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Based on observation, a review of the Critical Access Hospital (CAH) policies, and staff interview, it was determined the CAH failed to ensure emergency equipment was checked on a daily basis when surgical procedures were performed to ensure emergency equipment was maintained in safe operating condition in the surgical services area. This has the potential to affect 100% of the surgical patients serviced by the CAH.
Findings include:

1. During a tour of the surgical recovery room conducted 1/9/13 at 10:00 AM, it was observed that the "CRASH CART DAILY LOG" had missing entries for September 10, 14, 18, 21, and 22, 2012; October 3, 14, 20, 21, and 28, 2012; November 10 and 30, 2012; December 11, 20, 24, and 31, 2012. The OPERATING ROOM log book had surgical patients entered for surgery on these dates.

2. The CAH policy titled "CRASH CART CHECKS" last revised on 10/8/09, was reviewed on 1/9/13. Under "PROCEDURE: The cardiac monitor and defibrillator will be checked daily by personnel as assigned by the department director. EXPLANATION: Crash carts located in Surgery will be checked daily when the department is in operation. Crash cart is located in Recovery room."

3. An undated CAH policy titled "CRASH CART CHECKS" was reviewed. Under "PROCEDURE:... This daily check of equipment function will be recorded on the Crash Cart Log."

4. During a staff interview 1/9/13 at 10:00 AM, the Registered Nurse agreed the crash cart was not checked on the days with no entries and that surgeries were performed on those days according to the log book. It was further verbalized that the surgical nurse is expected to do the crash cart check on days there are surgical cases and document the check on the log sheet.

Based on observation, staff interview and document review during the Life Safety portion of the Critical Access Sample Validation survey conducted on January 7 & 8, 2013, the surveyors find that the Facility is not constructed and maintained as a safe environment for patients. See Tag C0231

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Sample Validation Survey conducted on January 7 & 8, 2013, the surveyors find 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 1/8/13.

Based on observation, a review of the Critical Access Hospital (CAH) policy, and staff interview, it was determined the CAH failed to ensure outdated drugs were not available for use in patient care areas. This has the potential to affect 100% of surgical patients serviced by the CAH.
Findings include:

1. During a tour of the surgical recovery room conducted 1/9/13 at 10:00 AM, it was observed that the crash cart contained two boxes of Atropine 0.1mg/ml 10 ml injectable syringes labeled with an expiration date of December 1, 2012.

2. The CAH policy titled "Pharmacy: Unusable Medications and Devices" last reviewed on 5/27/12, was reviewed on 1/9/13. Under "POLICY: Unusable medications and devices shall be handled and disposed of in accordance with this policy. DEFINITION OF UNUSABLE MEDICATIONS AND DEVICES: Unusable medications and devices include those that are: expired (outdated)..."

3. During a staff interview, on 1/9/13 at 10:00 AM, the Registered Nurse agreed the medications were expired and verbalized that Pharmacy was responsible for inspecting the medication contained in the crash cart.

4. During a staff interview, on 1/9/13 at 11:30 AM, with the Director of Risk Management and Quality Improvement, it was confirmed that Pharmacy performs the medication inspection of the crash carts and provided a "Medication Area Inspection Record" with a location identified as the A-wing and an inspection date of 1/2013. The Medication Area Inspection Record line list #10 states "There are no expired, recalled, deteriorated..... drugs." and has a check under "yes" indicating compliance. The record was completed and signed by the Pharmacy Technician, House Supervisor, and Pharmacist.

Based on observation, a review of the Critical Access Hospital (CAH) policies, and staff interview, it was determined the CAH failed to ensure food was stored and/or labeled in accordance with its policy to ensure the quality and safety of food storage and prevention of food borne illnesses. This has the potential to affect 100% of the patients and/or visitors who utilize the Dietary services.
Findings include:

1. During a tour of the CAH Dietary Department, on 1/7/13 at 10:34 AM, the following was observed: in the Walk-In Cooler: 1 bag of uncooked broccoli had a date of 12/24/12 marked on it. An unlabeled frozen package of what appeared to be french toast was opened with no date. In the freezer compartment of the refrigerator, 10 individual containers of ice cream were not marked with use-by date or expiration date.

