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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on February 28 - March 1, 2018, 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 cited. Also see C231.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on February 28 - March 1, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on document review, observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure multi-dose vials were safe for patient usage according to policy. This has the potential to affect all patients receiving medications, current census-11.

Findings include:

1. The CAH policy, revised, 3/2009, titled, "MULTIDOSE VIALS" was reviewed on 2/26/18 at 2:00 PM. The policy indicated under "VI. DOCUMENTATION: "Multi-dose vials will be documented (with) the date opened upon initial entry by the nurse."

2. On 2/26/18 at 2:15 PM, a tour of the medication room was conducted with the Chief Nursing Officer (E# 1). The medication room refrigerator contained, two (5 ml) opened vials of purified protein derivative, which lacked an opening date.

3. On 2/26/18 at 2:20 PM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 reviewed the opened vials and confirmed there was no opening date on the vials.

B. Based on document review, observation and staff interview, it was determined the CAH failed to ensure all expired drugs and biological's were removed from patient care areas, in order to maintain a safe environment. This failure has the potential to affect all patients and staff.

1. The CAH policy, revised 6/2007, titled, "Drug Storage Unit Inspection" was reviewed on 2/28/18 at 3:00 PM. The policy indicated under "V. PROCEDURE: Drugs shall not be kept in stock after the expiration date on the label. No unusable drugs shall be stored, distributed, or administered. All drugs scheduled to expire should be removed from stock..."

2. A tour of the emergency department was conducted with the Emergency Room Supervisor (E#7) on 2/27/18 at 10:30 AM. The emergency department's emergency supply pack contained, twelve prefilled, 10 cc syringes of normal saline with an 4/2017 expiration date. The emergency department had a five gallon pump container of Enzol enzymatic cleanser with an expiration date of 11/2016, a 5 gallon pump container of Safeguard antibacterial hand soap with an illegible expiration date, and a box of EZ surgical scrub sponges which expired 4/2016.

3. On 2/27/18 at 10:30 AM, an interview was conducted with the Emergency Room Supervisor (E#7). E#7 reported that central supply provides these items and does keep track of expirations within their department. E#7 indicated the emergency department (ED) staff should be checking items for expiration dates after receipt and replacing the items as necessary. An interview with the Chief Nursing Officer ( E#1) was conducted on 3/1/18 at 2:15 PM. E#1 provided central supply logs with a listing of supplies and expiration dates. The expired items observed in the ED were not on the list.

Based on document review, observation, and staff interview, it was determined the dietary department failed to ensure policies were followed regarding food storage and safety. This has the potential to affect all patients receiving food services-current census 11.

Findings include:

1. The CAH policy dated, 10/1/09, titled, "READY-TO-EAT FOODS, DATE MARKING" was reviewed on 2/26/18 at 4:15 PM. The policy indicated, under "V. PROCEDURES INFECTION CONTROL: N/A...." bullet 3, "A date-marking system may include: ...Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date...".

2. On 2/26/18 at 3:15 PM, a tour of the dietary department was conducted with the dietary manager (E#5). The dietary department's freezer contained one bag of coconut and one bag of powdered sugar, which lacked an opening dates. The dietary department's cabinet contained one package of dried beans, which lacked an opening date.

3. On 2/26/18 at 3:20 PM, an interview was conducted with the dietary manager (E#5). E#5 confirmed there was no date of opening on the above items. E#5 stated, "It is the policy to put the date on all food items when opened."

A. Based on document review and staff interview, it was determined the CAH failed to ensure medical records were completed within mandated timeframe per policy. This has the potential to affect all patients receiving services, current census-11.

Findings include:

1. The CAH "Medical Staff Bylaws Rules & Regulations" were reviewed on 2/27/18. Documentation indicated under "Section 9. Medical Records 1. For each patient there shall be an adequate, accurate, timely, and complete medical record...7. Medical charts must be completed in the current patient's file in the Health Information office within 30 days after discharge."

2. On 2/27/18 at 9:00 AM, a request for delinquent medical records was requested. At 9:30 AM, a "DEFICIENCY LIST" was reviewed indicating a total of 77 deficient records thru September 2017-January 2018.

3. On 2/27/18 at 9:40 AM, an interview was conducted with the medical records supervisor (E#6). E#6 was asked about the delinquencies. E#6 replied, "yes, I am aware of these deficient charts."

B. Based on document review and staff interview, it was determined in 2 of 20 (Pt #11, #12) medical records reviewed, the CAH failed to ensure history and physical exams were completed within 24 hours of admission. This has the potential to affect all patients receiving services, current census-11.

Findings include:

1. The. The CAH "Medical Staff Bylaws Rules & Regulations" were reviewed on 2/27/18. Documentation indicated under "Section 9. Medical Records 2. A complete medical history and physical examination shall in all cases be written no more than (30) days before or (24) hours after admission."

2. The medical record of Pt #11 was reviewed on 3/1/18 at 10:30 AM. Pt #11 was admitted on 10/19/17 with diagnosis of pneumonia. Documentation indicated the history and physical was completed on 11/2/17, which was over the 24 hour timeframe.

3. The medical record of Pt #12 was reviewed on 3/1/18 at 11:00 AM. Pt #12 was admitted on 12/26/17 with diagnosis of pneumonia. Documentation indicated the history and physical was completed on 1/2/18, which was over the 24 hour timeframe.

4. On 3/1/18 at 11:30 AM, an interview was conducted with the medical records supervisor (E#6). E#6 reviewed the history and physicals on Pt #11 and #12 and confirmed the signature by physician was over the 24 hour timeframe.

Based on document review and staff interview, it was determined the CAH failed to ensure all departments actively participated in an ongoing, data driven quality program to ensure optimal patient care services throughout the facility. This failure has the potential to affect all persons receiving services.

Finding include:

1. A review of the Continuous Quality Improvement Plan with effective date 3/1/2016 was completed on 2/28/18 at 3:30 PM. The plan indicates under " I. POLICY, a) PURPOSE To ensure that the governing body, medical staff and professional service staff demonstrate a consistent endeavor to deliver optimal care in an environment of minimal risk."

2. A review of the quarterly Quality Improvement Committee Meeting minutes from July 2016 through October 2017 was completed during the survey. The minutes indicated all departments had representation during the committee meetings. However, lab, health information and nursing did not participate in the process of quality improvement. The minutes indicated in 3 of the 6 quarters there were "no CQI studies reported." The departments that did participate and provide quality data were consistently the same and included lab, health information and nursing.

3. An interview with the Quality Improvement Director (E#2) was conducted on 2/28/18 at 11:00 AM. E#2 reported that the quality department has not made a continuous effort to follow up with each department to discuss areas of concern and the possible need to develop quality improvement projects. E#2 stated, "All employees receive training in quality improvement upon hire and as needed. I know they see problems and correct them often as a quick fix, but they don't document more detailed situations."