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The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on observation, and staff interview the CAH failed to ensure supplies are current, not outdated and available for emergency patient ' s use for one of one Emergency Pediatric cart observed. This failure has the potential to affect all pediatric patients who present to the Emergency Department (ED) seeking treatment for an emergent medical condition.

Findings include:

- Observation of the Emergency Pediatric cart on 3/21/16 at 10:20am revealed the following:

1. One-red drawer for 8-9 kilogram (kg) pediatric patient containing one Jamshidi needle (a needle used to take a bone marrow biopsy) with an expiration date of 3/10.

2. One-purple drawer for 10-11 kg pediatric patient containing one tracheostomy tube (a tube used to help the patient breath) size 4.0millimeters (mm) with an expiration date of 9/02, one intubation module with an expiration date of 4/05, one interosseous (method to infuse fluids into the bone) module with an expiration date of 8/05, and four electrode patches (used to place on the patient to monitor their heart rate) with an expiration date of 2015.

3. One-white drawer for 15-18 kg pediatric patient containing two tracheostomy tubes size 5.0mm with an expiration date of 9/05, one interosseous module with an expiration date of 8/05, one package of electrode patches with an expiration date of 6/05, and one flexible stylet (a metal like rod used to aide in inserting an endotracheal tube) with an expiration date of 8/05.

4. One-blue drawer for 19-23 kg pediatric patient containing one 4x4 sterile dressing with an expiration date of 10/04, two endotracheal tubes size 5.5mm with an expiration date of 9/05, and one endotracheal tube size 5.5mm with an expiration date of 11/15.

5. One-orange/yellow drawer for 12-14kg patient containing two endotracheal tubes size 6mm, and one flexible stylet with an expiration date of 8/05.

6. One-green drawer for 30-36 kg pediatric patient containing two endotracheal tubes size6.5mm with an expiration date of 5/08, one intravenous catheter size 18 gauge with an expiration date of 2/16, one endotracheal tube size 6.5mm with an expiration date of 6/15, and one flexible stylet with an expiration date of 8/05.

7. One-large bottom drawer in cart containing nine packages with five in each package of monitor electrodes with an expiration date of 10/14, and seven monitor electrodes with an expiration date of 2015.


Staff C, Registered Nurse, (RN) administrative staff interviewed on 3/21/16 at 10:20am explained they are aware of the outdated supplies in the pediatric crash cart and are in the process of restocking them with new supplies.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on observation, documentation, and staff interview the CAH failed to ensure outdated medications and biologicals were not available for patient use in one of Emergency Department (ED) medications cabinet, one of one operating room (OR), one of one OR crash cart, one of one anesthesia room and one of one anesthesia cart.. The failure of the CAH to ensure outdated medications and biologicals were not available for patient use has the potential to affect all patients in the CAH.

Findings include:

- The ED observed on 3/21/16 between 10:20am and 11:15am revealed the following medications with a date when opened.
Two -20ml (millimeter) open vials of Lidocaine (used to numb skin) with a date on them of 1/4/16 (49 days past the expiration date) when opened.

Staff C, Registered Nurse (RN), administrative staff interviewed on 3/21/16 explained that when the staff open the medication vial they must put the date on the vial and discard it after 28 days.

- Observation of the OR on 3/ 21/16 between 11:50am and 12:36pm revealed the following:
1. Two-1000ml bags of Dextrose (5%) in Lactated Ringers (used for intravenous (IV) hydration) with an expiration date of 10/2015.
2. Four-packages of a sterile dressing with an expiration date of 1/15.


-The OR crash cart revealed the following:
1. Five-Povidone swab sticks (used to clean skin) with an expiration date of 12/02.
2. One-endotracheal tube (used to help patients breath if they stop breathing) 7.5mm (millimeters) with an expiration date of 4/15.
3. One-endotracheal tube (used to help patients breath if they stop breathing) size 7.5mm with an expiration date of 2/13.
4. One-endotracheal tube size 7.0mm with an expiration date of 5/13.

- The anesthesia room revealed the following:
1. Two-povidone swab sticks one with an expiration date of 4/15, and one with an expiration date of 1/16.
2. Five-pairs of size 6 1/2 sterile gloves, one with an expiration date of 6/07, and four with an expiration date of 4/06.

