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Based on credential file review, interview, and document review, the Critical Access Hospital (CAH) failed to ensure 1 of 7 active medical staff (Medical Staff O) had a current Kansas license. This deficient practice has the potential to affect the accuracy and quality of medical care of all patients treated.


Findings include:


- Medical Staff O's credential file review on 8/15/2017 at 1:20 PM revealed Staff O lacked evidence of a current Kansas State license to practice medicine.


Interview with Medical Staff Coordinator AA interview on 8/15/2017 at 1:20 PM confirmed Medical Staff O lacked a current Kansas State License.


Interview with CEO Staff A on 8/15/2017 at 3:00 PM reported Medical Staff O is listed as an active member, but has not seen patients of the hospital since August of 2016.


- Document titled, "Mercy Maude Norton Hospital Medical Staff Bylaws" reviewed on 8/21/2017 at 4:00 PM directed, ...Qualifications of membership: Only practitioners licensed to practice in Kansas who continuously meet the qualifications are eligible for Medical Staff membership... and ...An individual may not admit patients to the hospital unless he is a member of the medical staff and then only within the scope of his licensure.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure emergency care necessary to meet the needs of all patients was provided. An Immediate Jeopardy (a situation in which non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified on 8/14/2017 at 5:18 PM when it was discovered that the facility used Succinylcholine (a medication to relax the muscles during a medical procedure which can be a trigger for Malignant Hyperthermia (MH - is a type of rare, severe reaction to particular drugs that are often used during surgery and other invasive procedures. Specifically, this reaction occurs in response to medication, which are used to block the sensation of pain, and with a muscle relaxants that are used to temporarily paralyze a person during a surgical procedure. If given these drugs, people at risk for malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in the blood and other tissues (acidosis), and a rapid heart rate. Without prompt treatment, the complications of MH can be life-threatening) and failed to have the emergency rescue drug Dantrolene (used to treat MH) available for use. This deficient practice placed all susceptible patients receiving Succinylcholine at risk for the life-threatening reaction, MH.


The CAH removed the Immediate Jeopardy on 8/17/2017 at 10:17 AM when they changed their Rapid Sequence Intubation Protocol (a special process for endotracheal intubation (medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose) that is used where the patient is at a high risk of pulmonary aspiration or impending airway compromise) to include the medication Rocuronium Bromide (a medication to relax the muscles during a medical procedure that does not trigger malignant hyperthermia) in place of the Succinylcholine.


Findings include:

Refer to C-0202 for further details.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure emergency care necessary to meet the needs of all patients. An Immediate Jeopardy (a situation in which non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified on 8/14/2017 at 5:18 PM when it was discovered that the facility used Succinylcholine (a medication to relax the muscles during a medical procedure which can be a trigger for Malignant Hyperthermia (MH - is a type of rare, severe reaction to particular drugs that are often used during surgery and other invasive procedures. Specifically, this reaction occurs in response to medication, which are used to block the sensation of pain, and with a muscle relaxants that are used to temporarily paralyze a person during a surgical procedure. If given these drugs, people at risk for malignant hyperthermia may experience muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), a high fever, increased acid levels in the blood and other tissues (acidosis), and a rapid heart rate. Without prompt treatment, the complications of MH can be life-threatening) and failed to have the emergency rescue drug Dantrolene (used to treat MH) available for use.

The CAH removed the Immediate Jeopardy on 8/17/2017 at 10:17 AM when they changed their Rapid Sequence Intubation Protocol (a special process for endotracheal intubation (medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose) that is used where the patient is at a high risk of pulmonary aspiration or impending airway compromise) to include the medication Rocuronium Bromide (a medication to relax the muscles during a medical procedure that does not trigger malignant hyperthermia) in place of the Succinylcholine.

The CAH failed to ensure Emergency room supplies and medications did not exceed the manufacturer's safe use date in one of two Emergency Room Crash Carts (Emergency Room 2). This deficient practice has the potential to cause compromised medications and unsafe supplies to be used during the care and treatment of emergent patients.


Findings include:

- Observation of the Pharmacy Formulary while in the pharmacy on 8/14/2017 at 3:50 PM revealed the medication Succinylcholine, but failed to list the medication Dantrolene.

