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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Sample Validation Survey conducted on January 3 & 4, 2010, the surveyor finds 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.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Sample Validation Survey conducted on January 3 & 4, 2010, the surveyor finds 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 1/4/2011.

A. Based on a request for documents, a review of the Illinois Administrative Code 250, Hospital Licensing Requirements and staff interview, it was determined that the CAH failed to ensure that the dietary manager developed policies and procedures to ensure that nutritional practices were met to ensure safe patient dietary practices were being followed.

Findings include:


1. During a tour of the dietary department on 01/05/11 at 11:00 AM when asked for dietary policies, the Dietary Supervisor reported that there are no specific policies for the dietary department but the guidelines for the Food Service Sanitation Code (Illinois Department of Public Health) are followed.

2. The Illinois Administrative Code 250 Hospital Licensing Requirements, section 250.1610 Dietary Department Administration under b) Staffing: Dietetic Service Director, "The dietetic department shall be directed by..., whose responsibilities shall include, but are not limited to, the following: 1) developing written policies and procedures to include..."

3. During an interview with the Chief Nursing Officer on 01/05/11 at 4:00 PM, the above findings were confirmed.


B. Based on observation, a review of the Illinois Administrative Code 750, Food Service Sanitation Code, and staff interview, it was determined that the dietary staff failed to follow guidelines to ensure that foods are held and served at the appropriate temperature.

Findings include:

1. During a tour of the Dietary Department on 01/05/11 at 11:00 AM the Dietary Supervisor was asked for information pertaining to the times that food temperatures are checked during holding and serving hours. It was reported by the Dietary Supervisor that random food temperatures are checked but this information is not documented.

2. The Illinois Administrative Code 750, Food Service Sanitation Code 750.150 Hot Storage, a) "Enough conveniently located hot food storage facilities shall be provided to assure the maintenance of food at the required temperature during storage. Where it is impractical to install thermometers... a product thermometer must be available and used to check internal temperature." Section 750.250 Food Display and Service of Potentially Hazardous Food, "... foods shall be held during display and service at an internal temperature of 41 degrees or below, unless the foods are dated and refrigerated... or held during display and served at an internal temperature of 140 degrees or above..."

3. During an interview with the Chief Nursing Officer on 01/05/11 at 4:00 PM, the above findings were confirmed.

C. Based on observation, a review of the Illinois Administrative Code 750, Food Service Sanitation Code and staff interview, it was determined that the dietary staff failed to label foods in a manner to ensure safe consumption.

Findings include:

1. During a tour of the dietary department on 01/05/11 at 11:00 AM, it was observed that the following items were not labeled with a final date of use or expiration:

Opened bag of shredded cheese
Chicken Strips transferred from larger bag
Sliced lunchmeats wrapped in foil
1 package of unidentified meat wrapped in foil
2 trays of Jello
Opened plastic container of applesauce

2. A review of the Illinois Administrative Code 750, Food Service Sanitation Code indicates under 750.2032, " Labeling- Use By Dates, Each package of refrigerated retail processed food in a reduced oxygen atmosphere shall bear a "use by" date."

3. During an interview with the Chief Nursing Officer on 01/06/11 at 12:30 PM, the above findings were confirmed.






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A. Based on a review of the CAH Medical Staff Bylaws, medical record review and staff interview, it was determined that in 11 of 20 (Pt #'s 5, 7, 8, 9, 10, 11, 12, 14, 17, 18, 19) medical records reviewed, the CAH failed to ensure that all physician's orders were complete and accurate as indicated per CAH policy.

Findings include:

1. The Medical Staff Bylaws were reviewed on 01/03/11. Documentation indicated under, D. General Conduct of Care, 4. "A verbal order shall be considered in writing... The responsible practitioner shall authenticate all orders with signature and date within one day."

2. The medical record of Pt. #5 was reviewed on 01/01/11. Documentation indicated Pt. #5 was admitted to the CAH on 07/10/10 with the diagnoses of Dehydration and Pharyngitis. Three verbal orders, dated 07/10/10 were signed, dated and timed by the physician on 10/14/10, over 90 days late.

3. The medical record for Pt #7 was reviewed on 01/04/11. Documentation indicated Pt #7 was admitted to the CAH on 12/13/10 with the diagnoses of Metastatic Carcinoma Brain & Cortical Dementia. Two verbal physician's orders, dated 12/14/10, were signed, dated and timed by the physician on 12/24/10, 9 days late.

4. The medical record for Pt #8 was reviewed on 01/04/11. Documentation indicated that Pt #8 was admitted to the CAH on 11/02/10 with the diagnoses of Cellulitis of Lower Leg, Diabetes and Hypertension. A verbal physician's order, dated 11/03/10, was signed, dated and timed by the physician on 11/15/10, 11 days late.

