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The Critical Access Hospital (CAH) reported a total current census of one acute patient and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to ensure that two of three Emergency Supply Carts and one of two medication storage rooms contained equipment and supplies that was constantly ready for use, according to the Hospital's policies and procedures. The CAH's failure to ensure emergency supplies were available to patients has the potential to cause harm and delay emergency care to patients.


Findings include:

- Emergency Supply Cart observed on 6/6/2016 at 11:45 AM revealed a log indicating the defibrillator required testing every 12 hour shift by ensuring it was plugged in, working, oxygen tank full with BVM (bag valve mask)(a device used to manually supply oxygen to the lungs), and locked. The log revealed the following number of shifts in which the code cart was not checked: November 2015 - 12 shifts, December 2015 - 16 shifts, January 2016 - 19 shifts, February 2016 - 17 shifts, March 2016 - 20 shifts, April 2016 - 16 shifts, and May 2016 - 19 shifts.

The Emergency supply cart contained the following outdated supplies:
1. One Endotracheal tube (a tube placed in the throat to provide a secure airway) with an expiration date of 3/2016.
2. One King LTS-D Size 4 (is a disposable, simple to use alternative airway device that provides superior patient ventilation (a means to providing air into the lungs) with an expiration date of 5/2016.
3. One Soft PVC Nasopharyngeal Airway (a device that is inserted into the nose to provide a way to provide air into the lungs) size 36 with an expiration date of 11/2015.
4. One Soft PVC Nasopharyngeal Airway (a device that is inserted into the nose to provide a way to provide air into the lungs) size 32 with an expiration date of 10/2015.
5. One Soft PVC Nasopharyngeal Airway (a device that is inserted into the nose to provide a way to provide air into the lungs) size 30 with an expiration date of 9/2015.
6. One Soft PVC Nasopharyngeal Airway (a device that is inserted into the nose to provide a way to provide air into the lungs) size 24 with an expiration date of 10/2015.
7. One Soft PVC Nasopharyngeal Airway (a device that is inserted into the nose to provide a way to provide air into the lungs) size 22 with an expiration date of 10/2015.

Registered Nurse Staff D interviewed on 6/6/2016 at 11:45 AM acknowledged the expired supplies located in the emergency supply cart and stated, "I'm embarrassed, they should not have been left in there". Staff D indicated the Emergency supply cart equipment is to be checked at the start of every shift 7AM and 7PM by the charge nurse.

- Emergency Supply Cart located in the Emergency department observed on 6/9/2016 at 7:45 AM revealed a log indicating the defibrillator required testing every 12 hour shift by ensuring it was plugged in, working, oxygen tank full with BVM (bag valve mask)(a device used to manually supply oxygen to the lungs), and locked. The log revealed the following number of shifts in which the code cart was not checked: November 2015 - 12 shifts, December 2015 - 7 shifts, January 2016 - 8 shifts, February 2016 - 10 shifts, March 2016 - 15 shifts, April 2016 - 13 shifts, and May 2016 - 24 shifts.

Document titled "End Of Shift Report" reviewed on 6/8/2016 at 10:15 PM revealed a "nurse checklist" directing "...Crash cart (ER/Floor) inventory/expirations checked the last week of each month ...and ...ER/Med surge checklist done q (every) shift ..."

Policy titled "Crash Carts" reviewed on 6/9/2016 at 8:30 AM directed " ...Daily. The crash carets are to be routinely checked daily by appropriate patient care personnel during unit specific time frames. Documentation on the Crash cart check list will include verification of the intact correct seal, effective defibrillator functioning and that the oxygen cylinder contains over 500 PSI and appropriate suction equipment is available and in working order ..."


- Nursing medication/supply room observed on 6/6/2016 at 11:50 AM revealed the following outdated supplies:

1) Four sterile vial IV spike adaptors with an expiration date of 12/2015.

2) Two boxes of OcuSoft eyelid cleanser (to cleanse the outer eyelid) #30 with an expiration date of 4/2015.

3) One sterile water for irrigation 1000ml (milliliter) single dose container open in cabinet.

Clinical Program Coordinator Staff B interviewed on 6/6/2016 at 11:50 AM acknowledged the outdated supplies should have been disposed. Staff B stated she did not think they use the adaptors or eyelid cleanser anymore.

Policy titled "Rotation of Inventory and Disposition of Expired Product" reviewed on 6/6/2016 at 5:45 PM directed "... Expired product will be placed on the shelves designated for overseas usage ... and ...the expired product will be donated to medical staff going on short term mission trips or disposed of it the product cannot be donated ... "

The Critical Access Hospital (CAH) reported a total current census of one acute patient and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to provide a clean and orderly environment in one of one kitchen observed. This failure has the potential to expose all patients to bacteria and other infectious materials.

