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Based on observation, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure that one expired medication was removed and failed to ensure that a bottle of normal saline was dated after it was opened for use. This failure had the potential to affect the effectiveness of the product and could impact the care of the patient.

Findings include:

Observation of the overflow emergency treatment room on 05/03/2021 at 12:30 PM revealed an open 250 milliliter bottle of sterile normal saline 0.9%. The bottle of 0.9% sterile normal saline was not dated to determine when it had been opened.

Observation of the medication storage room with Registered Nurse (RN)1 on 05/03/2021 at 2:15 PM revealed a box containing prednisolone sodium phosphate (a corticosteroid which decreases the immune system's response to reduce symptoms such as pain, swelling, and allergic-type reactions) oral solution 15 milligrams per milliliter in the refrigerator with an expiration date of 200331.

During an interview at the time of the observation RN1 stated she did not know what the expiration date of 200331 indicated.

During an interview on 05/04/2021 at 9:30 AM, the pharmacist identified that if the bottle of normal saline had been dated when opened it could be used for up to 28 days. The pharmacist verified that the bottle was not dated. During this same interview, the pharmacist stated the expiration date on the prednisolone sodium phosphate solution indicated the medication expired on 03/31/2020 and that it should have been removed from refrigerator.

Based on observation, interview, and policy review, the Critical Access Hospital (CAH) failed to ensure that staff were compliant with the requirement to wear a face mask while in the facility due to COVID-19. The failure had the potential to put all patients and staff at risk for disease transmission.

Findings include:

On 05/05/2021 at 11:30 AM, observed the Dietary Manager and another kitchen staff standing within 3 feet of each other while preparing food. The two staff were talking to each other and had their face masks pulled down under their chins exposing their mouth and nose.

During an interview on 05/05/2021 at 11:35 AM, the Dietary Manager confirmed it was the facility policy that masks should be worn at all times and that their face masks had not been covering their mouth and nose at the time of the observation. The Dietary Manager stated, "It gets so hot in the kitchen, and it makes it hard to breath."

During an interview on 05/05/2021 at 11:50 AM, the Administrator confirmed it was the expectation of the CAH that staff always wear a face mask.

Review of an undated policy titled, "COVID-19 Interim Guidance-Universal Source Control" revealed "Healthcare personnel (HCP) shall wear a facemask at all times while they are in this healthcare organization, including in breakroom or other spaces where they might encounter co-workers."

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure that infection control data elements and analysis were included in the facilities Quality Assurance Performance Improvement (QAPI) program. This had the potential to affect all patients admitted to the hospital.

Findings include:

Review of the monthly "Acute Infection Log" forms dated September 2020 through March 2021 revealed the facility documented infection information including patient identification (ID), age, sex, onset date, type of illness, symptoms, and laboratory results if tested. The tracking sheets did not include identification of whether the infection was community acquired or hospital acquired or any other potentially significant infection related information.

Review of the monthly QAPI meeting minutes dated September 2020 through March 2021 revealed committee members included the CAH's physicians, mid-level practitioners, Administrator, Chief Nursing Officer (CNO), Director of Social Services, Director of Plant Operations, Pharmacist/Infection Control Preventionist, and the Risk Manager. Review of the "Infection Control/Pharmacy" section of the QAPI meeting minutes revealed no information was included regarding the trending or analysis of the monthly acute infection tracking information, review of potential infection concerns, or opportunities for improvement.

Review of an undated policy titled, "Infection Control Policies and Procedures" showed "[Infection] Surveillance shall be conducted to determine rate of infections so that trends can be identified and investigated, and appropriate prevention strategies can be initiated ... An Infection Control Performance Improvement Plan shall be in place in order to evaluate the Infection Control Program and Plan, and to ensure continuous improvement in the prevention and control of infections throughout the organization."

Review of a policy titled, "Quality Assurance Performance Improvement," dated 04/22/2019 revealed, "QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality."

During an interview on 05/04/2021 at 9:10 AM, the Administrator confirmed the QAPI meeting minutes did not include presentation of data related to infections, discussion of infection trends, or identification of possible areas for improvement.

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure that infection control data elements and analysis were included in the facilities Quality Assurance Performance Improvement (QAPI) program. This had the potential to affect all patients admitted to the hospital.

Findings include:

Review of the monthly "Acute Infection Log" forms dated September 2020 through March 2021 revealed the facility documented infection information including patient identification (ID), age, sex, onset date, type of illness, symptoms, and laboratory results if tested. The tracking sheets did not include identification of whether the infection was community acquired or hospital acquired or any other potentially significant infection related information.

Review of the monthly QAPI meeting minutes dated September 2020 through March 2021 revealed committee members included the CAH's physicians, mid-level practitioners, Administrator, Chief Nursing Officer (CNO), Director of Social Services, Director of Plant Operations, Pharmacist/Infection Control Preventionist, and the Risk Manager. Review of the "Infection Control/Pharmacy" section of the QAPI meeting minutes revealed no information was included regarding the trending or analysis of the monthly acute infection tracking information, review of potential infection concerns, or opportunities for improvement.

Review of an undated policy titled, "Infection Control Policies and Procedures" showed "[Infection] Surveillance shall be conducted to determine rate of infections so that trends can be identified and investigated, and appropriate prevention strategies can be initiated ... An Infection Control Performance Improvement Plan shall be in place in order to evaluate the Infection Control Program and Plan, and to ensure continuous improvement in the prevention and control of infections throughout the organization."

Review of a policy titled, "Quality Assurance Performance Improvement," dated 04/22/2019 revealed, "QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality."

During an interview on 05/04/2021 at 9:10 AM, the Administrator confirmed the QAPI meeting minutes did not include presentation of data related to infections, discussion of infection trends, or identification of possible areas for improvement.

Based on interview and review of the facility's "Emergency Preparedness Plan (EPP)," the facility failed to ensure the emergency preparedness communication plan included all the following to include names and contact information for all staff, patient physicians, and volunteers. This failure had the potential to affect three of three current patients and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event.

Findings include:

Review of the facility's "Emergency Preparedness Plan" updated 02/19/2020 revealed a communication plan. Within the communication plan a "Contact List" was reviewed. The call list did not contain phone numbers for all staff, contact information for all physicians, or contact information for volunteers.

During an interview on 05/03/2021 at 1:05 PM, when the Emergency Preparedness Plan was reviewed with the Chief Executive Officer (CEO), the CEO was asked if there was contact information for patient physicians, all staff, and volunteers. The CEO stated, "I do not have the patient physicians listed in here. I never thought about that. No, I do not see them. I can add that." When the CEO was asked if there was any contact information for all staff, or volunteers that may be utilized, the CEO stated, "I don't have that information here. I will have to add it."