- The anesthesia cart revealed the following:
1. One-20ml vial of 1% Lidocaine lacked a date when opened.
2. One-Intravenous catheter (used to place in a vein to give medications) size 18 gauge with an expiration date of 12/05.
3. Three-endotracheal tubes size 5.5mm with an expiration date of 12/02.
4. One-endotracheal tube size 5.5mm with an expiration date of 11/15.
5. One-endotracheal tube size 8.0mm with an expiration date of 8/15.
6. One-endotracheal tube size 4.0mm with an expiration date of 1/13
7. Three-endotracheal tubes size 5.0mm with an expiration date of 1/14
8. Two-250ml bottles of Ultane (used as an inhalation anesthetic) with an expiration date of 3/17/16.
9. One female urinary catheter with an expiration date of 7/12.

- The CAH ' s policy titled, " Disposal of Outdated or Contaminated Drugs " reviewed on 3/24/16 at 3:55pm directed, " ...medications are to be checked monthly for outdates ...all outdates will be separated from the main stock of medication ... "

Staff C, Registered Nurse (RN), administrative staff interviewed on 3/21/16 acknowledged the outdated medications and supplies and explained the staff is to checks for all outdated medications and supplies monthly.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on observation, policy review, manufacturer ' s guidelines, and staff interview the CAH failed to develop an infection control plan, failed to develop an active and comprehensive infection control system which identified and investigated staff practices for one of one blanket warming cabinet observed, one of one exam room (outpatient) observed, two of six medication passes/treatments observed, three of three random observations, and seven of seven patient rooms observed (room # ' s 106, 108, 109, 110, 111, 112 and 113). The failure of the CAH to ensure infection control practices are followed has the potential to affect all patients in the CAH.

Findings Include:

- The CAH ' s job description for the infection control officer reviewed on 3/24/16 at 10:00am directed, " ...job summary: infection control officer implements ad directs a hospital wide infection control program. Responsibilities include (but not limited to ) surveillance, analysis, reporting, and recording activities as well as setting standards and evaluating compliance for practices that are associated with the prevention and control of health care associated infections ... "

- The CAH ' s policy titled " Infection Control Plan " reviewed on 3/24/16 at 10:00am directed " ...It is the policy of the CAH that the infection control committee will establish a formalized Infection Control Plan ...that provides direction for the structure and operation of the infection control program ... "

Staff D, Medical Laboratory Technician, Infection Control Officer, interviewed on 3/24/16 at 10:15am acknowledged the CAH failed to develop an infection control plan.

- The CAH ' s policy titled " Handwashing " reviewed on 3/24/16 at 10:00am directed ... " hospital personnel shall wash their hands, to prevent the spread of infections ...before applying and after removing gloves ...between handling of individual patients ... "

- Staff E, RN, observed on 3/22/16 at 8:35am revealed staff E entered patient #11 ' s room applied gloves, administered dose of insulin to the patient, removed their gloves, applied clean gloves and gave the patient their oral medications. Staff F failed to perform hand hygiene before and after applying gloves.

- Staff E, RN, observed on 3/22/16 at 9:00am revealed staff E entered patient #11 ' s room to perform a dressing change to both ankles that had open wounds. Staff E during the dressing change removed and applied their gloves twice without performing hand hygiene.

- Random observations revealed the following:

1. Observation on 3/21/16 at 10:20am revealed a staff nurse aide entered patient room #11, assisted the patient and left the room. The staff aide failed to perform hand hygiene before entering the patient room and after caring for the patient.

2. Observation on 3/21/16 at 10:30am revealed physical therapy staff entering room 112 with a patient in a wheel chair. The physical therapy staff assisted the patient in the wheel chair to their bed, assisted the other patient in the room to their lounge chair and left the room. The physical therapy staff failed to perform hand hygiene between the handling of individual patients, and when leaving the room.

3. Observation on 3/21/16 and 4:20pm revealed physical therapy staff entering room 111 visited with the patient, documented on a piece of paper and left the patient ' s room. The physical therapy staff failed to perform hand hygiene when entering and leaving the patient ' s room.

