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Based on hospital document review, record review, personnel file review, observations and staff interviews, the hospital failed to ensure Emergency Services:

1. provided adequate, experienced, and trained nursing staff in the emergency department (ED);

2. provided equipment and supplies commonly used in life saving procedures; and

3. were reviewed and included as part of the Performance Improvement and Quality Assessment program (Compliance).


Findings:

1. On the afternoon of 07/16/14, surveyors reviewed the ED log.

A. 50% of the ED triage log documented patients were triaged incorrect.

B. Staff B verified that 50% of patients on the ED log were triaged incorrectly.

The facility used a five level triage system. Level 1-resuscitation, 2-emergent, 3-urgent, 4-less urgent, 5-nonurgent.

C. Four (B, M, T, and CC) of four personnel files reviewed for triage competencies. None of the files had contained documented evidence of triage competencies.

D. These findings upon review were discussed with hospital administration.

2. On the afternoon of 07/16/14, surveyors toured the emergency department.

A. The ED is a one room department with lifesaving equipment.

B. Staff U told surveyors, "We use some of our in-patient rooms as ED over-flow rooms."

C. The in-patient room did not meet requirements of an ED and the in-patient rooms did not have the required equipment as needed for ED patients.

D. The Chief Executive Officer told surveyors, "We have been using our inpatient rooms for emergency department patients for years."

3. Meeting minutes for Compliance, Medical Staff and Governing Body did not reflect services provided in the ED were reviewed, evaluated/analyzed with corrective action taken when indicated through the quality program. Hospital administration verified the findings at the time of review.

Based on hospital documents, observation, and interview, the facility failed to maintain a safe environment with proper ventilation in all patient care areas.

Findings:
1. On the morning of 07/17/14, surveyors asked hospital staff to identify the emergency department (ED) entrance/exit.

2. Staff T identified an unlocked door as the ED entrance/exit. There was no signage indicating this was the ED entrance/exit.

3. Surveyors observed staff T who propped open the hospital's ED entrance/exit door prior to the ambulance's arrival leaving the door open and unsecured.

4. Staff T told surveyors, "We always prop open the door before the ambulance comes."

5. Surveyors observed the ambulance parked with the ambulance engine running, the exhaust pipe pointed directly into the open entrance of the hospital.

6. Surveyors smelled strong noxious fumes throughout the facility.

7. Surveyors asked the plant manager how long it would take for the ventilation to improve. The plant manager told surveyors, "I can open the doors to help air out the facility."

8. The director of nursing (DON) told surveyors that noxious fumes penetrate the facility any time ambulances or private vehicles bring patients to the ED.

9. On the afternoon of 07/17/14, surveyors smelled strong noxious fumes throughout the facility.

Based on record review, policy and procedure review and staff interview, the hospital failed to train staff on disaster preparedness.

Findings:

1. The hospital disaster plan was reviewed. The plan did not include identification of the types of disasters more likely to occur in the community.

The plan did not include what type of training staff would receive, or when and how often they would be trained. The plan did not include regular disaster drill exercises.

2. On 07/16/14 and 07/17/14, 16 staff education files were reviewed. The files had no documentation that disaster preparedness was included in new employee orientation or in annual re-training.

3. The hospital had no disaster training program to include departmental and individual job assignments in the event of various internal and external disasters.

4. On 07/17/14, the plant manager was asked if disaster training was included in routine employee training. She stated the staff was trained on fire safety.

5. On 07/17/14, the director of nursing was asked what to do in case of a fire. When asked if she was familiar with the RACE protocol (rescue, alarm, contain, extinguish/evacuate), she said was familiar with it, but did not think of it and did not remember any training on it.

6. When asked about other emergency preparedness training, staff CC stated she knew what to do in the event of a tornado. None of the staff interviewed stated they had been trained on various internal and external disasters. They stated they were not aware of their roles and responsibilities during a disaster. They stated they had not been involved in disaster drills.

7. Findings were discussed at the exit conference with hospital administration and no further documentation was provided.

Based on surveyor observations and staff interviews, the hospital failed to provide sufficient nursing staff.

Findings:

1. On the morning of 07/16/17, a surveyor observed one registered nurse (RN) working on the medical unit and headed towards the emergency department (ED). She was observed trying to take care of one inpatient and getting ready for an ambulance that was bringing in an ED patient.

2. Staff CC stated she was the only staff there besides the licensed practical nurse (LPN). Staff CC stated she makes the decision based on the ED patient's presenting chief complaint whether she calls the physician or mid-level provider.