Findings include:

Kitchen area observed on 6/8/2016 at 1:00 PM revealed the following:

1. Hobart water sanitizing system with a thick white substance crusted onto the top edge of the machine.

2. Three sink system with white and greenish stains along the bottom edge of the sanitize and rinse basins.

3. Freezer containing patient food with upper and lower doors with dark brown/black stains on inside the door gaskets and water settled on top of the first lower door.

Dietary Staff E interviewed on 6/8/2016 at 1:20 PM indicated the upper freezer door gasket leaked causing the water and the gasket staining. Staff E reported they had put in a work request but failed to follow up.

4. Grill with brown and black stains on surface.

5. Oven with food particles located on the outside surface.

6. Refrigerator containing patient food with white drip stains on the outside and food particles settled to the bottom of the shelves. Vent located at the top of the refrigerator contained a thick layer of dust embedded into the vent.

7. Eight bottles of cleaners located on the top shelf above the clean dish drying area with the potential to drip/leak onto clean dishes. This deficient practice has the potential to expose patients and hospital visitors to hazardous chemicals.

8. Two drink dispensing containers located on a bottom shelf below the clean dish drying area stored next to chemical cleaners. This deficient practice has the potential to expose patients and hospital visitors to hazardous chemicals.

9. Four white cutting boards observed; two at one prep station and two at the second prep station. The boards were unlabeled for specific uses and contained deep scratches to the surface. This deficient practice has the potential to expose patients and hospital visitors to contaminated food items.

10. Clean dishes stacked in a bin upside right under a countertop. This deficient practice has the potential to allow dust and debris to collect on/in the dishes causing them to be unsanitary.


Dietary Staff E interviewed on 6/8/2016 at 1:25 PM acknowledged the environmental concerns and indicated they were unaware of a policy directing kitchen staff to ensure cutting boards are identified to prevent cross contamination or when to replace them.

Dietary Management Staff N from network hospital interviewed on 6/8/2016 at 2:30 PM after requesting a tour of the kitchen area agreed with the concerns identified and indicated they would be assisting the kitchen staff from the CAH to correct the issues.

Policy titled "WHC Department Cleaning Protocols" reviewed on 6/8/2016 at 7:15 PM directed "... Each department/unit will be responsible for ongoing monitoring of cleanliness; cleaning designated equipment; reporting incidents requiring cleaning procedures beyond the Departments capabilities to Environmental Services; and reporting maintenance issues to Maintenance or Biomedical Equipment Department ..."

The Critical Access Hospital (CAH) reported a total current census of one acute patient and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to properly dispense drugs in accordance with acceptable professional principles and follow their policy for one of two medication storage areas observed. The CAH failed to ensure outdated drugs were not available for patient use in one of two emergency crash carts observed. This deficient practice had the potential to affect all patients receiving medication at the CAH.


Findings include:


- Medication and supply storage area observed on 6/6/2016 at 2:30 PM revealed the following expired medications:

1. Two 1,000 milliliters (ML) Intravenous (IV) (inside the vein)) bags of 5% Dextrose in Sodium Chloride (solution used to supply water, calories, and electrolytes (e.g. sodium, chloride) to the body) with an expiration date of 4/2016.

2. Three 500ML IV bags of Sodium Chloride (a solution used to supply electrolytes to the body) with an expiration date of 12/2014

3. Four 100ML IV bags of Lactated Ringer's and 5% Dextrose (a solution used supply the body with fluid, calories, and electrolytes) with an expiration date of 4/2016.


- Emergency Supply Cart located near the nurses station observed on 6/6/2016 at 11:45 AM revealed the following one 250ML IV bag of 10% Dextrose (a solution used supply the body with fluid, calories, and electrolytes) with an expiration date of 5/1/2016.


Policy titled "Out-dated Medications" reviewed on 6/7/2016 at 6:45 PM directed "... As medications go out of date they will be placed in a courier tote by the Pharmacy Manager or designated registered nurse and clearly marked as outdated and sent to Via Christi Hospital Manhattan ...and ... All medications in the facility will be checked monthly for outdates..."

The Critical Access Hospital (CAH) reported a total current census of one acute patient and four swing bed patients. Based on observations, staff interview and policy review, the hospital Infection Control Officer failed to ensure the infection control practices were followed for two of fifteen unoccupied inpatient rooms (#308 and #205), one of one observed operating room terminal cleaning (Staff K), two of two observations of staff wearing surgical masks improperly (Operating Room (OR) Staff I and N), two of two observations of the staff wearing shoe covers improperly (OR Staff L and RN Staff F), one of one observation of a staff wearing PPE (Personal Protective Equipment) improperly (Staff H) and one of one observation of a staff not wearing eye protection when required (Staff H), The facility failed to provide evidence temperature, humidity and airflow was monitored daily in one of one OR's, one of one procedure rooms, and one of one sterile supply rooms. The facility failed to ensure cleaning and proper storage of supplies in one of one kitchen areas. These deficient practices has the potential to expose all patients and healthcare workers to infectious diseases.