2. The CAH policy titled "STORAGE TIMES AND TEMPERATURE," last revised 12/05, was reviewed on 1/7/13. It indicated under "POLICIES... Food stored frozen should be kept no longer than 90 days. Food stored refrigerated should be kept no longer than expiration date... The "use-by" date is the last date that a food can be consumed." Under Table "Suggested Storage Times for Intact, Raw, Unwashed Vegetables" indicated Product: Broccoli is to be stored for "5 days."

3. The CAH policy titled "Purchasing, Storage and Time Temperature Controls," implemented 11/05, was reviewed on 1/7/13. It indicated under "STORAGE STANDARDS... Frozen and refrigerated foods shall be stored immediately upon deliver. Label and date all incoming foods... All food items stored after opening or preparation will be covered, labeled, and dated."

4. A staff interview was conducted with the Director of Dietary, on 1/7/13 at 11:00 AM. The Director of Dietary confirmed that all individual food items should be labeled, marked with an expiration date or "use by" date and that the Broccoli should only be kept for 5 days.

Based on a review Critical Access Hospital (CAH) policy and staff interview, it was determined the CAH failed to ensure medical records were completed within 30 days, as per the CAH's policy, for 21 records as of 1/7/13. This has the potential to affect 100% of the patients who receive services at the CAH.
Findings include:

1. The CAH policy titled "Incomplete/Delinquent Medical Records" revised 1/10/12, was reviewed on 1/7/13. The policy indicated under "POLICY:... All records will be completed within thirty (30) days of discharge and will be considered delinquent if not complete at that time."

2. During an interview with the Director of Risk Management/Quality Improvement on 1/7/13, it was reported that there were 21 delinquent medical records as of 1/7/13.

Based on a review of the Medical Staff Rules and Regulations, medical record review, and staff interview, it was determined that in 4 of 20 (Pt #7, #10, #17, #20) medical records reviewed, the Critical Access Hospital (CAH) failed to ensure discharge summaries were completed within 30 days following discharge, as per CAH policy, potentially affecting all patients receiving care at the CAH.
Findings include:

1. The Hospital Medical Staff Rules and Regulations were reviewed on 1/9/13. Documentation indicated under "L. Completion of Medical Records A. It is recommended that discharge summaries be dictated within twenty-one (21) days of discharge, however, will not be considered delinquent until 30 days following discharge... B. Medical records are to be completed within thirty (30) days of discharge including signatures, and will be considered delinquent at that time."

2. The medical record of Pt #7 was reviewed on 1/8/13. It indicated that Pt #7 was admitted on 7/30/12 with a diagnosis of Urosepsis. Documentation indicated that Pt #7 was discharged on 8/7/12. Documentation indicated that the discharge summary was dictated on 9/22/12, more than 30 days past discharge.

3. The medical record of Pt # 10 was reviewed on 1/8/13. It indicated that Pt #10 was admitted on 9/21/12 with a diagnosis of Nausea/Vomiting. Documentation indicated that Pt #10 was discharged on 9/24/12. Documentation indicated that the discharge summary was dictated on 1/6/13, more than 30 days past discharge.

4. The medical record of Pt. #17 was reviewed on 1/8/13. Documentation indicated Pt. #17 was admitted on 8/25/12 with diagnosis of Hematemesis and Encephalopathy. Documentation indicated Pt#17 was discharged on 8/28/12. The Discharge Summary was dictated on 10/3/12 and was not signed by the physician until 10/4/12, over 30 days late.

5. The medical record of Pt #20 was reviewed on 1/8/13. Documentation indicated Pt #20 was admitted on 11/6/12 with a diagnosis of Anemia. Documentation indicated Pt #20 was discharged on 11/12/12. There was no documentation indicating a discharge summary had been completed, making it over 30 days late.

6. During an interview with the Director of Risk Management/Quality Improvement on 1/8/13 at 10:00 AM she confirmed that discharge summaries should be completed on all patients and within 30 days post discharge.