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Based on staff interview the Critical Access Hospital (CAH) failed to implement a system to review medical services for medical necessity, quality of medical care provided, and written criteria for the evaluation of medical care that includes medical record review. This deficient practice puts all patients at risk for their medical care and responsibilities of the CAH.

Findings include:


- Administrative Staff B interviewed on 9/20/17at 4:30pm and 9/21/17 at 1:30pm confirmed the CAH does not have a system in place for peer review, quality review, and inpatient/outpatient medical record reviews.

Based on observations and staff interviews the Critical Access Hospital (CAH) failed to ensure Emergency room supplies and medications did not exceed the manufacturer's safe use date for 3 of 3 Crash Carts (special care unit crash cart, emergency room adult crash cart and one pediatric crash cart), 1 of 2 Trauma Bays, and 2 of 3 Airway Carts (Trauma Bay and operating room "C"). This deficient practice has the potential to cause compromised medications and unsafe supplies used during the care and treatment of emergent patients.

Findings include:

- Adult Crash Cart in the Trauma Bay observation on 9/18/2017 at 11:30 AM (MT) revealed the following expired items:

1. One, 100 ml bag of 5% IV Dextrose (intravenous sugar) with an expiration date of 9/1/2017
2. One, 250 ml bag of Dobutamine (used to increase blood pressure in an emergency) with an expiration date of 8/1/2017
3. Two Yankaur suction tubes (attachment used to suction the mouth), one with an expiration date of 3/2017 and another with an expiration date of 1/2016
4. Three packages of EKG electrodes (used to test the electricity of the heart), two with an expiration date of 7/2014 and one with an expiration date of 8/2015
5. One blue top blood collection tube with an expiration date of 9/5/2017

- Trauma Bay Airway Cart observation on 9/18/2017 at 11:30 AM revealed five disposable laryngeal scope blades (used to visualize the throat when placing a breathing tube); three, size 2.0 with an expiration date of 7/16/2017, and two, size 4.0 with an expiration date of 3/12/2017

- Emergency Room Manager, Staff Z interviewed on 9/18/2018 at 12:00 PM acknowledged the outdated items in both the crash cart and airway cart.



- Operating Room C Airway Cart observation on 9/18/2018 at 3:00 PM revealed three disposable laryngeal scope blades; one, size 3.0 with an expiration date of 1/5/2017, one, size 3.0 with an expiration date of 7/16/2017, and one, size 4.0 with an expiration date of 3/12/2017.

- Certified Registered Nurse Anesthetist (CRNA), Staff GG interview on 9/18/2018 3:00 PM acknowledged the items were expired.

- Observation in the emergency room on 9/18/17 at 11:45am revealed a chest tube insertion tray with the following expired supplies:

1-1000cc (centimeter) container of sterile water for irrigation with an expiration date of 7/1/17
1- Tegaderm (transparent dressing) 4inches x4 and a 1/4inches with an expiration date of 5/17
1- Tegaderm (transparent dressing) 4 inches x 4 and a 1 /4 inches with an expiration date of 12/15
2- Packages of sterile gloves size 8 with an expiration date of 11/16
2- Packages of sterile gloves size 71/2 with an expiration date of 10/16

- Observation in the emergency room on 9/18/17 at 12:15pm revealed a container on a counter with the following expired supplies:

1- Green top blood tube (a tube used to collect blood when the laboratory staff draw blood) with an expiration date of 6/17
1- Blue top blood tube with an expiration date of 1/17
1- Orange top blood tube with an expiration date of 5/17
1- Red top blood tube with an expiration date of 4/17

- Observation in the emergency department area on 9/18/17 at 12:20pm revealed a tracheostomy kit (supplies used to create a hole in the patient's breathing tube if the patient can't breathe normally) in a cabinet with the following expired supplies:

1- Package of 20- 4x4 sterile dressings with an expiration date of 7/17


- Observation in the emergency department area on 9/18/17 at 12:20pm revealed a sterile obstetric skin preparation tray with an expiration date of 3/12

- Observation in the emergency department area on 9/18/17 at 12:25pm revealed an emergency pediatric cart with the following expired supplies:

2- Blue top blood tubes with an expiration date of 9/5/17
1- Suction connecting tubing with an expiration date of 5/15

- Observation in the emergency department area on 9/18/17 at 8:20am revealed a cart that contained six 10cc syringes with sodium chloride (a solution used to flush intravenous lines) with an expiration date of 11/16

Administrative Staff Z, RN (Registered Nurse) interviewed on 9/18/17 at 1:00pm acknowledged the expired supplies in the emergency department.

- Observation in the special care unit on 9/19/17 at 8:20am revealed an emergency cart with the following expired supplies and medication:

1- Sterile syringe 20cc with an expiration date of 8/17
4- Red and black top blood tubes with an expiration date of 5/31/17
1- Vial of Levophed (a medication used to treat low blood pressure) 4cc with an expiration date of 9/1/17
1- Airway resuscitation pack (a mask like piece of equipment placed over the patient's mouth and nose to help them breathe) with an expiration date of 8/17

Administrative Staff KK, RN interviewed on 9/19/17 at 8:30am acknowledged the expired supplies and medication in the emergency cart.