Staff G, Pharmacy and Staff B Administration interviewed in the pharmacy on 8/14/2017 at 3:50 PM, verified the CAH formulary listed Succinylcholine and failed to list Dantrolene. Staff B explained the providers in the CAH occasionally use Succinylcholine and have not needed the medication Dantrolene. Staff G verified the facility failed to stock Dantrolene for the treatment of Malignant Hyperthermia.

Staff A, B, C and D, Administration interviewed in the team conference room on 8/14/2017 at 5:18 PM concerning an Immediate Jeopardy for the use of Succinylcholine and failure to have the medication Dantrolene available in the case of Malignant Hyperthermia. Staff A had the Succinylcholine locked in a remote refrigerator in the therapy department while they ordered Dantrolene for use in the CAH. The therapy manager was the only person with the keys to the refrigerator and was leaving for home after the meeting.

Staff A, Administration interviewed in the team conference room on 8/17/2017 at 8:17 AM explained the CAH will dispose of the vials of Succinylcholine and not stock Dantrolene. The facility will use Rocuronium in place of Succinylcholine in their Rapid Sequence Intubation Protocol.

- Observation in the nursing area on 8/17/2017 at 8:45 AM, Staff E, Administration showed this surveyor two vials of Rocuronium Bromide 5 ml (milliliter) locked in the refrigerator.

- Observation in the nursing medication area on 8/17/2017 at 9:21 AM, Staff G, Pharmacy wasted 24 vials of Succinylcholine. The empty vials were placed in the sharps container.

The Immediate Jeopardy was removed on 8/17/2017 at 10:17 AM when the facility secured the medication Rocuronium Bromide for the Rapid Sequence Intbuation Protocol and removed the Succinylcholine from their inventory. Staff A explained the Medical Director and all Providers were notified of the changes.


- Emergency Room 2, Emergency Crash Cart observation on 8/14/2017 at 3:19 PM revealed 2 boxes of Sodium Bicarbonate Injectable (used to combat acidosis in patients who are in shock or cardiac arrest) 8.4%, 50 Milliliters (ml) with an expiration date of 7/2017.

Director of Nursing Staff E interviewed on 8/14/2017 at 3:41 PM, verified the Sodium Bicarbonate with an expiration date of 7/2017 and they are supposed to be checked monthly for outdates.

Director of Nursing Staff E interviewed on 8/16/2017 at 5:00 PM reported the facility did not have any adult doses of sodium bicarbonate available that was not expired. Staff E reports the facility will obtain the medication by the next morning (8/17/2017). Two new boxes of sodium bicarbonate with an expiration date of 6/1/2019 were obtained, and presented to the survey team on 8/17/2017 at 8:30 AM.

- Document titled, " Medications For Crash Cart" reviewed on 8/17/2017 at 12:00 PM directed, " ... These medications should be on the crash cart in the quantity listed at all times. When you check for outdates, please check to make sure theses med are in place in sufficient amount ... Sodium Bicarb [sodium bicarbonate] adult, quantity 3..."

- Policy titled "Inventory" reviewed on 8/15/17 directed, ...drugs are checked monthly in all areas of the hospital. Outdated drugs are replaced.

Based on observation, staff interviews, and policy review, the facility failed to ensure expired supplies were unavailable for patient use in one of one outpatient services room (outpatient services room 3), one of one pharmacy supply rooms, one of one nursing station medication rooms, two of two ER rooms (ED Room 1 and 2), one of two emergency crash carts (in ED room 2) and in one of one Brosleow kit (emergency kit for treating children). This deficient practice has the potential to cause harm and increases risk to patient safety.


Findings include:


- Outpatient Services Room 3 observation on 8/14/2017 at 3:16 PM revealed 1 Catheter Sterilization Device (a device to sterilize a catheter) with an expiration date of 6/2017.

Director of Nursing Staff E interviewed on 8/14/2017 at 3:16 PM, verified the Catheter Sterilization Device with an expiration date of 6/17.

- Emergency Crash Cart in Emergency Room 2 observation on 8/14/2017 at 3:19 PM revealed 10 Safety Needles 23 gauge (g) x 1 inch with an expiration date of 3/2017.