Findings include:

- Unoccupied Inpatient room #308 observed on 6/6/2016 at 11:30 AM revealed dry brown spots on the foot rest of the patient's reclining chair.

- Unoccupied Inpatient room #205 observed on 6/6/2016 at 11:40 AM revealed two sticky brown/black spots on the foot rest of the patient's reclining chair.

Clinical Program Coordinator staff B interviewed on 6/6/2016 at 11:30 acknowledged the patient's chair was not clean. Staff B took a wet paper towel to the dry and sticky brown spots which was easily wiped off.

- The CAH policy titled "Management of the Environment of Care" reviewed on 6/7/2016 at 2:30 PM directed "...Covers on pillows, mattresses and furniture should be visibly clean and without stains, spots, rips or tears ..."

- Operating Room (OR) Suite terminal cleaning observed on 6/8/2016 at 3:00 PM revealed Staff K failed to clean the ceiling of the OR suite.

- Policy titled "Terminal Cleaning" reviewed on 6/8/2016 at 4:00 PM revealed the CAH failed to direct staff to clean the ceilings.

According to the 2015 Edition of Guidelines for Perioperative Practice, Association of Perioperative Registered Nurses: "I.e.3. Used cleaning materials (e.g., mop heads, cloths) should not be returned to the cleaning solutions container. Used cleaning materials are considered contaminated and returning them to the cleaning solution container contaminates the solution. VI.b.2. Cleaning should progress from top to bottom areas. During cleaning of top areas, dust, debris, and contaminated cleaning solutions may contaminate bottom areas. If bottom areas are cleaned first, these areas could potentially be re-contaminated with debris from the top areas."

Director of Nursing Staff B interviewed on 6/9/2016 at 8:30AM indicated the temperature, humidity, and airflow are monitored by a computer system but it does not keep a retrievable record of the data. Staff B revealed they are unable to provide evidence of the daily monitoring but indicated they will use a manual log in the future to provide documentation.

Administrative Staff M interviewed on 6/9/2016 at 9:50 AM revealed they follow Association of Perioperative Registered Nurses (AORN) guidelines.

The Association of Perioperative Registered Nurses (AORN) website on May 25, 2016 stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F . . . The recommended humidity range in an operating room is between 20% [percent] to 60% based on addendum d to ANSI (American National Standards Institute)/ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers)/ASHE (American Society for Healthcare Engineering) Standard 170-2008. Each facility should determine acceptable ranges for humidity in accordance with regulatory and accrediting agencies and local regulations. The Center for Medicaid and Medicare Services has modified their requirements to allow for the 20% lower limit effective June 2013. Both the temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system. . . ."

- Endoscopy Technician Staff H observed on 6/7/2016 at 9:55 AM revealed Staff H cleaning an endoscope previously used on Patient #31. Staff H failed to wear all required personal protective equipment (PPE) including eye protection. Eye protection was located on the top of the sink and available for use.

Endoscopy Technician Staff H interviewed on 6/7/2016 at 10:00 AM indicated they were unaware of a policy requiring them to wear eye protection. Staff H stated, " I think it (wearing eye protection) is optional ".

Policy titled "Surgical Attire" reviewed on 6/8/2016 at 4:10 PM directed "...in the surgical environment, protective eye wear or a mask with a face shield will be worn whenever there is anticipated exposures to splashes, spray, or splatter of blood, body fluids or other potentially infectious materials ..."

- Surgical Technician Staff I observed on 6/8/2016 at 11:00 AM revealed Staff I entering the nursing staff breakroom with a mask dangling around their neck.

Surgical Technician Staff I interviewed on 6/8/2016 at 11:05 AM acknowledged the mask around their neck and indicated it was a clean mask, and they were unaware of a hospital policy directing them to have the mask fully on or it must be removed completely.

- Operating room observed on 6/8/2016 at 11:45 AM revealed Staff N unstrung half the face mask letting it hang under their chin.

- Assistant Chief Nursing Officer Staff M interviewed on 6/8/2016 at 4:00 PM was informed Staff N in the Operating Room after the surgery on patient #32 did not dispose his face mask after the procedure, hung the face mask under his chin. Staff M stated they will counsel Staff N.

- Policy titled "Surgical Attire" reviewed on 6/8/2016 at 4:10 PM directed "...All personnel entering a restricted area of the surgical environment will wear a surgical mask ... and ... Masks will cover the nose and shall be discarded whenever removed.

- Registered Nurse Staff F observed on 6/8/2016 at 11:35 PM outside the surgical area walking into the nurse staff break room with shoe covers on.