- Observation in the Emergency Department on 9/18/2017 at 12:20pm revealed a Pediatric crash cart with the following expired supplies and medications:
1- Lidocaine unit dose injectable syringe with an expiration date of 9/1/17
1- Infant urinary catheter kit with an expiration date of 8/2017
1- Blood collection set
3- 25 gauge ¾ inch needles with expiration dates of 12/2015, 1/1 8/2016, 1/1 6/2017
4-23 gauge ¾ inch needles with an expiration date of 1/2016
2- 21 gauge ¾ inch needles with an expiration date of 7/2017
1- Suction connection tubing 1.5 feet with an expiration date of 5/2017
2- Sterile gloves size 7 with an expiration date of 2/2017
2- Sterile gloves size 8 with an expiration date of 8/2017
1- I-Gelo-O2 intersurgical (an instrument used to help patients breath, airway device) with an expiration date of 4/2014

Administrative Staff X, RN interviewed on 9/18/17 at 1:00pm acknowledged the expired supplies and medications.

- Observation in the Obstetric (OB) department room 194 on 9/18/2017 at 4:00 PM revealed the following expired supplies:
2- oral/nasal tracheal tube (a tube inserted in the patient's airway to help them breathe) size 3.00 millimeters (mm) with an expiration date of 1/2017.

Administrative Staff LL, RN interviewed on 9/18/17 at 4:00pm confirmed and verified the expired supplies.

- Observation in the Special Care Unit (SCU) station on 9/19/2017 at 8:33am revealed the following expired medication and supplies in the crash cart:

1- 100ml vial of Dextrose 5% (a concentrated sugar water) with an expiration date of 1/2017
2- 5 ml vials of Metoprolol tartrate (a medication to treat high blood pressure) with an expiration date of 9/1/2017
1- Dopamine 1600mg (milligrams)/250ml intravenous (IV) fluid bag (a medication used to treat shock by increasing blood flow) with an expiration date of 9/1/2017

- Observation in the SCU in a drawer, to the right side of the lower sink on 9/19/2017 at 8:47am revealed the following expired supplies:
1- 25 gauge 1 ½ inch needle with an expiration date of 7/2015
1- Culture swab with an expiration date of 2/013
1- Insyte 24 gauge IV catheter (used to insert into the vein) with an expiration date of 1/2016
1- 22 gauge IV catheter with an expiration date of 3/2017
1- 20 gauge IV catheter with an expiration date of 3/2016

- Observation in the SCU on 9/19/17 at 8:47am revealed under the sink the following expired medication:
1- 1000ml container of sterile water with an expiration date of 5/2013

- Observation in the SCU on 9/19/17 at 8:47am revealed above the sink in the locked cabinet the following expired supplies and medications:
1- Normal Saline (a salt solution) 250 ml with an expiration date of 8/2015
1- Set of sterile gloves size 7 ½ with an expiration date of 8/2016
1- Lidocaine 1% 10 ml (used to numb the skin, treat pain, and for heart irregularities) with an expiration date of 4/2016
2- Heparin flush 5ml syringe (an anti-clotting medication) with an expiration date of 11/2014 and 3/3 6/2015

Administrative Staff KK, RN interviewed on 9/19/17 at 8:50am confirmed and verified expired supplies and medications while in the SCU.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure patient care equipment is maintained in safe operating condition for 1 of 1 backflow drains in the facility kitchen, 1 of 1 decontamination room, and 2 of 2 negative air pressure rooms. This deficient practice puts all patients at risk for infection, illness and cross contamination of communicable diseases.

Findings include:

Staff E, Maintenance interviewed in the conference room on 9/18/17 at 11:46 AM verified the facility failed to install a backflow drain in the kitchen sink to prevent food backing up from the drain into the sink.

The CAH failed to develop and implement a policy regarding backflow drains.

- Observation in the lab bathroom on 9/18/17 at 12:38 PM revealed a yellow decontamination shower head attached to the ceiling. The lab bathroom was located inside the lab and off of the lab blood draw station. The floor in the lab bathroom failed to have a drain for water.

Staff E, Maintenance interviewed in the lab bathroom on 9/18/17 at 12:40 PM verified the decontamination shower head located in the lab, off of the lab blood draw station was there for both staff and patient use if needed. Staff E verified the flooring failed to have a drain for water and further explained if the shower was used the water would flood the lab floor and equipment and go out into the lab drawing room and into the CAH hallway. Staff E explained staff or patients who would use the decontamination room would walk through the facility, and through the lab blood drawing area to get to the decontamination shower area.

