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Based on observation, policy and procedure and staff interview, it was determined the CAH failed to ensure expired biologicals were removed from the patient care area, potentially affecting all patients receiving care in the Radiology Department.

Findings include:

1. On 12/8/15 at 11:00 AM, a tour of the Radiology Department with Radiology Manager (E#7) was conducted. During the tour, two (2), 16 fluid ounce bottles of hydrogen peroxide were found with expiration dates of 8/2014 and 3/2015.

2. On 12/9/15 at 2:00 PM, the CAH policy "Managing Outdates" revised 1/30/15, was reviewed. Under "F." it indicated "Any expired or about to expire items will be segregated and held for donation......"

3. On 12/9/15 at 11:15 AM, an interview with the Radiology Department Manager (E #7) was conducted. E #7 verified the hydrogen peroxide bottles had expired and verbalized they should have been removed from the patient care area.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on December 21- 22, 2015, 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 observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on December 21 - 22, 2015, 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 December 22, 2015.

Based on CAH policy, document review and staff interview, it was determined in 3 of 12 ( E#8, E#9, E#10) employees, the governing body failed to ensure all employees maintained training for emergencies and received annual evaluations to ensure competencies.
Findings include:

1. The CAH policies titled CPR Requirements ( review date 10/11) and Employee Position Description/Evaluation (review date 11/11) were reviewed on 12/10/15 at 11:00 AM. The policy for CPR indicates under "Responsibilities, 3. Maintain up to date certification every two years as required." The policy for employee evaluations indicates under "Policy, Employees are assessed at the end of their probationary period (90 days) and annually thereafter."

2. On 12/9/15 at 3:00 PM, a review of 12 personnel files was conducted. Three (3) of the 12 employee files were incomplete. E#8 (certified nurse aide) certification for CPR expired 9/2015, with no date for recertification scheduled as of 12/10/15. E#9 (operating room technician) has not received an annual evaluation to ensure current competencies since 2013. E#10 (Registered Nurse) had no evidence of a 90 day evaluation to determine competence.

3. On 12/9/15 at 4:30 PM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 stated "All employees are to maintain their CPR." E#1 reviewed employee CPR records. E#1 confirmed E#8 should have been scheduled for CPR recertification and was not current. E#1 reviewed annual and 90-day employee evaluations. E#1 confirmed the annual evaluation for E#9 and the 90-day evaluation for E#10 were not completed and in the personnel files.

Based on policy and procedure, record review and staff interview, it was determined in 1 of 2 (Pt #5) patients, who were treated in the Emergency Department (ED) and were restrained, the CAH failed to ensure the proper location of the restraint, per physician order. This has the potential to affect all patients receiving care in the ED.

Findings include:

1. On 12/9/15 at 2:00 PM, the CAH policy "Restraints, Use of" revised 4/2015, was reviewed. Under "Physician's Orders: 6.0" it indicated "Physicians are responsible for ordering the use of restraints......to include type of restraint, location of restraint."

2. On 12/9/15 at 10:30 AM, the medical record of Pt #5 was reviewed. Pt #5 was seen in the ED on 3/3/15 with a complaint of "Disruptive Behavior". Documentation on the "Behavioral Restraint Order" dated 3/3/15 at 2:10 PM, indicated the ED physician ordered "bilateral soft ankle restraint." Documentation by the ED Nurse (E #6) on the "Behavioral Restraint Order" indicated Pt #5 was restrained with soft ankle restraints and soft wrist restraints.

3. On 12/9/15 at 11:55 AM, an interview with the ED Manager (E #5) was conducted. E #5 verified that E #6 did not follow the restraint order as prescribed by the ED physician and should have only applied soft ankle restraints.