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Based on observation, interview and policy review, the facility staff failed perform required checks of the Emergency Department (ED) Pediatric Crash Cart (a cart utilized for time sensitive emergencies such as drowning). This failure could potentially delay care of critically ill patients. The ED treats about 900 patients per month. The ED had two crash carts: one adult, one pediatric.
The facility census was 0.

Finding included:

1. Record review of facility's policy titled, "Crash Cart/Defibrillator- Emergency Department," revised 12/11, showed the following staff direction:
-Monthly, the seal was broken and contents were checked by an ED nurse to assure all supplies were present and not outdated. Monthly checks were documented on the Monthly Crash Cart Contents check list.
-Crash cart checks should be done after each use.

2. Observation on 06/11/12 at 3:45 PM showed the monthly Pediatric Crash Cart checklist for May 2012 had not been completed. The checklist identified items that must be present on the cart. Verification that each item was present was confirmed by a check. The list was separated by: "Top, Drawer 1, Drawer 2, Drawer 3, Drawer 4, Drawer 5 and Bottom (Airway Box). Check marks indicated that items were verified in the "top" section of the crash cart in May 2012.
The checklist did not contain verification that items were present in "Drawer 1, Drawer 2, Drawer 3, Drawer 4, Drawer 5 or Bottom (Airway Cart) for May 2012.
The checklist contained verification of all items in January, February, March and April of 2012.

3. During an interview on 06/11/12 at 4:00 PM Staff B, ED Manager, stated that the checks should be done and documented monthly. Staff B stated, "I guess we missed part of the checklist in May".

Based on observation, interview and record review the facility failed to maintain any inpatient beds and thereby failed to provide critically needed inpatient services for which it was designated as a Critical Access Hospital (refer to C 0211)

The cumulative effect of this ongoing systemic failure resulted in the facility's overall noncompliance with 485.620 Condition of Participation: Number of Beds and Length of Stay.

Based on observation, interview and record review the facility failed to use certified Critical Access Hospital (CAH) inpatient beds for inpatient care. The facility census was 0.

Findings included:

1. During an interview on 06/11/12 at 1:40 PM Staff A, Administrator, stated the following:
-The facility did not have any inpatients.
-The facility has not had an inpatient since May 1995.
-The facility could admit patients but chose not to.
-The facility has no plans to admit any inpatients in the future.
-The facility administration chose not to have any inpatients.
-The facility administration felt not having inpatients met the needs of the community.

2. Observation on 06/11/12 at 3:05 PM on the first floor showed three rooms (numbered 1141, 1145 and 1146) with furnishings including:
-Room 1141 and room 1146 each had a hospital bed with examination table paper covering a sheet and no blanket.
-Room 1145 had an examination table, (no hospital bed), medical illustrations of ear, nose throat (ENT) anatomy on the walls plus supplies and equipment commonly used for ENT examination stocked in the room.

3. During an interview on 06/11/12 at 3:05 PM Staff A confirmed rooms 1141, 1145 and 1146 were routinely scheduled for use by ENT physicians and a pediatric cardiologist to examine clinic patients and could be used for inpatients if the facility ever chose to admit a patient.

4. During an interview on 06/12/12 at 3:35 PM, Staff B, Nursing Director, stated that the facility did not admit inpatients and utilized designated inpatient rooms for Emergency Department (ED) overflow (when all of the emergency department rooms were full) and clinic patients. On 06/13/12 at 10:05 AM Staff B stated that the physicians at our other facility decided that they did not want to travel here to round on one or two patients. Staff B stated that there was no current nurse staffing plan for inpatients.

5. Record review of the facility Program Review, Scope of Services, Patient Care Services (Nursing) dated 2012 showed the following descriptions and plans for nurse staffing:
-Staffing was determined by census, acuity and skill required meeting patient's needs.
-Emergency Department operated twenty four hours a day, three hundred and sixty five days a year.
-Outpatient clinics operated Monday through Friday from 8:00 AM to 5:00 PM or later.
-There were no staffed inpatient units.








29511

Based on observation, interview and record review facility Sleep Laboratory staff failed to ensure patient medical records were protected from loss, destruction or unauthorized use and Health Information Management (HIM) staff failed to ensure patient medical records being transported to an outside contractor were prepared for shipping to protect against loss, destruction and unauthorized access. The facility census was 0.

Findings included:

1. Record review of the facility's policy titled, "Medical Records Department; Confidentiality" reviewed 06/2005 showed the following direction:
-The facility assumed an obligation to keep in confidence all that pertained to the patient's personal affairs.
-Every person employed by the facility shared the responsibility.
-Reasons for admission, diagnosis and the treatment of the patient were all confidential information.
-Material contained in the medical record was "confidential."

2. Observations on 06/11/12 at 3:00 PM in the facility Sleep Lab showed the following:
-Staff stored video recordings (digital video discs or DVDs) of patient sleep sessions in four unlocked drawer-like boxes on a counter top in the Sleep Lab office area.
-Each DVD was in a paper sleeve with the patient's name and account number written on it.
-Staff stored folders of paper medical records of Sleep Lab patients in two unlocked file cabinet drawers in the Sleep Lab office area.
-Each paper file folder contained information including patient name, diagnosis, referrals from physicians and other personal information.

During an interview on 06/11/12 at 3:00 PM Staff C, Sleep Lab Co-ordinator confirmed the following:
-Sleep Lab routinely treated ten to twelve patients per week.
-Patients undergoing Sleep Lab testing sometimes brought family members with them who could be out in the office area.
-If a patient was incarcerated, a guard was present at all times and could be in the office area.
-Records were stored in the office and not sent to the Health Information department for permanent storage.
-It was possible for a patient's family member or a guard to access (read) or destroy any of the patient medical records on DVDs or paper because they were stored in unlocked cabinets.

During an interview on 06/12/12 at 9:14 AM Staff D, Manager of Health Information Management (HIM) confirmed the following:
-She was responsible for all patient medical records at the facility.
-She was not aware staff in the facility Sleep Lab held patient medical records (DVDs and paper medical records) unlocked in their office areas.

3. Observation on 06/12/13 at 9:09 AM in the HIM office showed staff piled sixteen unsealed cardboard boxes filled with paper patient medical records on a large cart.

During an interview on 06/12/13 at 9:10 AM Staff D stated the following:
-The multiple unsealed boxes of patient medical records on the cart were ready for transport to a contractor in another city.
-The boxes would be transported in a hired tractor trailer truck from the facility to a company for conversion to digital media.
-The company that does digital conversion was in another city (approximately four hours from the facility).
-The cardboard boxes were not taped, sealed or otherwise securely closed to prevent the paper patient medical records from loss, destruction damage or access during transport.
-Unsealed boxes could be opened and the contents could be destroyed, lost or accessed.
-She had never thought about sealing the boxes.