- The CAH's document titled "Hazardous Chemical Protocol" directed, ...decontaminate yourself being careful not to contaminate clean areas or other staff in the process...

- Observation of patient rooms 131 and 133 on 9/18/17 at 12:53 PM revealed the negative air pressure installed for both rooms failed to provide negative air pressure when tested.

Staff E, Maintenance interviewed at rooms 131 and 133 on 9/18/17 at 12:53 PM verified the negative air pressure failed to provide negative air pressure upon testing.

The CAH failed to develop and implement a policy regarding negative air pressure rooms.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure temperature, humidity and air exchanges were within safe limits for the facility's operating room, central sterilizing room and procedure rooms (procedure rooms A, B and C). This deficient practice has the potential to expose surgical and procedural patients to airborne microbes and potential infections.

Findings include:

- Document containing humidity and temperature readings for the Operating Room reviewed on 9/19/2017 showed in a three month lookback, humidity was out of compliance 54.4% of the days, and not recorded 3.8% of the days. Temperature log for the same look-back period revealed temperatures in the operating room were non-compliant for 20.3% of the days, and not recorded for 3.8% of the days.

Operating Room Staff DD interviewed on 9/18/2017 communicated that the temperature and humidity is "almost always out of range" and comments that "they [management] know that and usually maintenance lowers the temperature to decrease the humidity. Staff DD interviewed on 9/19/2017 at 2:40 PM communicated that only the operating room temperature and humidity is monitored because the central sterilizing and procedure rooms are on the same air-handler. Staff DD was unsure if the individual rooms would have variations in temperature or humidity.

Maintenance Staff E interviewed on 9/19/2017 at 4:21 PM stated "the only thing I can do is drop the temperature to lower the humidity."

On 9/21/2017, the facility failed to provide air exchange monitoring results for the operating room, central sterilizing or the procedure rooms (A, B and C).

- Document titled, "Environment of Care" from the Guidelines for Perioperative Practice by the AORN (Association of periOperative Registered Nurses) reviewed on 9/19/2017 directed the functional area of the operating room should be maintained at 20%-60% humidity, 68-75 degrees Fahrenheit and should have a minimum outdoor air changes of 4 per hour, and a minimum total air changes of 20 per hour. Sterile storage should be maintained at a maximum of 60% humidity, temperatures of a maximum of 75 degrees Fahrenheit, and a minimum outdoor air changes of 2 per hour, and a minimum total 4 air changes an hour. Procedure rooms should maintain humidity between 20%-40%, temperatures between 70-75 degrees Fahrenheit and a minimum outdoor air changes of 3 per hour and a total minimum of 15 air changes per hour.

Based on staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure a plan to address emergency water needs in the event of an emergency/disaster. This deficient practice puts all staff, and patients at risk for water availability in regards to staff, patient, and facility usage to meet the standards for safe effective care of the patient.

Findings include:

Staff E, Maintenance interviewed in the basement storage on 9/18/19 at 12:53 PM explained the facility failed to maintain a supply of back up water needed in case of an emergency/disaster.

Staff F, Administration interviewed in his/her office on 9/18/17 at 2:52 PM verified the facility failed to maintain a supply of back up water needed in the case of an emergency/disaster.

The CAH failed to develop and implement a policy regarding emergency water in the case of an emergency/disaster.

- The Center for Disease Control (CDC) article titled "Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities", In order to maintain daily operations and patient care services, health care facilities need to develop an Emergency Water Supply Plan (EWSP) to prepare for, respond to, and recover from a total or partial interruption of the facilities ' normal water supply.

Based on staff interview the Critical Access Hospital (CAH) failed to assure the physicians participate in the development, and implementation of the CAH's policies that direct the services it provides. This deficient practice could potentially lead to staff providing care to the patients in an unsafe and ineffective manner.

Findings include:

- Administrative Staff B interviewed on 9/18/17 at 10:50am verified the physicians do not participate in the development and implementation of the CAH's policies.

Based on staff interview the Critical Access Hospital (CAH) failed to assure the physician assistant or nurse practitioner participate in the development, and implementation of the CAH's policies that direct the services it provides. This deficient practice could potentially lead staff to provide care for the patients in an unsafe and ineffective manner.

Findings include:

- Administrative Staff B interviewed on 9/18/17 at 10:50am verified the physician assistant or nurse practitioner do not participate in the development and implementation of the CAH's policies.

Based on staff interview the Critical Access Hospital (CAH) failed to assure they develop policies with the advice of the CAH's professional staff including one or more physicians and one or more physician assistants or nurse practitioners. This deficient practice can affect the care provided to all patients who present to the CAH for services.

Findings include:

- Administrative Staff B interviewed on 9/18/17 at 10:50am explained the CAH does not have a group of professionals that include a physician, physician assistant and or nurse practitioner that help develop the CAH's policies.

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to ensure that outdated, mislabeled or otherwise unusable drugs are not available for patient use in 1 of 1 Anesthesia Carts. This deficient practice may cause patients to receive ineffective medications or supplies, which has the potential to cause harm to all patients.