- The manufacturer ' s guidelines titled " Sodium Chloride Irrigation-Warming of IV and Irrigation Solutions " reviewed on 3/24/16 at 1:45pm directed " ...plastic pour bottles, with their plastic screw caps intact and unopened, may be warmed up to 40 degrees Celsius (104 degrees (F) Fahrenheit) ...for a period no longer than two weeks (14 days).

- Observation on 3/24/16 at 11:15am of the blanket warmer cabinet in the radiology department revealed three 500cc (centimeters) bulging plastic bottles that contained sodium chloride irrigation fluid. The bottles lacked a date of when the staff put the bottles in the blanket warmer. The temperature of the blanket read 150 degrees F.

- Staff B, RN, Administrative staff verified the bottles lacked a date when put in the warmer and the temperature of the blanket warmer was at 150 degrees F.

- Observation on 3/22/16 between 9:50am to 11:15am of patient room #'s 106, 108, 109, 110, 111, 112, and 113 revealed a yellow vinyl high back chair with a wooden frame and wooden arms in on them. The wooden arms had the finish and varnish worn off exposing the bare wood of the arms of the chairs. The bare wood made the arms of the chairs a non-cleanable surface.

Staff H, maintenance supervisor interviewed on 3/22/16 at 11:15am acknowledged the bare wood on the arms of the chairs and that they were not a cleanable surface.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on medical record review and staff interview the CAH failed to ensure the medical record contained evidence the patient received an informed consent for treatment signed by the patient or the patient's representative for five of thirty two medical records reviewed patient (#'s 21, 23, 27, 28, and 30). 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 patient care.

Findings include:

- Patient #21 ' s closed medical record reviewed on 3/23/16 revealed an admit date of 2/9/16 with diagnoses of a urinary tract infection and sepsis (infection in the blood), with a discharge date of 2/12/16. Review of patient #21 ' s medical record lacked evidence the patient received and signed the informed consent for treatment.

- Patient #23 ' s closed medical record reviewed on 3/23/16 revealed an admit date of 3/3/16 with diagnoses of colitis (an infection in the bowl), with a discharge date of 3/6/16. Review of patient #23 ' s medical record lacked evidence the patient received and signed the informed consent for treatment.

- Patient #27 ' s closed medical record reviewed on 3/23/16 revealed an admit date of 1/18/16 with a diagnosis of pyelonephritis (an infection in the kidneys), with a discharge date of 1/21/16. Review of patient # ' s 27 medical record lacked evidence the patient received and signed the informed consent for treatment.

- Patient #28 ' s closed medical record reviewed on 3/23/16 revealed an admit date of 1/21/16 with diagnoses of nausea/vomiting and abdominal pain, with a discharge date of 1/21/16 (the patient was transferred to a higher level of care acute care hospital). Review of patient #28 ' s medical record lacked evidence the patient received and signed the informed consent for treatment.

- Patient #30 ' s closed medical record reviewed on 3/23/16 revealed an admit date of 2/1/16 with diagnoses of nausea/vomiting, dehydration (patient not getting enough fluids), and kidney disease, with a discharge date of 2/3/16. Patient #30 ' s medical record lacked evidence the patient received and signed the informed consent for treatment.

- The CAH ' s Medical Staff Bylaws/Rules and Regulations reviewed on 3/24/16 at 2:00pm directed " ...Medical Records: ...content of the record shall be pertinent and current ... "

Staff B, RN, Administrative staff interviewed on 3/24/16 at 9:10am reviewed the medical records of Patient (#'s 21, 23, 27, 28, and 29) and confirmed the CAH failed to ensure the patients received the informed consent for treatment.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on lack of documentation for review and staff interview the 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.

- Staff A, Administrative staff interviewed on 3/22/15 at 11:00am confirmed the CAH failed to conduct an evaluation of their total program for the year 2014.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on review of patient rights and staff interview the CAH failed to ensure Swing bed patients were informed of all of their rights for five of five swing bed records reviewed (patient # ' s 11, 12, 13, 14, and 15). This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings Include:

- Patient #11 ' s medical record reviewed on 3/22/16 revealed an admit date of 3/19/16 with diagnoses of chronic kidney failure, pneumonia, and type II diabetes. Patient #11 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right in the case the courts adjudged the patient incompetent; any legal-surrogate designated may exercise the patient ' s rights.

