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Based on observation, review of policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure a preventative maintenance program for 1 of 3 emergency crash carts (medical/surgical floor). Failure to ensure staff maintained equipment critical to patient health and safety in safe operating conditions, such as a defibrillator and suction, could result in serious injury or death if the equipment failed to function properly.

Findings include:

Review of the policy "CHECKING THE CRASH CART" occurred on 10/24/19. This policy, revised July 2014, stated, ". . . The crash cart is to be checked daily to make sure that life support equipment is available and functioning properly at all times. Checking the crash cart is the responsibility of the night nurse . . . ."

Observation of the crash cart located on the medical/surgical floor occurred on the morning of 10/24/19 with a nurse (#3). Review of the crash cart check sheets for September and October 2019 showed nursing staff failed to ensure items on the crash cart were available and in safe operating conditions 30 of 54 days.

During interview on 10/24/19 at 1:00 p.m., an administrative staff member (#1) stated she expected staff to follow the facility policy and check the crash cart daily.

Based on observation, record review, policy and procedure review, review of facility Rules and Regulations, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to ensure the secure storage of contrast agents (Readi-Cat2 and Omnipaque) in the Radiology Department (Refer to C276); failing to ensure staff followed manufacturer's instructions for the use of chemicals used for cleaning endoscopes and dating the Cidex (disinfection) container (Refer to C278); failing to ensure staff met the individualized needs of patients with suicidal risks (Refer to C294); failing to ensure staff assessed the effectiveness of as needed medications in a timely manner after administration (Refer to C297); and failing to ensure staff established a comprehensive care plan for each patient (Refer to C298). Failure to ensure the provision of services placed patients at risk of receiving improper care and could result in the patients experiencing adverse consequences.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner that prevented unauthorized access for 1 of 7 (Radiology Department) medication storage areas. Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

Observation of the Radiology Department on 10/22/19 at 3:00 p.m. with the department's director (#1) showed bottles of a contrast agent (Readi-Cat2) in an unlocked cabinet located in the X-ray room and several bottles of a contrast agent (Omnipaque) in an unlocked cabinet located in the computed tomography (CT) scan room. The X-ray, CT room, and radiology suite lacked a locking system.

During interview on 10/22/19 at 3:00 p.m., the radiology director (#2) confirmed the above areas had no locking systems.

Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer's instructions for cleaning and disinfecting equipment and supplies for 1 of 1 procedure room. Failure to follow manufacturer's instructions may result in transmission of organisms and pathogens from equipment to patients.

Findings include:

Review of the manufacturer's instructions for endoscopes occurred on 10/23/19. The undated instructions stated, "PENTAX Medical [brand name of the equipment] Optimized Manual Cleaning; . . . Endoscope Cleaning: a. Add the proper amount of detergent to the basin of water . . . Proceed with manual high level disinfection of the endoscope and accessories . . . . "

Review of the instruction label on the bottle of Prolystica 2X Concentrate Enzymatic Presoak and Cleaner occurred on 10/23/19. The instructions stated, ". . . Manual . . . Fill sink or basin with warm water to the appropriate level to full immerse surgical instruments. Dilute chemical 1/8 to ½ fl. [fluid] oz. [ounce] per gallon (1 to 4 ml [milliliters] per L [liter] . . . ."

Review of the instruction label on the bottle of CIDEX OPA Solution occurred on 10/23/19. The instructions stated, "High Level Disinfections: This solution may be used for the high level disinfection of heat sensitive reusable semi-critical medical devices for which sterilization is not feasible. Storage and Disposable: Do not reuse beyond 14 days. . . ."

Observation on 10/23/19 at 9:15 a.m. showed two staff members (#4 and #5) cleaning and disinfecting endoscopes in a room across the hall from the procedure room. One staff member (#4) filled a plastic tub with water, placed the endoscope in the water, rinsed the scope, and then added a couple squirts of Prolystica Enzymatic cleaner to the container. During an interview at this time, the staff member (#4) stated she puts enough water in the tub to cover the endoscope and then adds about an ounce of the cleaner "and a little bit more" to the water. After the staff member (#4) finished cleaning and rinsing the endoscope, she placed it in the container of Cidex Opa solution. During an interview at this time, the staff member (#4) stated she forgot to mark the Cidex container with the date she filled it, but she knew it was 12 days ago.