3. The director of nursing (DON) stated there is one RN and one to two licensed practical nurse (LPNs) who are scheduled for patient care during the day, twelve hour shifts. The DON told surveyors that there is an RN and an LPN scheduled for patient care on night shift, twelve hour shifts.

4. The DON told surveyors that she is the on call person if extra staff is needed. The DON stated the facility does not have enough resources to have an on call staff list.

Based on observation and staff interview, the hospital failed to ensure the pharmacist in charge (PIC) is responsible for developing, supervising, and coordinating all the activities of the CAH's (Critical Access Hospital) pharmaceutical service. There was no evidence licensed hospital personnel were trained in drug room duties, had a job description describing duties in the drug room and had been oriented to drug room principles by the pharmacist. The drug room policies and procedures were not approved by the PIC

Findings:

1. Staff B's, the Drug Room Supervisor, personnel file did not have evidence of a job description, orientation or competency evaluation for the drug room.

2. These findings were verified on 07/17/14 with hospital staff.

Based on infection control policy and procedure review, review of infection control meeting minutes, observation, and staff interview, the Critical Access Hospital (CAH) failed to have a system in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings:

1. On the morning of 07/16/2014, Staff A was asked who the infection control practitioner was. Staff A stated that staff E has been designated as the infection control practitioner.

2. On the morning of 07/16/2014, Staff E was asked how long she had been the infection control practitioner. Staff E told surveyors that she had just taken the infection control practitioner position in April of 2014.

3. There was no documentation that Staff E had been designated in writing as the infection control practitioner.

4. On the morning of 07/16/2014, surveyors asked Staff E what infection control training she had received. Staff E told surveyors she had not received any infection control training but she had been a nurse for 20 years.

5. On the morning of 07/16/2014, surveyors reviewed the personnel file for Staff E, there was no documentation of any infection control training and there was no job description for the infection control practitioner.

6. There was no documentation that all disinfectants used in the CAH had been reviewed and approved by the infection control practitioner, the infection control committee, and medical staff. Staff E was asked if all disinfectants had been reviewed and approved. Staff E told surveyors she was working on it.

7. On the morning of 07/16/2014, surveyors reviewed infection control surveillance documentation. There was no documentation of any environmental rounds in the CAH. Staff E told surveyors that she was working on a process to start environmental rounds. Staff E told surveyors that linen service was a contracted service at the CAH. Staff E told surveyors that she had not observed the laundering process at the contracted linen service site. Staff E told surveyors that she had not observed food preparation processes in the kitchen.

8. The CAH did not have infection control policies and procedures that were specific to the CAH. Surveyors reviewed an infection control binder with broad policies and procedures. Staff E told surveyors that the CAH is working on developing infection control policies and procedures. There was no documentation that infection control policies and procedures had been developed by the infection control practitioner and approved by medical staff and governing body.

9. Administrative staff told surveyors that the CAH does not perform surgical procedures. Administrative staff told surveyors some sterile processing is done at the CAH.

10. Surveyors requested and reviewed the CAH's sterilization log. Surveyors were given a piece of paper, titled, "Log". The log documented a biological test was only ran when a load of instruments was ran. There was no daily Bowie-Dick (daily load test) test being done, and no log of the loads that were ran and the parameters (load number, temperature, time exposed) that needed to be met. Staff P told surveyors that she did not run a daily load test.

11. Administrative staff told surveyors that staff P is responsible for sterile process of instruments for hospital and clinic. Surveyors reviewed the personnel file of staff P.The personnel file contained no documentation of sterile processing competencies.

observations:

1. On the afternoon of 07/16/2014, surveyors toured the CAH.

2. Surveyors observed a linen storage room that contained clean linen. The linen was not covered. There were corrugated shipping boxes stored in the linen room.

3. Surveyors observed two public shower rooms. Both shower rooms contained large bottles of shampoo and conditioner. Staff B and staff CC told surveyors that all patients use the same shampoo and conditioner bottles in the shower.

4. Surveyors observed three wheelchairs in the hallway stored by the emergency department. Staff CC was asked how she would know that the wheelchairs were clean. Staff CC told surveyors that all staff cleaned wheelchairs after use. The wheelchairs were not marked as clean. Surveyors could not determine if the wheelchairs were clean or dirty.

5. Surveyors observed a housekeeping storage room. There was a shelf in the storage room that was full of all different types of chemical and disinfectants. There was no documentation that any of the chemicals and disinfectants had been approved by the infection control practitioner, infection control committee, and medical staff.

6. Surveyors observed multiple fly swatters stored in various areas of the hospital. Staff U told surveyors that patients request fly swatters because of the flies in their hospital rooms.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to:
a. ensure that the nutritional needs of all patients were met
b. ensure that a qualified dietitian supervised nutritional aspects of patient care.

