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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Re-certification survey conducted on August 5, 2014, the surveyor found that the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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 Medicare Critical Access Hospital Re-certification Survey conducted on August 5, 2014, the surveyor found 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.

Based on observation and interview, it was determined the Critical Access Hospital failed to ensure outdated biologicals were not available for use in patient care areas. This has the potential to affect all patients serviced by the Critical Access Hospital.

Findings include:

1. During a tour of the Emergency Department, conducted on 7/15/14 at approximately 12:20 PM with the Chief Nursing Officer (E#2) and the Emergency Department Manager (E#4), the following were examples of outdated biologicals observed available for patient care use: In the "Airway Cart": One emergency cricothyrotomy catheter set expired 4/12 and two 5.0 pediatric Shiley pediatric tracheostomy tubes expired 3/14. In the "Pediatric Crash Cart": two 3.5 endotracheal tubes expired 2/13; one 8 french Foley catheter expired 4/14; one size 8 duodenal tube expired 8/13; and one 4.0 endotracheal tube expired 3/14.

2. An interview was conducted with E#4 on 7/15/14 at approximately 12:45 PM, with E#2 present. When asked to describe the process for checking of the supplies for the emergency carts, E#4 stated the pharmacy checked all the carts with medications and that E#4 "believes Materials Management would be the ones to check the carts without medications, but I'm not completely certain. We have checklists for the crash carts, but I'm not sure that these (the Airway Cart and the Pediatric Crash Cart) are on them."

3. The policy titled "Outdated Supplies" (Review Date: 12/2011) was reviewed on 7/15/14 at approximately 3:00 PM. The policy stated "Procedure: 2. Each department staff and Materials Management check their area for outdated supplies on a monthly basis as part of the quality control monitoring process." The policy titled "Restocking Crash Carts" (Date: 01/2014) was reviewed on 7/15/14 at approximately 3:00 PM. The policy stated "Procedure: 1. Pharmacy will call Materials Management..." Once Materials Management checks the crash cart for used and expired biologicals, a new expiration date is written on the label on the lower left corner of the top of the cart.

4. An interview was conducted with E#2 on 7/15/14 at approximately 3:15 PM. E#2 stated the checklists for the crash carts did not include the Airway Cart or the Pediatric Crash Cart. "We didn't realize these two carts were not on any of the checklists. There apparently was a disconnect. We'll get them added.