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Based on observation, document review and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired medical supplies were not available for patient use, potentially affecting all patients receiving care in the CAH

1. On 08/28/17 at 12:30 PM, a tour of the Surgery Department was conducted with the Director of Surgery (E #7). During the tour the following items were found expired: (3) dozen 3-0 plain gut sutures, expired 07/2017, and (1) disposable scalpel, expired 06/2017.

2. On 08/28/17 at 12:45 PM, an interview with the Director of Surgery (E #7) was conducted. E #7 confirmed the sutures and scalpel had expired and indicated those items should have been removed from the patient care area and disposed of properly.

3. On 8/29/17 at 1:15 PM, a tour of the Cardiac Rehab Department was conducted with the Cardiac Rehab Manager (E #14). During the tour the following items were found expired: (2) 7 inch Pressure Infusion Extension Sets expired 06/2017, (1) Triflex Sterile Latex Powdered Surgical Glove Size 7 expired 01/2013, and (1) Shiley Tracheostomy Tube expired 08/2016.

4. On 8/29/17 at 1:30 PM, an interview with the Cardiac Rehab Manager (E #14) was conducted. E #14 confirmed the extension sets, gloves, and tracheostomy tube had expired and indicated those items should have been removed from the patient care area and disposed of properly.

5. On 08/29/17 at 3:00 PM, the CAH policy "Supply Checks" was reviewed. Under "E." it indicated "All disposable patient supplies with expiration dates should be checked monthly, and before use. a. Expired supplies........... and taken out of use."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on09/07/2017, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on 09/07/2017, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired biologicals/drugs were removed from the patient care area, potentially affecting all patients receiving care in the CAH.

Findings include:

1. On 08/28/17 at 12:30 PM, a tour of the Surgery Department was conducted with the Director of Surgery (E #7). During the tour the following item was found to be expired in the anesthesia refrigerator, a vial of Botox 100 units with an expiration date of 2/17.

2. On 08/28/17 at 12:45 PM, an interview with the Director of Surgery (E #7) was conducted. E #7 confirmed the Botox was expired and should have been removed from the anesthesia refrigerator.

3. On 8/29/17 at 1:15 PM, a tour of the Cardiac Rehab Department was conducted with the Cardiac Rehab Manager (E #14). During the tour the following item was found, (1) Cetacaine Spray 56g Canister expired 12/2016.

4. On 8/29/17 at 1:30 PM, an interview with the Cardiac Rehab Manager (E #14) was conducted. E #14 confirmed the Cetacaine Spray had expired and indicated the item should have been removed from the patient care area and disposed of properly.

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Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure infection control practices were in place and followed to prevent the transmission of infections, potentially affecting all staff, visitors, and patients receiving care or visiting the CAH.

Findings include:

1. A tour of operating room #2 was conducted on 08/28/17 at 12:30 PM. The tour was conducted after all surgery cases had been completed. The endoscope storage cabinet contained a nylon rope that was attached to the retractable door, and the tip of the rope was touching the floor. When the retractable door was pushed open, in an upward motion, the nylon rope would come in contact with the endoscopes. The anesthesia machine had excess dust on the horizontal surfaces and the anesthesia trash can had trash in it.

2. On 08/28/17 at 3:00 PM, the "Operating Room 1 &2 Cleaning Checklist" for 08/28/17 was reviewed. Under the column that reads "clean and disinfect a. Anesthesia cart and equipment and 6. remove trash" it indicated Registered Nurse (E #12) initialed off and verified those tasks had been completed.

3. On 08/29/17 at 12:30 PM, the CAH policy "Cleaning and Maintaining Endoscopic Equipment" (8/17/17) was reviewed. Under "Procedure 12." it indicated "Scopes are stored in a clean, dry, hanging cabinet to protect from dust and contaminants."

4. On 08/28/17 at 12:45 PM, an interview with Central Supply Surgical Technician (E #8) was conducted. E #8 confirmed the nylon rope came in contact with the endoscopes when the endoscope, retractable door was opened and indicated nothing should come in contact with the scopes once they are cleaned.

5. On 08/28/17 at 12:45 PM, an interview with the Manager of Surgical Services (E #7) was conducted. E #7 confirmed there was excess dust on the anesthesia machine and trash in the anesthesia trash can. E #7 indicated the anesthesia machine should have been wiped down and the trash can should have been emptied.

6. On 08/29/17 at 2:30 PM, an interview with the Infection Prevention Nurse (E #3) was conducted. E #3 indicated the nylon rope had been removed from the endoscope cabinet and all the scopes were going to be re-cleaned and dried prior to use.

