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A. Based on State licensure, observation, and staff interview it was determined that the Critical Access Hospital (CAH) failed to ensure that all state licensure rules are followed.

Findings include:

1. The Hospital Licensing Act "(210 ILCS 85/6. 14 c) Sec. 6.14 c. Posting of information. Every hospital shall conspicuously post for display in an area of its offices accessible... (2) a description, provided by the Department, of complaint procedures...".

2. During a tour of the Emergency Department on 1/12/10 at 11:00 AM, it was observed in the waiting areas that there was no posting of complaint procedures.

3. During an interview with the Chief Nursing Officer on 1/12/10 at 1:30 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 11, 2010, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

A. Based on policy and procedure, observation, and staff interview it was determined that the CAH failed to ensure that drugs, biologicals, and supplies were appropriately maintained and safe for patient use.

Findings include:

1. The CAH policy titled, "Outdated Drug Control" under "PROCEDURE: 2. The pharmacy personnel will constantly check all medication physically for dated items and remove... 6. Nursing stations will be checked monthly for outdated items with replacement stock immediately."

2. During a tour of the radiology department on 1/12/10 at 11:30 AM, it was observed in the Computerized Tomography (CT) room that the crash cart contained outdated medicine and supplies. The items were: 4- 0.9% Sodium Chloride syringes-expired 3/1/06 and 3- Iodophor swab sticks-expired 11/05.

3. During a tour of the respiratory department on 1/12/10 at 10:00 AM, it was observed in the cardiac room that the crash cart contained outdated medicine and supplies. The items were: 1- 1000cc 0.9% bag and 1 -1000 cc Lactated Ringers bag -expired 12/09, 1-Atropine sulfate 1mg injectable-expired 10/1/09.

4. During a tour of the laboratory outpatient drawing room on 1/11/10 at 2:30 PM, it was observed that 4 small brown blood collection tubes had expired 11/09.

5. During an interview with the Chief Nursing Officer on 1/12/10 at 3:00 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 11, 2010, the surveyors find 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, dated February 11, 2010.

A. Based on CAH policy, record review and staff interview, it was determined that in 1 of 1 (Pt. # 5) records reviewed of patients presenting to the Emergency Department (ED) with suicidal thoughts, the hospital failed to provide services in accordance with written policies.

Findings include:

1. The CAH policy titled "Care of the Suicidal Patient" under Procedure 1.0 "Any patient who displays or verbalizes signs of suicidal or self-destructive behavior will be placed on suicide precautions by order of the physician. If the attending physician... the professional nurse will place these people on temporary suicide precautions with observation approximately every 15 minutes...".

2. The medical record of Pt. # 5 was reviewed on survey date 1/13/10. Pt. #5 presented to the ED on 11/16/09 at 1350 with "attempted suicide yesterday with Xanax" as chief complaint. Documentation failed to indicate that the physician or nurse placed Pt. #5 on suicide precautions. There was no documentation by the nurse or physician after 1600 to indicate ongoing assessment. Pt. #5 was in the ED on 11/16/09 from 1350 to 2020, the time of transfer.

3. During an interview with the Chief Nursing Officer on 1/14/10 at 11:30 AM, the above findings were confirmed.

A. Based on policy and procedure, observation, and staff interview it was determined that the CAH failed to ensure that food is appropriately stored and labeled.

Findings include:

1. The policy titled, "Receiving Food" under " IV. PROCEDURE 4. All items will be dated with the month and year prior to being stored."

2. During a tour of the Dietary department on 1/11/10 at 1:30 PM, it was observed in the freezer an open bag of mixed vegetables and a bag of okra were not labeled. Also observed some pieces of broccoli and carrots at the bottom of the freezer. There were 8 individual ice-creams in a silver tray with no dates.

3. During an interview with the Chief Nursing Officer on 1/11/10 at 2:30 PM, the above findings were confirmed.

A. Based on policy and procedure, record review, and staff interview it was determined that in 4 of 21 (Pt#5, 10, 12, 20) medical records reviewed that the CAH failed to ensure that physician orders were signed, dated, and timed.

Findings include:

1. The policy titled, "Physician Orders" under PROCEDURE Supervision of a Physician: 1. Each physician's orders must be signed by the physician and dated when the order was signed." "Telephone Orders: 2. Verbal orders must be countersigned by the physician within 24 hours."

2. The medical record of Pt. #5 was reviewed on 1/13/10. Pt. #5 was admitted to the CAH on 11/16/09 with the diagnoses of Schizophrenia and Suicide Attempt. The physician's transfer orders did not have the time the order was written.

3. The medical record of Pt. #10 was reviewed on 1/13/10. Pt. #10 was admitted to the CAH on 4/9/09 with the diagnosis of Acute Cellulitis. Documentation indicated that admission orders written on 4/9/09 were not timed. Documentation indicated that discharge orders written on 4/11/09 were not timed.

4. The medical record of Pt. #12 was reviewed on 1/13/10. Pt. #12 was admitted to the CAH on 10/11/09 with the diagnosis of Alcohol Intoxication Anemia. Documentation indicated that the admission orders were written on 10/11/09 at 0845, there was no physician signature. Documentation indicated that two telephone orders written on 10/11/09 were not signed by the physician until 10/13/09. There was no time recorded and both orders exceeded 24 hours.

5. The medical record of Pt. #20 was reviewed on 1/13/10. Pt. #20 was admitted to the CAH on 10/16/09 for outpatient surgery of the Left Hallus Limitus. Documentation indicated that the surgical orders written on 10/16/09 were signed but were not timed. Documentation indicated that a verbal order written on 10/16/09 by the Certified Registered Nurse Anesthetist has not been signed as of survey date 1/13/10.

6. During an interview with the Chief Nursing Officer on 1/14/10 at 11:00 AM, the above findings were confirmed.