Findings include:

- Anesthesia Cart observation on 9/18/2017 at 1:57 PM revealed one multi-use vial of Kenalog (injectable steroid) opened, with out an opened-on date.

- Operating Room Director, Staff DD interviewed on 9/18/2017 at 1:57 PM acknowledged the undated vial and communicated that the normal practice is for staff to write a date on the vial.

- On 9/18/2017, the CAH failed to provide a policy regarding the use multi-dose vials.

- According to the American Society of Health-Systems Pharmacists (ASHSP), " ...Unless otherwise specified by the manufacturer, the maximum beyond use date for multiple-use vials after initial entry is 28 days ..."

Based on staff interview the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for adverse drug reactions (ADRs). This deficient practice puts patients at risk for possible harm from a medication and lack of direction for the staff if an adverse drug reaction occurs.

Findings include:


- Pharmacy Staff Y, interviewed on 9/20/17 at 9:00am acknowledged there is no policy or procedure to direct staff if an adverse drug reaction occurs.

Based on observation, policy review, manufacturer's guidelines, and staff interview the Critical Access Hospital (CAH) failed to develop an active and comprehensive infection control system which identified and investigated staff practices for one of one observed emergency department, one of one special care unit, one of one soiled instrument department, one of one computerized Tomography room, one of one observation of cleaning of an endoscope, one of one anesthesia cart, one of one dietary dry storage room, two of two observed uses of blood sugar testing device (glucometer) (Staff T), six of six observed lack of hand hygiene performed (Staff CC, Staff AA, Staff BB, Staff II, ). The failure of the CAH to develop an active and comprehensive infection control system to assure infection control practices are followed has the potential to affect all patients in the CAH.

Findings include:


- Observation in the emergency department area on 9/18/17 at 11:35am revealed a fluid warming cabinet with a temperature of 106 degrees. The following fluids in it that lacked a date when staff placed the fluids in the warmer: one-1000cc (centimeter) container of 0.9% sodium chloride (a salt solution) and four-1000cc of 0.9% intravenous fluids.

Administrative Staff Z, Registered Nurse (RN) acknowledged the CAH lacked a policy regarding the placement of fluids in the warmer.

- The manufacturer's guidelines for the use of warming fluids directed, ...fluids for injection ...may be warmed at a temperature not to exceed 40 degrees Celsius (104 degrees Fahrenheit) and for a period no longer than two weeks (14days) ...solutions for irrigation may be warmed up to 40 degrees Celsius (104 degrees Fahrenheit) and for a period no longer than two weeks (14 days)...

- Observation in the emergency department area on 9/18/17 at 12:20pm revealed aYankauer suction tube (used to remove mucus from the mouth) open and attached to the tubing on the suction machine.

Administrative Staff Z, RN (Registered Nurse) interviewed on 9/18/17 at 1:00pm acknowledged the Yankauer suction tube open there by making it unusable.

- Observation in the Special Care Unit on 9/19/17 at 8:20am revealed a Yankauer suction tube (used to remove mucus from the mouth) open and attached to the tubing on the suction machine.

Administrative Staff KK, RN interviewed on 9/19/17 at 8:20am acknowledged the Yankauer suction tube opened making it unusable.

- The manufacturer's label on the package that contained the Yankauer suction tube reviewed on 9/19/17 noted ...this item is sterile...do not use if package is open or damaged.

- Staff CC, RN observed on 9/19/17 at 8:50am revealed staff CC entered patient room 137 with medications for the patient. Staff CC failed to perform hand hygiene when entering the patient's room.

- Staff CC, RN observed on 9/19/17 at 10:10am revealed staff CC failed to perform hand hygiene before mixing medications for intravenous (IV) use.

- The Critical Access Hospital's (CAH) policy titled "Infection Control- Hand Hygiene" reviewed on 9/20/17 directed " ...if hands are not visibly soiled, use alcohol-based hand rub for decontaminating hand ...before direct contact with a patient's intact skin ...after skin or mucous membrane contact ..."

- Staff AA and BB, housekeepers observed on 9/19/17 at 11:50am cleaning a discharged patient room (134). Staff AA failed to perform hand hygiene after removing their gloves and before applying clean gloves one time. Staff BB failed to perform hand hygiene after removing their gloves and before applying clean gloves two times.

Staff AA and Staff BB interviewed on 9/19/17 at 11:50am acknowledged they failed to perform hand hygiene when removing their gloves and applying clean gloves.

Staff BB using "Crew" disinfectant toilet bowl cleaner, squirted some in the toilet, swished it around inside the toilet bowl with a toilet bowl brush, flushed the toilet and squirted some more crew in the toilet bowl. Staff BB explained after they flush the toilet they put more "Crew" in the toilet swish it and let it sit for a while than flush the toilet.