Registered Nurse (RN) Staff F interviewed on 8/14/2017 at 3:41 PM, verified the Safety Needles with an expiration date of 3/2017.

- Pharmacy Supply Room observation on 8/14/2017 at 4:05 PM revealed the following expired supplies: 39 stat-lock catheter holders (used to secure urinary catheters to the leg) with an expiration date of 6/2017 and five with an expiration date of 5/2017.

Nurse Manager Staff B interview on 8/14/2017 at 4:05 PM confirmed the expired stat-lock devices.


- Nursing Station Medication Room observation on 8/14/2017 at 4:22 PM revealed 2 Aquacel Surgical Pads (a waterproof dressing to use in wound care) with an expiration date of 7/2017 and 1 Aquacel Surgical Pad with and expiration date of 4/2017.


RN Staff F interviewed on 8/14/2017 at 4:22 PM, verified the Aquacel Surgical Pads with expiration dates of 7/2017 and 4/2017.


- ER Room 1 observation on 8/14/2017 at 4:16 PM revealed the following expired supplies: 10 - 23g needles with an expiration date of 3/2017, 15 packages of ECG electrodes (heart monitor patches) with an expiration date of 4/2017, and two catheter (used to drain the bladder) kits with an expiration date of 7/2016.


- Broselow Emergency Bag observation on 8/14/2017 at 4:47 PM revealed the following expired supplies: three stylets (used to guide a breathing tube in an emergency) with an expiration date of 6/2017, one packet of lubrication jelly with an expiration date of 3/2017, one ET tube (breathing tube) with an expiration date of 6/2017, one 22g IV catheter (used to give medications and fluids though the veins) with an expiration date of 6/2017 and one with an expiration date of 7/2017.


RN Staff F interview on 8/14/2017 at 4:47 PM acknowledged the supplies from ER room 1 and the Broselow emergency bag were expired.


- As of 8/17/2017, the CAH failed to provide a policy regarding managing supplies to prevent outdates.

Based on observation, staff interview and document review, the Critical Access Hospital (CAH) failed to ensure physical therapy equipment was in safe working condition. The CAH failed to provide evidence of ongoing monitoring of paraffin wax temperatures to ensure the wax inside the paraffin bath was maintained at a safe temperature in one of one therapy rooms. This deficient practice has the potential to expose patients to overheated was that could cause burns.

Findings Include:

- Physical Therapy Room observation on 8/15/2017 at 11:35 AM revealed a paraffin wax warmer without a corresponding temperature log.

Physical Therapy Staff Q interviewed on 8/15/2017 at 11:40 AM confirmed therapy staff do not monitor the paraffin wax temperatures. Staff Q indicated the therapy department does not use the paraffin wax often.

- Document titled, "Paraffin Bath" reviewed on 8/16/2017 at 2:21 directed, ... check the temperature of the bath to be certain it is 126-134 degrees Fahrenheit.

Based on medical staff credentialing files review, interview and document review, the Critical Access Hospital's Governing Body failed to ensure the Medical Staff completed reappointments for 4 of 7 medical staff (Medical Staff K, L, M and N). This deficient practice has the potential to affect the quality of patient care, and place all patients at risk for harm due to lack of credentialing oversight.

Findings include:

- Medical Staff credentialing review on 8/15/2017 at 1:00 PM revealed Medical Staff K's, L's, M's, and N's files lacked a current reappointment application and corresponding reappointment signatures from the medical staff and board of directors.

Interview with Medical Staff Coordinator AA interview on 8/15/2017 at 2:25 PM confirmed Medical Staff K, L, M and N did not have evidence of reappointment application and corresponding reappointment signatures from the medical staff and board of directors in their files. Staff AA reported the medical staff credentialing team uses medical staff meeting minutes to track appointment dates for renewal.

Interview with CEO (Chief Executive Officer) Staff A on 8/15/2017 at 3:00 PM acknowledged Medical Staff K, L, M and N did not have evidence of reappointment applications and corresponding reappointment signatures from the medical staff and board of directors in their files.