During an interview on 10/24/19 at 1:20 p.m., the infection control nurse (#6) stated she expected staff to follow the manufacturer's instructions for cleaning endoscopes and the directions are on the bottles.

Based on record review, review of policy and procedure, facility Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff met the individualized needs for 2 of 2 closed patient (Patient #14 and #20) records reviewed with suicidal risks. Failure to ensure nursing staff met each patients' individualized needs has the potential for inappropriate care and treatment and potential for harm/injury.

Findings include:

Review of the facility's "Rules and Regulation"occurred on 10/24/19. These Rules and Regulations, revised March 2013, stated, ". . . ADMISSION AND DISCHARGE . . . The admitting practitioner shall be held responsible for giving such information reasonably obtainable and known to the practitioner as may be necessary to assure the protection of this patient from self harm. . . ."

Review of the policy "NOTICE OF PATIENT RIGHTS" occurred on 10/24/19. This undated policy stated, ". . THE PATIENT HAS THE RIGHT TO: . . . Receive care in a safe setting. . . ."

Review of the policy "HANDLING OF SUICIDAL PATIENTS" occurred on 10/24/19. This policy, revised December 2011, stated, ". . . Procedure in the Emergency Room: . . . If the patient is be be admitted to the hospital, the physician/midlevel physician is to assess the patient for suicide risk and document this in the patient's medical record. Suicide Precautions at a level determined by the physician or midlevel physician are to be ordered . . . Two levels of Suicide Precautions will be used to address the suicide risk presented by the patient . . . Minimal suicide precautions . . . Strict suicide precautions . . . Procedures for Medical Floor: . . . Minimal suicide precautions will be ordered by the physician or mid level physician for patients who present with a significant level of depression and suicidal preoccupation . . . These patients will be placed in room 230 or SCU [special care unit] so close observation or video surveillance can be maintained. . . . c. The patient's room will be cleared of all objects with which the patient could use to injure themselves. These should include . . . tubing . . . pull cords . . . d. All personal belongings will be taken . . . Document #c and d above in patient's electronic record . . . Staff will make visual contact with the patient at least every 30 minutes and document these on the Observation Flow sheet every 30 minutes . . . Staff will document in the patient's electronic record under PROGRESS NOTES every shift and PRN [as needed]. . . ."

- Review of Patient #20's closed record occurred on 10/24/19 and identified the CAH admitted the patient for observation on 06/13/19 to room 233. Admitting diagnoses included depression, cardiomyopathy, bipolar disorder, and lorazepam (anti anxiety) overdose.

Patient #20's medical record failed to show documentation of the physician's emergency room (ER) and admission assessment for suicide risk and failed to include physician's admission orders for suicidal precautions.

