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A. Based on observation, document review and interview, it was determined in 1 of 2 Automated External Defibrillator (AED) reviewed for log Sheets, the Hospital failed to ensure emergency equipment was checked daily as per policy. This has the potential to effect all patients receiving outpatient therapy services.

Findings include:

1. The policy titled "Maintenance and Cleaning Policy (approved: 07/30/2020)" was reviewed 10/27/22 at approximately 10:45 AM. The policy noted "...Guidelines/Procedures:...C. Daily- Check AED in the upper R (right) corner for flashing arrow which indicates battery is working..."

2. A tour was conducted on 10/25/22 at approximately 1:30 PM of the outpatient therapy services with the Chief Nursing Officer (E#7) and Manager of Outpatient Therapy (E#6). During the tour the AED lacked a log sheet for daily checks.

3. An interview was conducted during the tour with E#6 and E#7. E#6 and E#7 verbally confirmed the AED lacked documentation of the daily checks.




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B. Based on observation, and staff interview, it was determined the Facility failed to ensure expired emergency supplies were not available for patient use. This failure has the potential to affect all patients, staff, and visitors serviced by the facility.

Findings include:

1. On 10/25/2022 at approximately 11:00 AM, an observational tour was conducted on the Medical/Surgical Unit. During the tour it was noted there were expired supplies available for immediate patient use to include the following:

a. Ten (10) pediatric endotrachael tubes; 2 (two) 3.0 mm expired 8/21/2022, 2 (two) 3.5 mm expired 7-13-2021, 2 (two) 4.0 mm expired 11-7-2021, 2 (two) 4.5 mm expired 4/20/2020 and 2 (two) 5 mm expired 11/2/2020.

b. One (1) one piece, single use laryngoscope blade combination, size- mill 0, expired 10/15/2022.

2. On 10/22/2022 at approximately 11:30 PM, an interview was conducted with the Medical/Surgical Unit Manager (E#2). E#2 verbally agreed the items were expired, and should not have been available for patient use.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on November 9, 2022 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.625, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

A. Based on document review, observation, and interview, it was determined the Hospital failed to ensure all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to effect all patients receiving outpatient therapy services.

Findings include:

1. The policy titled "GE Clinical Services Medical Management Program 800-525-1516 (approved: 07/19/2019)" was reviewed on 10/27/22 at approximately 12:15 PM. The policy noted, "Procedure:...Inspect medical equipment prior to use...and at intervals not to exceed twelve months..."

2. A tour was conducted on 10/25/22 at approximately 1:30 PM of the outpatient therapy services was conducted with the Chief Nursing Officer (CNO E#7) and manager of outpatient therapy (E#6). During the tour the following equipment lacked evidence a preventative maintenance (PM) was conducted or equipment was inspected prior to use:

a) exam table with plug, in room- no inspection conducted
b) 1 game ready machine (used for ice compression)- no PM sticker
c) 1 game ready machine- PM sticker expired 4/2022

3. An interview was conducted on 10/26/22 at approximately 10:00 AM with the Chief Nursing Officer (E#7). E#7 verbally confirmed the above equipment was not current on inspections and preventative maintenance.






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B. Based on observation, document review, and interview it was determined the Critical Access Hospital (CAH) failed to ensure eyewash stations were checked weekly per policy. This has the potential to affect all patients, staff, and visitors serviced by the facility.

Findings include:

1. An observational tour of the Laboratory Department was conducted on 10/25/22 at approximately 1:00 PM. During the tour the weekly checks log for the "emergency shower and eyewash" were reviewed. The log lacked weekly checks for 2 weeks (no checks completed from 10/5/22 through 10/24/22).

2. The policy titled "Emergency Shower/Eyewash/ Drench Hose Maintenance" (revised 11/30/2020) was reviewed 10/25/22 at approximately 1:15 PM. The policy noted "A weekly activation of emergency equipment is a simple but effective check to make sure that it is working properly."

3. An interview was conducted with the Lab Manager (E #8) on 10/25/22 at approximately 1:30 PM. E #8 verbally agreed the weekly checks were not completed.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on November 9, 2022 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on document review and interview, it was determined for 1 of 3 (Pt #16) patients transfer records reviewed the Hospital failed to ensure records were complete and authenticated. This has the has the potential to affect all patients, serviced by the facility.

Findings include:

1. The policy titled "Transfer Documentation" (approved 4/9/21) was reviewed 10/27/22 at approximately 10:00 AM. The policy noted, "COBRA sheet, must be filled out by nurse via physician instructions. The ERP (Emergency Room Physician), the nurse, and the patient/family must sign the form prior to transfer."

2. The medical record of Pt #16 was reviewed on 10/27/22 at approximately 11:00 AM. Pt #16 presented to the Emergency Department on 8/10/22 with a diagnosis of right ankle pain. The COBRA form (Authorization for Patient Transfer) lacked a witness signature along with date and time.

3. An interview was conducted with the Med Surge Director (E #2) on 10/27/22 at approximately 11:15 AM. E #2 stated, "Yes the Transfer Form is not complete and should be."

Based on observation and staff interview it was determined the CAH failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. This has the potential to effect all patients receiving outpatient therapy services.

Findings include:

1. A tour was conducted on 10/25/22 at approximately 1:30 PM of the outpatient therapy services with the Chief Nursing Officer (E#7) and manager of outpatient therapy (E#6). During the tour, it was observed in room #1 the exam table had tears in the vinyl at corner ends of the table.

2. An interview was conducted with the E#6, during the tour. E#6 observed the tears in the exam table and confirmed the need for repair.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient records reviewed, who required the use of violent restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. This has the potential to affect all inpatients and outpatients who require the use of restraints by the Hospital.

Findings include:

1. The Policy titled "Restraint and Seclusion (approved 10/13/2022)" was reviewed on 10/25/2022 at approximately 1:00 PM. On page 3, the policy noted, "D. Provider Orders... 3. Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)... b. Violent or Self-Destructive Situations... v. Each order for a physical restraint or seclusion is limited to 4 hours for adults 18 years of age and older.... vi. The RN (Registered Nurse) may request a renewal for another period of time (not to exceed original limit)."

2. The clinical record of Pt #1 was reviewed on 10/26/2022 at approximately 9:00 AM. A violent restraint order for lockable hard wrist restraints was placed on 01/10/2022 at 8:23 PM. The Emergency Department (ED) "Nursing Note" date 01/10/2022 at 8:40 PM stated, "Pt became extremely agitated after given Narcan (narcotic reversal medication), kicking bedrails, and hitting / slapping at rails and staff. Pt unable to be calmed or redirected. Protocol for restraints initiated." Another ED nursing note on 01/11/2022 at 1:23 AM stated, "Pt sleeping on side, restraints released....." The record lacked a discontinue order or renewal order for violent restraints.

3. An interview was conducted on 10/26/2022 at approximately 10:30 AM with the Medical/Surgical Director (E #1) and Emergency Department Manager (E #3). E #2 and E #2 reviewed Pt #1's record and stated, "there is only 1 order for violent restraints. There is no renewal order and there should have been."