- Patient #12 ' s medical record reviewed on 3/22/16 revealed an admit date of 2/29/16 with a diagnosis of post-surgery abdominal surgery. Patient #12 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right in the case the courts adjudged the patient incompetent; any legal-surrogate designated may exercise the patient ' s rights.

- Patient #13 ' s medical record reviewed on 3//22/16 revealed an admit date of 12/10/15 with diagnoses of fall, dizziness, and cerebral vascular accident (stroke). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right in the case the courts adjudged the patient incompetent; any legal-surrogate designated may exercise the patient ' s rights.

- Patient #14 ' s medical record reviewed on 3/22/16 revealed an admit date of 12/23/15 with diagnoses of low blood pressure and sepsis (infection in the blood). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right in the case the courts adjudged the patient incompetent; any legal-surrogate designated may exercise the patient ' s rights.

- Patient #15 ' s medical record reviewed on 3/22/16 revealed an admit date of 1/20/16 with a diagnosis of post-surgery back surgery. Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right in the case the courts adjudged the patient incompetent; any legal-surrogate designated may exercise the patient ' s rights.

Staff I, Reregistered Nurse (RN) Swing Bed coordinator acknowledged Swing Bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on review of patient rights and staff interview the CAH failed to ensure Swing bed patients were informed of all of their rights for five of five swing bed records reviewed (patient # ' s 11, 12, 13, 14, and 15). This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings Include:

- Patient #11 ' s medical record reviewed on 3/22/16 revealed an admit date of 3/19/16 with diagnoses of chronic kidney failure, pneumonia, and type II diabetes. Patient #11 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

- Patient #12 ' s medical record reviewed on 3/22/16 revealed an admit date of 2/29/16 with a diagnosis of post-surgery abdominal surgery. Patient #12 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

- Patient #13 ' s medical record reviewed on 3//22/16 revealed an admit date of 12/10/15 with diagnoses of fall, dizziness, and cerebral vascular accident (stroke). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

- Patient #14 ' s medical record reviewed on 3/22/16 revealed an admit date of 12/23/15 with diagnoses of low blood pressure and sepsis (infection in the blood). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

Patient #15 ' s medical record reviewed on 3/22/16 revealed an admit date of 1/20/16 with a diagnosis of post-surgery back surgery. Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

Staff I, Reregistered Nurse (RN) Swing Bed coordinator acknowledged Swing Bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported a census of one acute inpatient and six swing bed patients. Based on review of patient rights and staff interview the CAH failed to ensure Swing bed patients were informed of all of their rights for five of five swing bed records reviewed (patient # ' s 11, 12, 13, 14, and 15). This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #11 ' s medical record reviewed on 3/22/16 revealed an admit date of 3/19/16 with diagnoses of chronic kidney failure, pneumonia, and type II diabetes. Patient #11 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to deny or withdraw consent at any time, immediate family, or other relatives of the patient or other visitors visiting the patient.

- Patient #12 ' s medical record reviewed on 3/22/16 revealed an admit date of 2/29/16 with a diagnosis of post-surgery abdominal surgery. Patient #12 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to deny or withdraw consent at any time, immediate family, or other relatives of the patient or other visitors visiting the patient.

- Patient #13 ' s medical record reviewed on 3//22/16 revealed an admit date of 12/10/15 with diagnoses of fall, dizziness, and cerebral vascular accident (stroke). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to deny or withdraw consent at any time, immediate family, or other relatives of the patient or other visitors visiting the patient.

- Patient #14 ' s medical record reviewed on 3/22/16 revealed an admit date of 12/23/15 with diagnoses of low blood pressure and sepsis (infection in the blood). Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to perform services for the CAH or perform services for the facility if he/she chooses.

Patient #15 ' s medical record reviewed on 3/22/16 revealed an admit date of 1/20/16 with a diagnosis of post-surgery back surgery. Patient #13 ' s medical record lacked evidence the CAH informed them or their representative of the patient ' s right to refuse to deny or withdraw consent at any time, immediate family, or other relatives of the patient or other visitors visiting the patient.

Staff I, Reregistered Nurse (RN) Swing Bed coordinator acknowledged Swing Bed patient rights lacked the required patient rights.