Review of Patient #20's nursing progress notes showed the following:
* 06/13/19 at 4:00 p.m.," . . . Admission Note Chief Complaint: Ativan OD [overdose] Room Number: 233 [non video monitored] . . . Admitted From: ER. . . ."
* 06/13/19 at 4:13 p.m., ". . . Abnormal Assessment Note . . . Psycho/Social Assessment: Has Bipolar, talkative and jumps to other topics most of the time. . . ."
* 06/13/19 at 8:33 p.m., " . . . awake now and very anxious and agitated . . . requested one of his clonazepam . . .Dr. notified and ok' d him to have. . . ."
* 06/13/19 at 11:07 p.m., ". . . Pt [patient] has moments of anxiety. . . ."
* 06/14/19 at 2:15 a.m., ". . . Abnormal Assessment Note . . . Ineffective Coping. . . ."
* 06/14/19 at 6:00 a.m., ". . . Pt laying with his eyes closed. . . ."
* 06/14/19 at 6:50 a.m., ". . . Call light on, feeling very anxious, reported he needed his med's [sic]. . . ."
* 06/14/19 at 7:00 a.m., ". . . Med's taken down to pt's room, found pt with IV [intravenous] tubing wrapped couple times around his neck, didn't want nurse to remove, reported how he just didn't want to live any more. 'I have nothing to live for. No one is concerned about me' . . . Staff remained in room with patient . . . Places pillow over his face at times--removed. . . ."
* 06/14/19 at 7:10 a.m., ". . . Call placed to provider . . . about patient's verbal statements about 'want to to die' and 'wishing he would have taken more medication' . . . Advised to just give his Psychotropic medications early. . . ."
* 06/14/19 at 7:51 a.m., ". . . Abnormal Assessment Note . . . IV tubing removed from room, patient is a 1:1 . . . due to suicidal risk. . . ."
* 06/14/19 at 8:08 a.m., ". . . Patient remains 1:1 . . . Depakote ER [extended release] unavailable for administration. . . ."
* 06/14/18 at 8:30 a.m., " . . . Patient grabbed call light and wrapped cord around his neck . . . Patient stated 'I'm done. I don't want to breathe'. . . ."
* 06/14/19 at 09:14 a.m., ". . . Patient threatening to leave AMA [against medical advice] . . . Patient walking down the hallway, patient able to be redirected back to room. . . ."
* 06/14/19 at 9:21 a.m., ". . . Patient given Ativan 1 mg [milligram] IV. . . . Patient agitated. . . ."
* 06/14/19 at 9:42 a.m., ". . . Law enforcement called for safety concerns . . . Police on scene within 5 minutes of call . . . remain in room with patient . . . Provider in room making arrangements to transfer to [location] for psychiatric evaluation. . . ."
* 06/14/19 at 11:20 a.m., ". . . Patient immediately became upset. Aggressively exited the bed. Patient began putting on clothes. Patient grabbed backpack . . . had to hand cuff patient . . . due to safety concerns. . . ."
* 06/14/19 at 11:35 a.m., ". . . Patient transferred by law enforcement on emergency hold . . . to [name of hospital]. . . ."

Patient #20's Discharge Summary, dated 06/14/19, stated, ". . . History of the present illness . . . history of anxiety, depression and bipolar disorder. He states that he is rather destitute at this time. He feels hopeless and helpless . . . recent prescription for lorazepam 0.5 mg. He said that he took five to six of them . . . He presented to the emergency room feeling weak, down and hopeless . . . patient was admitted last evening with a suicide attempt . . . He has a longstanding history of bipolar disorder . . . He states he also has had suicide attempts in the past . . . Suicide Attempts Times Three in the Last 24 hours . . . transferred to [name of hospital]. . . ."

Patient #20's chart review showed staff failed to place the patient in room 230 for close observation or video monitoring, failed to show documentation of visual contact with the patient every 30 minutes, and failed to complete an Observation Flow Sheet.

During interview on the morning of 10/24/19, an administrative nurse (#1) stated Patient #20 transferred from the ER to the medical floor for observation without a suicidal diagnoses by the physician.

- Review of Patient #14's closed record occurred on 10/23/19 and 10/24/19 and identified the CAH admitted the patient on 05/02/19 to room 230. Admitting diagnoses included overdose of cyclobenzaprine, depression, and suicidal ideation.

Review of Patient #14's nursing progress notes showed the following:
* 05/02/19 at 11:45 p.m., ". . . Psycho/Social Interventions . . . Patient checked on hourly. . . ."
* 05/03/19 at 1:14 a.m., ". . . Nauseated. Zofran given. . . ."
* 05/03/19 at 5:16 a.m., ". . . some nausea and vomiting during the night . . . vital signs are stable. . . ."
* 05/03/19 at 7:37 a.m., ". . . Slept well this shift. . . ."
* 05/03/19 at 10:00 a.m., ". . . Patient up to shower. . . ."
* 05/03/19 at 10:29 a.m., ". . . headache. . . ."
* 05/03/19 at 11:58 a.m., ". . . Patient discharged. . . ."

The nursing progress notes failed to show documentation of visual contact with the patient every 30 minutes. The record lacked staff completion of the Observation Flow Sheet.

Patient #14's Discharge Summary, dated 05/03/19, stated, ". . . found by her boyfriend to be rather distraught . . . had been drinking some beers. . . had then taken approximately 25 cyclobenzaprine [muscle relaxant] 10 mg tablets and had made cuts on her left wrist. She said she was attempting to harm herself. She claimed to be overwhelmed . . . The patient was admitted following an overdose . . . along with depression and suicidal intentions . . . Through the night she was stable . . . transfer to the psychiatric department in [location] . . . Final Diagnosis: Suicidal Attempt, Self Inflicted Wrist Lacerations, Depression, Intentional Overdose of Cyclobenzaprine. . . ."