5. The medical record for Pt #9 was reviewed on 01/04/11. Documentation indicated that Pt #9 was admitted to the CAH on 10/09/10 with the diagnoses of Pneumonia, Anemia, Ulcer to Heel and Acute Renal Failure. A verbal physician's order, dated 10/09/10, was signed, dated and timed by the physician on 11/06/10, 27 days late.

6. The medical record of Pt. #10 was reviewed on 01/04/11. Documentation indicated that Pt. #10 was admitted to the CAH on 10/14/10 with diagnoses of Diabetes Mellitus II, uncontrolled and Dehydration. Nine verbal orders dated 10/14/10 were signed, dated and timed by the physician on 10/26/10, 11 days late. Three verbal orders dated 10/14/10 were signed, dated and timed on 11/19/10, over 30 days late. Three verbal orders dated 10/17/10, were signed, dated and timed on 11/11/10, 24 days late.

7. The medical record for Pt #11 was reviewed on 01/05/11. Documentation indicated that Pt #11 was admitted to the CAH on 07/28/10 with the diagnoses of Acute Pancreatitis, Anemia, Acute Respiratory Failure, Mental Disorder and Impaction of Intestine. Pt #11 expired on 08/01/10. Two verbal physician's orders, dated 07/28/10 and two dated 08/01/10, were signed, dated and timed by the physician on 08/30/10, and verbal physician's orders, dated 07/29/10, 07/30/10 and 07/31/10, were signed, dated and timed on 12/31/10. Also, the Death Summary was dictated on 12/02/10, making it more than 30 days late, and was not signed by the physician, as of this survey date.

8. The medical record for Pt #12 was reviewed on 01/05/11. Documentation indicated that Pt #12 was admitted to the CAH on 10/05/10 with the diagnoses of Acute Bronchitis and Parkinson's Disease. A verbal physician's order, dated 10/05/10, was signed, dated and timed by the physician on 10/14/10, 8 days late.

9. The medical record of Pt. #14 was reviewed on 01/05/11. Documentation indicated that Pt. #14 was admitted to the CAH on 08/17/10 with a diagnosis of Left Inguinal Hernia. Documentation indicated there were 2 verbal orders written on 08/19/10 that were signed, dated and timed on 12/31/10 and 1 verbal order written on 08/19/10 that was signed, dated and timed on 11/05/10, all over 3 months late.

10. The medical record for Pt #17 was reviewed on 01/05/11. Documentation indicated that Pt #17 was admitted to the CAH on 10/12/10 with a diagnosis of B12 Deficiency Anemia. A verbal physician's order, dated 10/12/10, was not signed, dated or timed, as of this survey date. A verbal physician's orders, dated 10/15/10, was signed, dated and timed on 12/31/10. Six verbal physician's orders, dated 10/17/10, were signed, dated and timed on 11/11/10. Three verbal physician's orders, dated 10/19/10, were signed, dated and timed on 12/31/10.

11. The medical record of Pt. #18 was reviewed on 01/06/11. Documentation indicated that Pt. #18 was admitted to the CAH on 08/05/10 with a diagnosis of Gastrointestinal Bleeding. Documentation indicated 2 verbal orders written on 08/06/10 and 2 written on 08/08/10 were signed, dated and timed on 11/19/10, over 3 months late.

12. The medical record of Pt. #19 was reviewed on 01/06/11. Documentation indicated Pt. #19 was admitted to the CAH with a diagnosis of Pneumonia. Documentation indicated 9 verbal orders written on 11/01/10 that were signed, dated and timed on 11/15/10, 13 days late. Eight verbal orders written on 11/02/10 were signed, dated, and timed on 01/04/11, over 2 months late.

13. During a interview conducted on 01/05/11 at 4:00 PM with the Assistant Chief Nurse Officer, the above findings were confirmed.


B. Based on a review of the CAH Medical Staff Bylaws, medical record review and staff interview, it was determined that in 2 of 20 (Pt#'s 15 and 16) medical records reviewed, the CAH failed to ensure medical records were complete and accurate as indicated per CAH policy.

1. The Medical Staff Bylaws were reviewed on 1/3/11. Documentation indicated under Medical Records- Inpatients, 15. The patient's record shall not be permanently filed until it is complete at time of discharge. 16. Delinquent Charts. If the record still remains incomplete 30 days after all essential reports have been received and placed in the record... and 8. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

2. The medical record for Pt #15 was reviewed on 01/05/11. Documentation indicated that Pt #15 was admitted to the CAH on 09/07/10 with a diagnosis of Malignant Neoplasm Liver/Brain. Pt. #15 9/7/10. Documentation indicated that the Death Summary was dictated by the physician on 10/24/10, 17 days late.

3. The medical record for Pt #16 was reviewed on 01/05/11. Documentation indicated that Pt #16 was admitted to the CAH on 12/01/10 with a diagnosis of Anemia. A document titled, "Medication Reconciliation..." was reviewed. There was no physician's signature, date or time, as of this survey date.

4. During a interview conducted on 01/05/11 at 4:00 PM with the Assistant Chief Nurse Officer, the above findings were confirmed