- The CAH's policy titled "Environmental Services Procedure Manual TOILETS AND URINALS" reviewed on 9/20/17 directed ...use the bowl swab to push water from bowl into the drain...pour the solution from the pail into the toilet or urinal...use the bowl swab to clean the inside of the bowl..."

- The manufacturer's guidelines for the Crew disinfectant toilet bowl cleaner reviewed on 9/20/17 directed " ...remove water from bowl by forcing over trap with applicator ...pour 1 ounce of product on applicator ...clean entire unit ...wait one minute then flush ..."

- Observation of staff T performing blood sugar test on patient #7 on 9/19/17 at 10:55am revealed staff T retrieved a container from the nurses station that contained the following: glucometer (a machine use to measure the blood sugar), lancets (needles to perform the finger stick), a bottle of strips (used in the glucometer machine to place the drop of blood on), cotton balls, and alcohol wipes. Staff T entered patient #7's room placed the container on the bed side table, removed the glucometer from the container and placed it on the bed side table, performed the blood sugar test, placed the glucometer back in the container, picked up the container and exited the patient's room. Staff T then entered patient #8's room with the container used to perform blood sugar checks, placed the container on the bedside table, removed the glucometer and placed it on the bedside table, performed the blood sugar test, placed the glucometer back in the container, picked up the container and placed the container on the counter at the nurses station. Staff T failed to disinfect the container and glucometer between patient's use and before placing it back at the nurse's station.

Administrative Staff A, RN interviewed on 9/19/17 at 11:30am explained the staffs usually take the glucometer, strips, and cotton balls to the patient's room to perform blood sugar tests not the container. Staff A explained the staffs are to disinfect the glucometer between patient use and before putting back in the container.

Administrative Staff A, RN interviewed on 9/19/17 at 1:00pm explained they have a policy for the use of the glucometer and disinfecting it in surgery, but do not have a hospital wide policy.

- Observation in the Obstetric department on 9/18/17 at 4:00pm revealed in room 196 a reclining chair with a one inch triangle shaped tear in the vinyl of the footrest and a similar area on the left armrest exposing the foam, thus failing to provide a cleanable surface to prevent cross contamination.

Administrative Staff LL interviewed on 9/18/17 at 4:00pm acknowledged the tears in the chair and confirmed they were not a cleanable surface.

- Observation in the Special Care Unit (SCU) on 9/19/17 at 8:20am revealed a three drawer cabinet attached to the wall by a patient's bed with a two and a half inch piece of trim torn off that exposed the wood and left a sharp edge on the bottom drawer, failing to make it a cleanable surface.

- Observation on the Medical/Surgical unit on 9/19/17 at 9:00am revealed in patient room 103 a counter with a five inch by two inch piece of trim tore off exposing the wood and the bottom drawer below the counter had three areas of paint chipped off exposing the wood. Room 104 revealed a counter with a two inch by three inch piece of trim tore off exposing the wood. The trim torn off in room 103 and 104 failed to make the areas on the counter a cleanable surface.

Administrative Staff LL, RN interviewed on 9/19/17 at 9:00am acknowledged the cabinet in SCU and the counters in room 103 and 104 failed to be a cleanable surface.

- Trauma Bay observation on 9/18/2017 at 12:25 PM revealed two Yankauer suction tubes (used to suction the mouth) open and attached to the suction containers.

- Yankauer suction tube label review on 9/18/2017 at 12:27 PM notes this item is sterile, and directed ...do not use if package is open or damaged.

Emergency Room (ER) Manager, Staff Z acknowledged the items were open and removed them.

- Anesthesia Cart from the OR observation on 9/18/2017 at 2:04 PM revealed a Yankauer suction tube opened and attached to suction.

OR Director, Staff DD interviewed on 9/18/2017 acknowledged the open Yankauer suction tube and stated, "Ok, good to know."

On 9/21/2017, the CAH failed to provide a policy for opened, sterile supplies.

- Terminal Cleaning of the Operating Room (OR) observation on 9/18/2017 at 1:57 PM revealed an unsecured sharps container, falling and nearly dumping its contents onto the surgical technologist.

OR Director, Staff DD interviewed on 9/18/2017 at 1:57 PM acknowledged the unsecured sharps container and stated, "That needs secured."

On 9/21/2017, the CAH failed to provide a policy on the securing of sharps containers.

Dietary Dry Storage area observation on 9/19/2017 at 9:38 AM revealed the following expired spices:
1. One container of lemon pepper with a date received at the facility of 7/19/2011
2. One container of mild chili powder with a date received at the facility of 7/25/2016
3. One container of cayenne pepper with a date received at the facility of 10/12/2014
4. One container of onion powder with an opened on date of 3/30/2016
5. One container of ground mustard with a date received at the facility of 10/2/2014
6. One container of paprika with a date received at the facility of 12/23/2015
7. One container of parsley with an opened on date of 9/2001
8. One container of dill weed with a date received at the facility of 10/2015

Dietary Manager, Staff HH interviewed on 9/19/2017 acknowledged the items were expired and threw all of the containers away.