- Operating room Staff L observed on 6/8/2016 at 12:50 PM outside the surgical area walking past the nurse's station with shoe covers on.

Administrative Staff M acknowledged shoe covers should be removed before leaving the surgical area.

- Policy titled "Surgical Attire" reviewed on 6/8/2016 at 4:10 PM directed "...Shoe covers will be removed and discarded in a designated container before leaving the surgical environment ..."

- Endoscopy Technician Staff H observed on 6/8/2016 at 10:30 AM revealed Staff H failed to remove their PPE (Personal Protective Equipment) when leaving the dirty instrument room. Staff H continued to walk through the doctor's lounge to the clean room crossing the yellow line on floor next to the Operating Room. This deficient practice has the potential to spread infectious materials in the sterile OR and expose surgical patients to the bacteria and/or blood borne pathogens.

Surgical Technician Supervisor Staff I interviewed on 6/8/2016 at 10:45 acknowledged Staff H should have taken off her PPE prior to leaving the dirty instrument room.

Policy titled "Cleaning of the Endoscopy Suite" reviewed on 6/8/2016 at 4:10 PM directed "...all contaminated instruments, to include scopes, will be handled by personnel wearing PPE until the items are properly cleaned ... "

- Kitchen area observed on 6/8/2016 at 1:00 PM revealed the following:

1. Hobart water sanitizing system with a thick white substance crusted onto the top edge of the machine.
2. Three sink system with white and greenish stains along the bottom edge of the sanitize and rinse basins.
3. Freezer containing patient food with upper and lower doors with dark brown/black stains on inside the door gaskets and water settled on top of the first lower door.

Dietary Staff E interviewed on 6/8/2016 at 1:20 PM indicated the upper freezer door gasket leaked causing the water and the gasket staining. Staff E reported they had put in a work request but failed to follow up.

4. Grill with brown and black stains on surface.

5. Oven with food particles located on the outside surface.

6. Refrigerator containing patient food with white drip stains on the outside and food particles settled to the bottom of the shelves. Vent located at the top of the refrigerator contained a thick layer of dust embedded into the vent.

7. Eight bottles of cleaners located on the top shelf above the clean dish drying area with the potential to drip/leak onto clean dishes. This deficient practice has the potential to expose patients and hospital visitors to hazardous chemicals.

8. Two drink dispensing containers located on a bottom shelf below the clean dish drying area stored next to chemical cleaners. This deficient practice has the potential to expose patients and hospital visitors to hazardous chemicals.

9. Four white cutting boards observed two at one prep station and two at the second prep station. The boards were unlabeled for specific uses and contained deep scratches to the surface. This deficient practice has the potential to expose patients and hospital visitors to contaminated food items.

10. Clean dishes stacked in a bin upside right under a countertop. This deficient practice has the potential to allow dust and debris to collect on/in the dishes causing them to be unsanitary.

11. One case of Tyson Chicken Breasts located in the freezer with a label indicating the product expired on 5/27/2016.

Dietary Staff E interviewed on 6/8/2016 at 1:25 PM acknowledged the environmental concerns and indicated they were unaware of a policy directing kitchen staff to ensure cutting boards are identified to prevent cross contamination or when to replace them.

Dietary Management Staff N from network hospital interviewed on 6/8/2016 at 2:30 PM after requesting a tour of the kitchen area agreed with the concerns identified and indicated they would be assisting the kitchen staff from the CAH to correct the issues.

Infection Control Officer Staff J interviewed on 6/8/2016 at approximately 3:00 PM revealed they had not been performing infection control audits in the kitchen area and had failed to monitor Operating Room staff for compliance with infection control practices.

Policy titled "WHC Department Cleaning Protocols" reviewed on 6/8/2016 at 7:15 PM directed " ... Each department/unit will be responsible for ongoing monitoring of cleanliness; cleaning designated equipment; reporting incidents requiring cleaning procedures beyond the Departments capabilities to Environmental Services; and reporting maintenance issues to Maintenance or Biomedical Equipment Department ..."

The Critical Access Hospital (CAH) reported a total current census of one acute patient and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to safeguard confidential patient information from possible destruction or unauthorized use in one of two medical record storage areas. This practice has the potential to affect the patient's records in one of one medical record storage areas.

Findings include:

- Health Information room observed on 6/6/2016 at 11:05 AM revealed three banker boxes (cardboard boxes used to store medical records) containing patient medical records stored on the floor with the potential for damage from flooding.

Health Information Technician Staff G interviewed on 6/6/2016 acknowledged the banker boxes on the floor did contain patient medical records. Staff G believed they were just waiting to be scanned and/or destroyed.

Policy titled "Disaster Policy" reviewed on 6/7/2016 at 12:00 PM directed "...Health records will be maintained in permanent storage in shelving units that are raised from the floor to prevent flooding and/or water damage ..."