This occurred in 8 of 8 (#4, 7, 13, 14, 19, 20, & # 21) inpatient medical records where a nutritional screen was needed by a dietician and occurred in 2 of 2 ( #3 & # 6) swing bed medical records.

Findings:

1. On the afternoon of 07/17/2014, Staff B told surveyors that the nursing staff does an initial nutritional screen on the patients and if a nutritional assessment is needed by the dietician then the dietician is "flagged" through the electronic medical record.

2. On the afternoon of 07/17/2014, surveyors reviewed medical records of inpatients and swing bed patients. Eight of eight inpatient records reviewed where the nursing nutritional screen indicated a nutritional assessment was needed by the dietician contained no dietician screen or assessment. Two of two swing bed patient medical records contained no documentation of a nutritional screen from the dietician.

3. Staff BB told surveyors that the dietician told her she has only ever done one nutritional screen on any patients.

4. There was no documentation of a dietary screen and/or assessment by a dietician in all medical records reviewed.

5. The medical record of patient #3 documented that the patient had a diagnosis of pneumonia.

6. The medical record of patient #4 documented that the patient had a gastrointestinal bleed.

7. The medical record of patient #6 documented that the patient had weight loss, and appetite changes.

8. The medical record of patient #7 documented that the patient had diabetes mellitus type II.

9. The medical record of patient #13 documented altered laboratory values, with shortness of breath, and a diagnosis of diabetes mellitus.

10. The medical record of patient #14 documented the patient had coronary artery disease, hypertension, swallowing issues, and the patient had a low sodium diet ordered by the physician.

11. The medical record of patient #19 documented a low blood sugar.

12. The medical record of patient #20 documented weight loss and difficulty swallowing.

13. The medical record of patient #21 documented the patient had pneumonia.

Based on policy and procedure review, hospital document review, and staff interview, the hospital failed to ensure policies hospital wide were reviewed at least annually.
Findings:
1. All hospital policies were outdated.
2. Hospital administrative staff told surveyors they were in the process of updating all department policies and procedures.
3. Emergency Department policies and Swing Bed policies had been updated but not yet approved by the medical staff.

Based on record review, policy and procedure review, and staff interview, the hospital failed to ensure radiology services:

1. were supervised and performed according to accepted national standards.
2. provided orientation, training, and oversight of radiology services personnel.
3. have documentation showing all personnel operating radiology equipment were qualified and trained.
4. written policies that were developed and approved by the medical staff.
5. documented which studies required interpretation by a radiologist.

Findings:

1. The hospital did not provide proper protective equipment in radiology for patients and personnel.

2. Surveyors observed two lead gowns that did not have thyroid shields on them.

3. The radiology manager told surveyors that the hospital did not have any thyroid shields. She told surveyors that they have never had thyroid shields and did not realize the importance to protect the patients and staff.

4. Surveyors asked the radiology manager why radiology issues identified by the medical physicist had not been addressed from July 10, 2013 through present. The radiology manager did not have an answer for surveyors.

5. A hospital document provided to the hospital by the medical physicist dated January 14, 2014 and July 10, 2013 documented, "...CT laser alignment is outside of tolerance..." and "...Adult head exceeded ACR limits. We suggest reducing radiation limits..."

6. Surveyors asked the radiology manager if the CT laser alignment was corrected as indicated by the medical physicist. The radiology manager told surveyors she thought so but did not have documented evidence that it was. There was no documented evidence that the medical physicist had conducted testing to ensure this identified issue was corrected and safe for patient use.

7. Surveyors asked the radiology manager if the radiation limits for the adult head was corrected as identified by the medical physicist. The radiology manager stated it was not.

8. Contracted staff personnel files (Y and Z) reviewed did not contain documented evidence that they were designated and qualified to use radiological equipment and administer procedures involving intravenous contrast for computed tomography (CT) scans.

9. On the afternoon of 05/07/14, emergency department staff told surveyors that they are not notified when CT studies are administered.

10. On the afternoon of 07/16/14, surveyors spoke with the radiology department manager. She told surveyors the hospital did not have any orientation, training, competencies or evaluations for any contracted employee.

11. On the afternoon of 07/17/14, surveyors were given all radiology personnel files including contract personnel. Five (E, W, X, Y, and Z) of five radiology personnel files did not contain orientation, training, competency or evaluation.

12. On the afternoon of 07/16/14, the radiology manager told the surveyors the department switched from Cidex to Cidex OPA for cleaning the trans-vaginal probes.