- Document titled, "Spices, Herbs, Condiments, Extracts" reviewed on 9/19/2017, ground spices and herbs can be stored up to 6 months.


- OR Dirty Instrument Room observation on 9/18/2017 at 3:00 PM revealed the following clean supplies being stored on open shelving above a hopper (a flushable basin that can splash and cause contamination of items in the area) that lacked a splash guard:
1. 14 bottles of Betadine scrub (surgical skin cleanser)
2. 24 bottles of sterile water
3. 16 bottles of sodium chloride (saline solution).

- OR Director. Staff DD interviewed on 9/18/2017 acknowledged the clean items in the dirty room, promptly cleaned, and removed the items.

On 9/21/2017, the CAH failed to provide a policy on the storage of clean supplies.

- Preoperative room observation on 9/19/2017 at 12:01 revealed a wooden rocking chair with the finish worn off of the arm rests.

Infection Control Staff F interviewed on 9/19/2017 at 3:50 PM acknowledged the finish had worn off.

- CT (three-dimensional x-ray) Room observation on 9/20/2017 at 11:20 AM revealed one blue x-ray shield (used to protect patients and staff from radiation) with multiple cracks in the covering, revealing the interior of the shield.

- Radiology Director, Staff FF interviewed on 9/20/2017 at 11:20 AM acknowledged the cracks and shares they will discard of the shield.

- On 9/21/2017 the CAH failed to provide a policy regarding un-cleanable surfaces.


- Procedure Observation on 9/19/2017 at 12:49 PM revealed Medical Staff II coughing into gloved hand and touching their face and nose, failing to perform hand hygiene and change gloves.

OR Director, Staff DD interviewed on 9/19/2017 at 1:15 PM shared the physician has been ill with a sinus infection and was on antibiotics.

- The Critical Access Hospital's (CAH) policy titled "Infection Control- Hand Hygiene" reviewed on 9/20/17 directed ...if hands are not visibly soiled, use alcohol-based hand rub for decontaminating hand ...before direct contact with a patient's intact skin ...after skin or mucous membrane contact ...

- Endoscope cleaning observation on 9/19/2017 at 1:20 PM revealed Scope Cleaning Staff JJ failing to don protective goggles.

Scope Cleaning Staff JJ interviewed on 9/19/2017 at 1:20 PM stated, "I don't normally wear the goggles."

- Policy titled, "High-Level Disinfection of the Endoscopes" review on 9/19/2017 directed, ...protective gear, i.e., gown, gloves, mask and goggles will be worn by the staff member cleaning and disinfecting the endoscopes...

- Endoscope cleaning observation on 9/19/2017 at 1:20 PM revealed Scope Cleaning staff JJ filling the sink with tap water enough to cover the scope, and places 4 squirts of cleaner called Intercept into the water, failing to measure the water or the disinfectant.

Scope Cleaning Staff JJ interviewed on 9/19/2017 at 1:20 PM communicated they only filled the sink to cover the scope. Staff JJ communicated they do not measure the disinfectant.

- Intercept Cleaner Label review on 9/19/2017 directed, ...for cleaning immersible endoscopes ... use INTERCEPT at 1/3 oz/gal. of water (0.25% use concentration) with one full stroke of the hand-pump to three gallons of water...

- Scope Cleaning Staff JJ interviewed during endoscope cleaning demonstration on 9/19/2017 at 2:30 PM revealed final drying procedures of flushing with 70% alcohol is not done until after the last case of the day, potentially leaving the interior of the scope wet for long periods of time.

OR Director, Staff DD interviewed on 9/19/2017 at 2:30 shared they do not need to perform the alcohol step of drying because there is not enough time between cases to use the alcohol flush. Staff DD shared a recent in-service was given by the scope company who said the alcohol flush was not necessary between cases. The facility failed to provide documentation of this education.

- Document titled, "Quick Steps for Scope Cleaning" review on 9/19/2017 directed, 22. Flush scope with 90 ml of alcohol using a syringe...

- Document titled, "Olympus Rinsing the Endoscope and Accessories Following Disinfection" review on 9/19/2017 directed, ...Some national or professional guidelines recommend using sterile water for rinsing endoscopes. If sterile water is not available, these guidelines recommend using potable tap water and flushing endoscope channels with alcohol...

CT (three-dimensional x-ray) Room observation on 9/20/2017 at 11:20 AM revealed two bottles of Omnipaque IV contrast (injected to highlight areas of the body during a CT scan) and a saline flush (used to flush an IV line) in a fluid warmer, failing to have the date it was placed in the warmer.

- Radiology Director, Staff FF interviewed on 9/20/2017 at 11:20 AM acknowledged that there were no dates on the warmed contrast dye or the saline flush.

