b. Patient #904 was a 46 year old who was evaluated on 04/28/24 for abdominal pain. The Surveyor found no evidence of a suicide screening/assessment documented in the medical record.

3. At the time of the review, Staff #901 verified there was no suicide screening documented in the medical records.

Item #4 Blood administration vital signs

Based on interview, record review, and document review of the hospital's policy and procedures, the Critical Access Hospital failed to ensure staff followed its policy and procedure for blood product transfusions for 1 of 3 blood transfusion patient records reviewed (Patient #908).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood or Blood Derivative Administration," no policy number, last revised 03/24, showed the following:

a. For all blood components, vital signs will be taken at a minimum before starting the transfusion, 10-15 minutes from the start of the infusion, 60 minutes from the start of the transfusion, at the end of the transfusion, and 10-15 minutes following a deviation in the patient's baseline vital signs.

b. Complete documentation for all blood component administration will occur in the patient's electronic chart.

2. On 05/30/24 between 10:30 AM and 11:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical charts of three patients who had received blood transfusions. The review showed Patient #908 received a blood transfusion which was initiated on 04/13/24 at 1:38 PM and finished on 04/13/24 at 4:10 PM. The Surveyor found no evidence of documentation of vital signs at the initiation of the blood transfusion.

3. At the time of the review, Staff #901 verified the missing vital sign documentation.

Item #5 Blood administration consent

Based on interview and document review, the Critical Access Hospital staff failed to obtain informed consent for blood transfusion for 1 of 3 blood transfusion patient records reviewed (Patient #909).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood or Blood Product Transfusions Informed Consent and Refusal," no policy number, last reviewed 07/21, showed that informed consent is to be signed by all patients receiving a transfusion of blood products in non-emergent cases not associated with a surgical procedure.

2. On 05/30/24 between 10:30 AM and 11:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical charts of three patients who had received blood transfusions. The review showed Patient #909 received a non-emergent blood transfusion for anemia which was initiated on 01/19/24 at 3:29 PM and finished on 01/19/24 at 6:20 PM. The Surveyor found no evidence of a signed consent for blood transfusion in the medical record.

3. At the time of the review, Staff #901 verified the missing signed consent and stated that during the hospital's transition to a different electronic health record there was some confusion regarding the signing of consents which should be clarified now.
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Item #1 - Cleanable and sanitary surfaces

Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Reference: AORN (Association of Perioperative Registered Nurses) Guidelines for Perioperative Practice: Design and Maintenance, (2020) - "Recommendation 12.2. Maintain the integrity of structural surfaces (e.g., doors, floors, walls, ceilings, cabinets) and have surfaces repaired with damaged." 12.2.1 "...Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

Findings included:

1. Document review of the hospital's plan titled, "Infection Prevention, Quality & Risk Management, Quality Assurance Performance Improvement (QAPI) Plan, Lincoln Hospital District #3, 2024," approved 12/23, showed environment of care rounding will be done a minimum of 6 times per year.

Document review of the hospital's work order checklist titled, "Maintenance Sched 248," no policy # or approval date, showed a checklist used for hospital environment of care rounding inspections. The checklist includes inspecting for damage to walls and surfaces (Item #18: "paint- tiles- door- floors- ETC").

2. On 05/29/24 at 9:30 AM Surveyor #4 observed a terminal cleaning of the hospital's operating room (OR). During the observation, the surveyor noticed the wall of storage cabinets had unsealed wood trim around all the glass panes. Additionally, the door into the OR had areas where the varnish or seal had worn off and was exposing the wood as well as the door into the sub-sterile storage room just outside the OR (where anesthesia supplies are kept).

3. During the observation, Surveyor #4 discussed the unsealed wood as being a non-cleanable surface with the OR Supervisor (Staff #403).