13. The radiology manager was unable to provide surveyors with Cidex OPA information. The radiology manager told surveyors that the staff member who cleaned the equipment with the Cidex OPA was not at work and did not know where the cleaning product and information was kept.

14. Surveyors asked the radiology manager if radiology staff had received training with the Cidex OPA products that the radiology department used for cleaning the trans-vaginal probes. She stated that the contract ultra sound personnel bring the equipment with them.

15. On 7/17/14, surveyors were given Governing Body and Medical Staff Meeting Minutes. Review of minutes did not indicate there was any type of radiology department review.

16. On the morning of 07/17/14, the facility could not provide documentation indicating the Medical Staff or radiologist had deemed radiology personnel were competent to provide radiology services.

17. On 07/17/14, the radiology policies and procedures were reviewed. Surveyors asked to review the Infection Control Policies that are currently used in the Radiology Department.

18. There was no documented evidence that cleaning products used in the radiology department had been approved by the Infection Control Practitioner and the Medical Staff.

19. There was no departmental description of all radiology procedures performed by the hospital.

20. There was no evidence of a written policy that was developed and approved which designates which personnel are qualified to use the radiological equipment, administer procedures, and which studies require interpretation by a radiologist.

21. The policies had no documentation they were developed based on accepted standards of practice.

22. The radiology manager was asked for documentation of which studies required interpretation.

23. The Chief Executive Officer verified that there was no Radiologist appointed over radiology services and had no knowledge that there was a document indicating which radiologic studies required interpretation by a radiologist.

Based on record review, policy and procedure review, and staff interview, the hospital failed to ensure medical records are legible, complete, accurately documented, readily accessible, and systematically organized.
Findings:
1. On the afternoon of 07/16/14 surveyors reviewed one (#14) of one open medical record. The medical record was missing the chief complaint of why the patient presented to the emergency department (ED).
2. Patient's record (#14) did not document the patient's respiratory rate and lung sounds yet the medical record indicated the patient was short of breath.
3. The medical record for patient #14 contained a code status of "prior". None of the hospital staff was able to tell surveyors what a prior code status was.
4. The medical record for patient #14's outpatient ED record documented all the inpatient information within the ED record.
5. All outpatient ED records (#1 through 22) contained inpatient information within the ED record.
6. All patients medical records reviewed (#1 through 22) did not contain documented evidence of patient re-assessments after change of medical status and or interventions performed.
7. The director of nursing (DON) and chief executive officer (CEO) verified that all ED patient records (#1 through 22) contained the inpatient admission data within the outpatient ED record.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has an effective facility wide quality assurance (QA) program that includes all services provided under contract; The quality assurance meeting minutes for 2013 and 2014 provided for review did not have review of services provided to the CAH under contract. These findings were verified with hospital staff.

Based on hospital document review and staff interview, the Critical Access Hospital (CAH) failed to provide swing bed residents with all rights, rules and regulations governing resident conduct and responsibilities during their stay in the facility.

Findings:

1. On the afternoon of 07/16/2014, administrative staff were asked to provide the surveyors with swing bed resident's rights and responsibilities. A document, titled, "Notice of Privacy Practices" was provided.

2. The "Notice of Privacy Practices" did not contain information of resident rights and responsibilities. Staff B told surveyors this was the resident rights that were given to swing bed patients upon admission to swing bed.

Based on hospital document review and staff interview, the Critical Access Hospital (CAH) failed to:
a. inform each resident entitled to Medicaid benefits, in writing the items and services that are included in nursing facility services for which the resident may not be charged.
b. provide the resident of other items and services for which the resident may be charged.

Findings:

1. On the afternoon of 07/16/2014, administrative staff were asked to provide the surveyors with swing bed resident's rights and responsibilities. A document, titled, "Notice of Privacy Practices" was provided.

2. The "Notice of Privacy Practices" did not contain information of items and service that the resident may or may not be charged for.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure each resident was given a comprehensive nutritional assessment to ensure the resident maintains acceptable parameters of nutritional status, such as body weight and protein levels. This occurred in 2 of 2 swing bed medical records (#3 & #6)

Findings:

1. On the afternoon of 07/17/2014, surveyors reviewed 2 swing bed medical records (#3 & #6). Both swing bed records contained no documentation of a nutritional screen from the dietician.

2. Patient #6's medical record documented, "weight loss and appetite changes"

3. Patient #3 had a diagnosis of pneumonia.

4. Staff BB told surveyors that she had discussed nutritional screening on the phone with the dietician and the dietician told staff BB that she had only ever performed one nutritional screen.