7. A tour of the radiology department was conducted on 08/29/17 at 10:45 AM with the Radiology Manager (E #9). In the ultrasound room several smaller bottles of ultrasound gel and a large refill container of the gel were observed. When the Ultrasound technician (E #10) was asked if the bottles were refilled and reused E#10 indicated "yes, we refill them from the large amount in the plastic container." When asked if the smaller bottles are cleaned prior to refilling, E#10 stated "No".

8. On 08/29/17 at 11:20 AM an interview with E #9 was conducted. E#9 reported there is no policy regarding the cleaning and reuse of the ultrasound gel bottles and no policy regarding dating the bottles with a use by or expiration date. E #9 agreed the bottles were not cleaned and should be either cleaned or new bottles used.

9. A tour of the Outpatient Therapy department was conducted on 08/29/17 at 2:00 PM with the Outpatient Therapy Manager (E #13). In the hallway hanging on the wall were covers for heating packs. When E # 13 was asked how the covers were cleaned, E #13 stated "I take them home and wash them in my personal washer by themselves with bleach." When asked if that was per hospital policy, E #13 stated "No."

10. On 08/29/17 at 2:30 PM, an interview with E #3 was conducted. E #3 stated that the covers should not have been taken home and washed. E #3 stated the facility has contracted laundry services that would wash the covers.

B. Based on observation, document review and staff interview, it was determined the dietary consultant failed to ensure foods items were properly labeled using dietary practices for sanitation and prevention of disease transmission by food. This failure has the potential to affect all patients, staff and public consuming food in the CAH.

1. A tour of the medical surgical unit was conducted on 8/28/17 at 11:00 AM with the Quality Improvement Manager (E#5). During the tour the refrigerator storing patient food supplies was observed to have the following items with no labeling of use by or expiration date: 10 plastic bags of condiments including ketchup, mustard, steak sauce, jelly, honey, butter, sour cream and several salad dressings which were individually packaged but with no manufacturer expiration date and no use by date.

2. A tour of the kitchen was conducted on 8/29/17 at 9:30 AM with the
Dietary Consultant (E# 11). During the tour of the walk in refrigerator the following items were observed opened with no labeling of an open date or use by date: several bags of shredded cheeses, muffins and brownies wrapped in plastic wrap, diced tomatoes in a plastic container and shredded potatoes in plastic wrap. In the walk in freezer the following items were observed to be opened with no identification of the item and no labeling of open date or use by date. Labels with this information were on some of the food wrappings but the information was not included: An open bag of what appeared to be hot dogs, 4 other meats wrapped in plastic, a bag with green squares of what appeared to be spinach, and 2 other bags of frozen vegetables.

3. A review of the "Dietary Consultant Services Agreement" was completed on 8/29/17 at 4:00 PM. The agreement indicates under "Responsibilities of the Facility" 4 a. The Facility Dietary Manager is responsible for daily food-service operations and quality control monitoring."

4. An interview with E#11 was conducted on 8/29/17 at 10:45. E#11 was asked to explain what the expectation is for labeling of food for safe preparation and use, since there is no written policy. E#11 stated "The labels are to be completed with the open date and a use by date. If items are placed into a plastic bag, the bag should have at least a use by date", (for individually packaged items). E#11 agreed all items observed should not be used for consumption. E#11 agreed written policies are needed.

Based on document review and staff interview, it was determined for 2 of 3 patients (Pt #1, and Pt #6), the Critical Access Hospital (CAH) failed to ensure necessary medical records accompany individuals being transferred to another hospital. This has the potential to affect all patients transferred from the CAH.

Findings include:

1. On 08/30/17 at 9:30 AM, the medical record of Pt #6 was reviewed. Pt #6 was admitted on 01/15/17 for Hypertensive Urgency and Epistaxis. Pt #6 was transferred to another hospital on 01/16/17. There was no documentation to indicate copies of the medical record accompanied the patient upon transfer.

2. On 08/30/17 at 10:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted on 08/27/17 for cellulitis to left hand. Pt #1 was transferred to another hospital on 08/28/17. There was no documentation to indicate copies of the medical record accompanied the patient upon transfer.

3. On 08/30/17 at 11:00 AM, the CAH policy "Transfer to Other Facilities (revised 09/01/14) was reviewed. Under "Procedure: A. 1." it indicated "Whenever a patient is ordered to be transferred to another hospital, a Transfer Form, a copy of the history and physical, current progress notes, lab and X-ray results, etc., should accompany the patient."

4. On 08/30/17 at 11:10 AM, an interview with the Quality Improvement Nurse (E #5) was conducted. E #5 reviewed the medical record of Pt #1 and Pt #6 and was unable to find evidence that copies of the patient's medical record accompanied the patients upon transfer. E #5 verbalized that the medical records had a consent for transfer and certification for transfer but no evidence that X-rays, a copy of the history and physical and the other required documents accompanied the patients.