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Based on observation, document review and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated, improperly stored medications/biologicals were removed from patient care areas, potentially affecting all patients.

Findings include:

1. On 8/12/14 at 9:00 AM the CAH policy titled "Unusable and Outdated Medication Storage and Disposition" revised 8/14, was reviewed. It indicated "....outdated medications, unopened contaminated medications, improperly stored medications should be returned to the pharmacy department for proper disposal."

2. On 8/11/14 at 11:30 AM a tour of the medical surgical department was conducted with the medical surgical Charge Nurse (E #4). During the tour, the following expired medications were found in the crash cart:

2-Aminophylline 10 ml, expired 7/1/14

3. On 8/11/14 at 11:45 AM an interview with the medical surgical Charge Nurse (E #4) was conducted. E #4 verified the medication was expired and reported the pharmacy checks the medications monthly and the med should have been removed.

4. On 8/11/14 at 1:40 PM a tour of the surgery department was conducted with the Surgery Supervisor (E #2). During the tour the following expired medications were found in the anesthesia cart:

1-Metoclopramide 10 mg vial, expired 7/1/14
1-Adenosine 12 mg/ml vile, expired 6/20/14
1-Dynalube tube 4 oz lubricant, expired 7/14

5. On 8/11/14 at 2:00 PM AM an interview with the surgical Charge Nurse (E #4) was conducted. E #4 verified the medications were expired and stated "they should have
been removed from the unit".

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 21-22, 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 21-22, 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, document review and interview it was determined that CAH failed to ensure narcotics were properly wasted, potentially affecting all patients receiving care in the CAH.

Findings include:

1. On 8/11/14 at 1:40 PM a tour of the surgery department was conducted with the Surgery Supervisor (E #2). During the tour it was observed on the "Anesthesia Department Narcotic Record", that entries recorded on 1/8/14 did not indicate two nurses witnessed the wasting of unused narcotics.

2. On 8/12/14 at 9:00 AM the CAH policy "Controlled Drug Management Surgery/Anesthesia/Recovery" revised 5/14 was reviewed. Under "Wastage:" it indicated "In the event of a controlled substance being discarded or wasted (all or part of an issued dose), the waste should be physically witnessed and requires the signatures of 2 nurses..... . "

3. On 8/11/14 at 2:00 PM an interview with the Pharmacy Director (E #3) was conducted. E #3 verified that two nursing signatures were missing on the anesthesia department narcotic record for entries on 1/8/14. E #3 stated "two persons should have signed off the wasted narcotic."

Based on observation, document review and staff interview, it was determined the CAH failed to ensure infection control measures were maintained to prevent potential cross contamination in patients receiving surgical services. This has the potential to effect 100% of the patients receiving care in the surgery department.

Findings include:

1. On 8/11/14 at 1:40 PM a tour of the surgical department was conducted with the Surgery Supervisor (E # 2). During the tour, the following items were found in the anesthesia cart, opened, in the original packaging, laying in a drawer:

1-salem sump tube
1-cuffed tracheal tube, 7.5 millimeter (mm)
2-cuffed tracheal tube, 7.0 mm
2-cuffed tracheal tube, 6.5 mm
2-cuffed tracheal tube, 6.0 mm
1-tracheal tube cuffed, 7.5 mm
2-Dr Brain laryngeal mask airway, size 3


2. On 8/12/14 at 2:00 PM a review of CAH policy revised 10/95 titled, "Infection Control" under "I. Sterile fields should be prepared as close to the time of use as possible. Unguarded set ups are considered contaminated."

3. On 8/11/14 at 2:00 PM an interview with E #2 was conducted. The Certified Nurse Anesthetist, responsible for the anesthesia cart, was on vacation and unable to be interviewed. E #2 verified the above equipment was not in the original sterile packaging from the manufacturer and indicated the supplies should have been removed from the department.

Based on observation and staff interview it was determined the CAH failed to ensure all dietary practices are followed per food service standards to ensure safe food is provided to all patients in the CAH.

Findings include:

1. On 8/11/14 at 1:40 PM a tour of the surgical department was conducted with the Surgery Supervisor (E #2). During the tour, the following expired food was found in the patient refrigerator:
4-strawberry jello containers, expired July 2014
2-orange jello containers, expired June 2011

2. On 8/11/14 at 2:30 PM an interview with E #2 was conducted. E #2 verified the food was expired and stated "it should have been thrown away."