4. On 05/29/24 at 11:30 AM, Surveyor #4 observed a room cleaning (Room 18) in the Transitional Care Unit (TCU). During the observation, the surveyor noted that the wood handrails outside of Room 18 and all down the TCU main hall had several areas where the sealer or varnish had completely worn off (especially in the areas underneath the wall mounted alcohol-based hand rub dispensers). The surveyor later discussed the non-cleanable surfaces on the handrails with the hospital's Chief Financial Officer (Staff #404). Staff #404 stated he was aware of the handrails and the facility was considering removing unnecessary older rails in some areas of the hospital and would address fixing the needed ones.

Item #2 - Outdated cleaning supplies

Based on observation and interview, the Critical Access Hospital failed to prevent the use of cleaning supplies that exceeded the manufacturer's recommended expiration date.

Failure to maintain cleanng supplies that do not exceed their beyond-use or expiration date in patient care areas puts patients at increased risk of infection.

Findings included:

4. On 05/29/24 between 1:05 PM and 2:00 PM, Surveyor #2 and Surveyor #9 and the Surgery Department Manager (Staff #202) inspected the Operating Room (OR), Procedure Room, Pain Procedure room and the two Peri-Anesthesia Rooms (PAR Rooms). The inspection of the Pain Procedure Room showed the following:

a. One container of Clorox healthcare bleach germicidal wipes, with a manufacturer's expiration date of 03/24.

b. One container of Clorox healthcare hydrogen peroxide wipes, with a manufacturer's expiration date of 12/21.

5. At the time of the review, Staff #202 verified the expired supplies and removed them from use.
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Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights for 2 of 5 patients reviewed (Patient #204 and #205).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital policy and procedure titled, "Informed Consent for Delivery of Care," no policy ID number, last revised 10/23 showed the goal of informed consent is to give the patient autonomy and self-determination. All patients have the right to make an informed, un-coerced decision about their medical care. To that end the patient should be provided with sufficient information to be able to give meaningful consent concerning their medical care.

2. Document review of the hospital policy and procedure titled, "Patient Registration and Admitting," no policy ID number, last revised 02/23, showed the following:

a. The functions of Admitting Personnel are vital to the overall operational success of the hospital.

b. Admitting Personnel are responsible for obtaining signatures on the Patient Rights and Responsibilities form.

3. Document review of the hospital document titled, "Lincoln Hospital Swing Bed Resident Rights," not dated, listed all the Swing Bed Resident Rights, and page 3 included the Notice of Swing Bed Resident Rights Acknowledgement that indicates by your signature below, you acknowledge receipt of Lincoln Hospital Swing Bed Resident Rights.

4. On 05/30/24 between 1:15 PM and 3:15 PM, Surveyor #2 and Surveyor #9 and the Director of Nursing Services (Staff #203) reviewed the records of 3 Swing Bed patients. The review showed the following:

a. Patient #204 had an order to admit to Swing Bed in the transitional care unit on 05/10/24 as a non-skilled extended care Swing Bed. Surveyor #2 found no evidence of a Swing Bed Residents Rights form signed from this admission in the medical record.

b. Patient #205 had an order to admit to Swing Bed in the transitional care unit on 06/09/23 as a non-skilled extended care Swing Bed (date of transition to new EMR). Surveyor #2 found no evidence of a Swing Bed Resident Rights form signed from this admission in the medical record.

5. At the time of the review, Staff #203 verified the missing signed Swing Bed Resident Rights.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy regarding dental care and dentures for Long Term Care Services "Swing Bed" patients.

Failure to develop and implement a policy regarding dental care risks poor oral care, infection, and nutritional deficiencies.

Findings included:

1. On 05/30/24, Surveyor #9 reviewed the policies and procedures provided by the Critical Access Hospital. The Surveyor was unable to locate policies that addressed the dental care of the long term care services "swing bed" patient.

2. On 05/30/24 at 4:00 PM, Surveyor #9 interviewed Chief Clinical Officer (Staff #903) regarding the dental policy. Staff #903 stated that they were unable to locate a policy regarding dental care and dentures for long term care services "swing bed" patients however they do have a dentist who provides dental care for their patients.
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