Patient #14's medical record failed to show documentation of the physician's ER and admission assessment for suicide risk and failed to include physician's admission orders for suicidal precautions.

Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to assess the effectiveness of medications given to patients on an as needed (PRN) basis within the expected time frame for 7 of 20 patient records (Patient #1, #2, #6, #8, #9, #14, and #18) reviewed. Failure to evaluate the patients' responses to PRN medications within the expected time frame limited the nursing staffs' ability to assess whether the medications achieved the desired effect.

Findings include:

Review of the facility policy titled, "Medication Preparation and Administration" occurred on 10/23/19. This undated policy stated, ". . . All PRN medications need to have a note added on administration . . . A note will also be required within an hour of giving a PRN medication to document the patient's response to the PRN medication . . ."

Review of Patient #1, #2, #6, #8, #9, #14, and #18's medical records occurred on all days of survey and showed nursing staff administered PRN medications but failed to assess and document a response as follows:
- Patient #1's medication administration record (MAR), dated 09/10/19 to 10/24/19 showed nursing staff administered Hydrocodone (a narcotic pain medication) 12 times and Tylenol twice.
- Patient #2's received Tramadol (a pain medication) on 10/20/19 at 6:41 a.m.


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- Patient #6 received Zofran (a medication to prevent nausea/vomiting) and Tylenol on 05/03/19.
- Patient #8 received Zofran on 05/03/19.
- Patient #9 received Tylenol on 07/09/19.
- Patient #14 received Ativan (an antianxiety medication) on 05/16/19.
- Patient #18 received Zofran on 09/10/19, 09/11/19, and 09/12/19 and Ativan on 09/10/19, 09/11/19 and 09/12/19.

During interview on 10/23/19 at 1:52 p.m., an administrative nurse (#1) stated she expected staff to assess the effectiveness of PRN medications within 30-60 minutes after administration.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to establish a comprehensive care plan which described the services furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 20 closed patient (Patient #14 and #20 ) records reviewed. This failure limited the CAH's ability to ensure continuity of care and provide the greatest benefit to the patient.

Findings include:

Review of the policy "Care Plan" occurred on 10/24/19. This policy, revised December 2011, stated, ". . . each patient admitted to the hospital should have an individualized Plan of Care based on his needs and problems . . . Nursing histories are obtained by an RN or LPN, supervised by an RN on admission of the patient. This collected information is used to make an individualized Nursing Care Plan . . . It is outlined by statements of patient's needs and problems . . . The care plan should be used as a guide for charting and continuity of care. . . ."

- Review of Patient #14's closed patient record occurred on 10/23/19 and 10/24/19 and identified the CAH admitted the patient on 05/03/19 with diagnoses including overdose of cyclobenzaprine, depression, and suicidal ideations. Review of Patient #14's care plan failed to include a plan and nursing interventions for the admitting diagnoses.

- Review of Patient #20's closed patient record occurred on 10/24/19 and identified the CAH admitted the patient on 06/13/19 with diagnoses including depression, cardiomyapathy, and lorazepam overdose. Review of Patient #20's care plan failed to include a plan and nursing interventions for the admitting diagnoses.

On the morning of 10/24/19, an administrative nurse (#1) confirmed the above care plans failed to include a plan and nursing interventions related to the patients' admitting diagnoses.

Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 1 of 2 radiology medical record storage areas (cupboard and file cabinets in general radiology suite). Failure to store medical records in a secure manner limited the CAH's ability to prevent loss or destruction of records and to ensure the maintenance of patient confidentiality.

Findings include:

Review of the radiology policy "Reports" occurred on 10/24/19. This policy, dated November 2016, failed to provide information regarding secure storage of records.

Observation on 10/22/19 at 2:45 p.m. identified patient radiology films stored in an unlocked cabinet and patient radiology paper reports stored in unlocked file cabinets in the unlocked general radiology suite.

During an interview on 10/22/19 at 3:15 p.m., the radiology director (#2) confirmed the CAH did not have the films and reports in locking cabinets, and the radiology suite lacked a locking system.