- Document titled, "Dosage and Administration" reviewed on 9/20/2017 directed, ...Omnipaque injection in all presentations may be stored in a contrast media warmer for up to one month at 98.6 degrees Fahrenheit...

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to ensure the medical record contained evidence the patient received an informed consent for treatment signed by the patient or the patients representative for two of five swing bed medical records reviewed (#11 and #12) The CAH's medical records lack necessary information for healthcare staff involved in the care of the patient to have access to information necessary to provide authorized care in a safe effective manner.

Findings include:


- Patient #11's closed swing bed medical record revealed an admission date of 3/2/17 with a diagnosis of cellulitis (a skin infection) and a discharge date of 3/13/17. The medical record lacked a consent for treatment signed by the patient or patient's representative when admitted to swing bed. The swing bed medical record contained a consent to treat the patient signed when admitted to the acute care unit.

- Patient #12's closed swing bed medical record revealed an admission date of 6/4/17 with a diagnosis of pneumonia and a discharge date of 6/9/17. The medical record lacked a consent, for treatment signed by the patient or patient's representative when admitted to swing bed. The swing bed medical record contained a consent for treatment the patient signed when admitted to the acute care unit.

Administrative Staff X, RN interviewed on 9/19/17 at 2:00pm acknowledged patient #11's and patient #12's medical record lacked a consent for treatment. Staff X explained the staff on the acute unit make copies of the patient's acute stay and attach it to the swing bed medical record and verified the consents for treatment on patient #11's and #12's medical record were the ones from the acute stay.

Based on observation, staff interview, and document review the Critical Access Hospital (CAH) failed to ensure precautions are taken to prevent physical damage of patient records in the basement storage area as evidence by 15 boxes of patient records stored on the floor. This deficient practice puts all patients at risk for physical damage to their health information due to flood or pests.

Findings include:

- Observation in the basement storage room on 9/18/17 at 12:08 PM revealed 14 boxes of patient medical records, and 1 box of deceased patient records stacked on the floor waiting for the shredding company to pick them up to be destroyed.

Staff E, Maintenance interviewed in the basement storage room on 9/81/17 at 12:08 PM verified the 14 boxes of patient medical records, and 1 box of deceased patient records stacked on the floor waiting for the shredding company to pick them up to be destroyed.

The CAH's policy titled "Retention and Destruction of Health Information Records" directed ...records will be maintained in the Health Information Department as long as storage space permits. Records will then be transferred to the basement where they are kept in a locked enclosure. Every effort will be made to destroy records on a yearly basis, if possible...

Based on lack of documentation for review and staff interview the Critical Access Hospital (CAH) failed to conduct or arrange for a periodic evaluation of their total program at least once a year (Refer to tag C-0331), failed to conduct reviews of a sample of active and closed medical records (Refer to tag C-0333), failed to ensure the CAH reviews health care policies as part of the annual evaluation (Refer to tag C-0334), failed to ensure the evaluation determined the utilization of services was appropriate, the CAH followed policies and made any changes needed (Refer to tag C-0335), failed to ensure an effective quality assurance program that includes an ongoing monitoring and data collection, problem prevention that includes identifying the problem, data collection and analysis, measures to improve, and quality on a continuous basis (Refer to tag C-0336), failed to ensure the evaluation of patient care services and other services affecting health and safety of the patients (Refer to tag C-0337), failed to ensure the evaluation of the quality and appropriateness of the diagnoses an treatment provided by the physicians (Refer to tag C-0340), failed to ensure a Quality Improvement Officer (QIO) evaluates the quality and appropriateness of the diagnoses an treatment provided by the physicians, and the CAH takes corrective action if necessary (Refer to tag C-0341), and failed to ensure an effective quality assurance program was in place to address deficiencies and actions taken (Refer to tag C-0342).


The cumulative effect of the CAH's failure to develop, implement and monitor a systematic quality assurance/quality improvement program to continually evaluate and monitor patient care services puts all patients of the CAH at risk for ineffective and unsafe care.

Findings include:

The CAH failed to provide documentation of an annual program evaluation or quality assurance program.

Administrative Staff B, interviewed on 9/18/17 at 10:50am confirmed the CAH failed to conduct an evaluation of their total program.

Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am acknowledged the CAH has not reviewed policies annually. Staff C explained they just started a committee to review policy but did not include an Advanced Nurse Practitioner or Physician Assistant on the committee. Staff C explained the physician is invited but has not come to the meeting. Staff C explained none of the departments are doing monitoring for quality improvement purposes.

Based on lack of documentation for review and staff interview the Critical Access Hospital (CAH) failed to conduct or arrange for a periodic evaluation of their total program at least once a year.

Findings include:

- The CAH failed to provide evidence of an annual program evaluation.

Administrative Staff B, interviewed on 9/18/17 at 10:50am confirmed the CAH failed to conduct an evaluation of their total program.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to conduct reviews of a sample of active and closed medical records.

Findings include:

- The CAH failed to provide evidence of an annual program evaluation.

Administrative Staff B, interviewed on 9/21/17 at 1:30pm acknowledged the CAH failed to conduct reviews of active and closed medical records.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure the CAH reviews health care policies as part of the annual evaluation.

Findings include:

Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am acknowledged the CAH has not reviewed policies annually. Staff C explained they just started a committee to review policy but did not include an Advanced Nurse Practitioner or Physician Assistant on the committee. Staff C explained the physician is invited but has not come to the meeting.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure the evaluation determined the utilization of services was appropriate, the CAH followed policies and any changes needed.

Findings include:

- The CAH failed to provide evidence of an annual program evaluation.

Administrative Staff B, interviewed on 9/18/17 at 10:50am confirmed the CAH failed to conduct an evaluation of their total program to determine if utilization of its services met the community needs.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure an effective quality assurance program that includes an ongoing monitoring and data collection, problem prevention that includes identifying the problem, data collection and analysis, measures to improve, and quality on a continuous basis.

Findings include:

Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am explained none of the departments are doing monitoring for quality improvement purposes. Staff C explained the departments monitor some daily tasks.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure the evaluation of patient care services and other services affecting health and safety of the patients.

Findings include:

Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am explained none of the departments are doing monitoring for quality improvement purposes. Staff C explained the departments monitor some daily tasks.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure the evaluation of the quality and appropriateness of the diagnoses an treatment provided by the physicians.

Findings include:

Administrative Staff B, interviewed on 9/20/17 at 1:30pm confirmed the CAH does not have in place a system for peer review and quality.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure a Quality Improvement Officer (QIO) evaluates the quality and appropriateness of the diagnoses an treatment provided by the physicians, and the CAH takes corrective action if necessary.

Findings include:

Administrative Staff B, interviewed on 9/20/17 at 1:30pm confirmed the CAH does not have a system in place for assessing the quality and appropriateness of physician care and treatment.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure an effective quality assurance (QA) program was in place to address deficiencies and actions taken.

Findings include:


Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am explained they do not have an effective QA program. Currently the departments are monitoring task on a daily basis.

Based on lack of documents for review and staff interview the Critical Access Hospital (CAH) failed to ensure an effective quality assurance (QA) program was in place to address deficiencies and actions taken and documentation of outcomes of all actions taken.

Findings include:


Administrative Staff C, Quality/Risk Manager interviewed on 9/20/17 at 9:50am explained that the CAH does not have an effective QA program to document the deficiencies and the actions taken to correct the deficiencies.

Based on medical record review, swing bed patient rights reviewed, and staff interview the Critical Access Hospital (CAH) failed to ensure the patient's and/or responsible patient representative received their patient rights both verbally and in writing for two of five swing bed patient's medical record reviewed (#12 and #13). Failure to provide verbal and written rights to all patients prevents all patients from the knowledge necessary to act on those rights.

Findings include:

- Patient #12's closed swing bed medical record revealed an admission date of 6/4/17 with a diagnosis of pneumonia and a discharge date of 6/9/17. Review of the medical record revealed the patient and/or responsible patient representative did not receive the patient rights verbally or in writing when admitted to swing bed.

- Patient #13's closed swing bed medical record revealed an admission date of 7/28/17 with diagnoses of chest pain and elevated blood pressure with a discharge date of 8/3/17. Review of the medical record revealed the patient and /or responsible patient representative did not receive the patient rights verbally or in writing when admitted to swing bed.


Administrative Staff X, RN interviewed on 9/19/17 at 2:00pm acknowledged patient #12's and #13's swing bed medical record lacked evidence the patients received their patient rights.

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to provide activities for four of five (#9, #10, #11, and #12) sampled swing bed records reviewed. This deficient practice fails to meet the interests and psychosocial needs of the patient.

Findings include:

- Patient #9's open swing bed medical record revealed an admission date of 9/12/17 with a diagnosis of pneumonia and dismissed during the survey process on 9/19/17. The medical record lacked evidence the patient received activities.

- Patient #10's open swing bed medical record revealed an admission date of 9/16/17 with diagnoses that include, congestive heart failure (CHF) (inability for the heart to pump efficiently) and chronic obstructive pulmonary disease (COPD (a chronic lung disease that makes it difficult to breath). The medical record lacked evidence the patient received activities.

- Patient #11's closed swing bed medical record revealed an admission date of 3/2/17 with a diagnosis of cellulitis (a skin infection) and a discharge date of 3/13/17. The medical record lacked evidence the patient received activities.

- Patient #12's closed swing bed medical record revealed an admission date of 6/4/17 with a diagnosis of pneumonia and a discharge date of 6/9/17. The medical record lacked evidence the patient received activities.


Staff X, Registered Nurse (RN), Swing Bed coordinator interviewed on 9/19/2017 at 11:45am indicated the CAH has no organized activities scheduled or implemented for swing bed patients.