- Document titled, "Mercy Maude Norton Hospital Medical Staff Bylaws" reviewed on 8/21/2017 at 4:10 PM directed, ... At least five months prior to the expiration of a Member's Medical Staff Appointment, the hospital will send the Member a written reappointment application form prescribed by the Medical Staff. The applicant must complete and submit a written and signed reappointment application form and supporting documents not later than 90 days prior to the expiration of his appointment...and...the duty to file a complete, written and signed application, including the duty to procure peer references where required and provide supporting documentation, rests exclusively with the applicant... and ...the board must review each favorable recommendation of the Medical Staff respecting Medical Staff appointment and Clinical Privileges.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure medications were secured and locked in 1 of 1 Therapy Room and 1 of 1 Patient Medication Refrigerator in the Nursing Lounge. This deficient practice put all staff, patients and visitors at risk for unauthorized individuals to access medications. The CAH failed to remove outdated medications in 1 of 1 Therapy Room, 1 of 2 Emergency Department (ED) Rooms (Room 2), 1 of 1 Nursing Medication Room, and 1 of 1 Patient Medication Refrigerator in the Nursing Lounge. The CAH also failed to date opened multi-dose vials (to be used in 28 days) in 1 of 2 ED rooms (room 2), and 1 of 1 Patient Medication Refrigerator in the Nursing Lounge. . The deficient practices of failing to discard expired medications and failing to date opened multi-dose vials after opening put all patients at risk for receiving medications that are ineffective and unsafe for use.

Findings include:

- Observation in the unlocked Nursing Lounge off of the nursing station area in the patient hallway on 8/14/2017 at 4:54 PM revealed a refrigerator unlocked with the following medications: 10 vials of Tetanus and Diptheria (a bacteria that is found in soil, manure, or dust that enters the body and a serious infection of the nose and throat), 3 vials of Biorad Plus Control (to test for urine in pregnancy), 1 vial of Humulin R (a short acting insulin), 1 vial of Flourenscein Sodium and Benoxinate Hydrochloride (a rapidly acting medication to numb the eye), 1 bottle of Acetylcysteine (a cough medicine), 1 vial of Levimir (insulin to treat diabetes), 1 vial of Tenecteplase ( a medication to dissolve blood clots during a heart attack) and 1 vial of Procrit (a medication to treat a lower than normal number of red blood cells).

Staff B, Administration interviewed in the Nursing Lounge on 8/14/2017 at 4:54 PM verified the Nursing Lounge door failed to have a lock on it with an unlocked patient medication refrigerator.


- Physical Therapy Room observation on 8/15/2017 at 11:38 AM revealed an unlocked supply drawer containing a box with a vial of dexamethasone (steroid medication) punctured with a needless access device, to allow a luer-lock (screw on) syringe to attach. This box also contained a used syringe and needless access device.

Physical Therapy Staff Q interview on 8/15/2017 at 11:38 AM acknowledged the unsecured medication and that it is normally kept in the office locked in a desk.

- The CAH failed to ensure a policy concerning securing medications.


- Observation in the Therapy room on 8/14/2017 at 1:00 PM revealed a refrigerator for patient medications that contained 9 vials of Sterile Diluent (a liquid used to mix a medication) with an expiration date of 6/27/2017, and 4 vials of Tetanus (a bacteria that is found in soil, manure, or dust that enters the body), Diptheria (a serious infection of the nose and throat), and Pertussis (a highly contagious respiratory tract infection) (Tdap) vaccine with an expiration date of 4/19/2015.

Staff C, Administration interviewed in the therapy room on 8/14/2017 at 1:02 PM verified the expired Sterile Diluent with a date of 6/27/2017 and the expired Tdap with an expiration of 4/19/2017.


- Observation in ED room 2 on 8/14/2017 at 3:19 PM revealed the Emergency Crash Cart contained 2 injections of Sodium Bicarbonate 8.4% 50 milliliter (ml) (a medication used to treat high levels of acid in the bloodstream).

Staff F, Registered Nurse (RN) interviewed in ED room 2 on 8/14/2017 at 3:41 PM verified the expired Sodium Bicarbonate with an expiration date of 7/2017.


- Observation in the Nursing Station Medication room on 8/14/2017 at 4:24 PM revealed the Omnicell (a electronic locked medication dispensing machine) contained 4 tablets Carvedilol 25 milligrams (mg) (a medication to treat high blood pressure and heart failure) with an expiration date of 3/4/2013, 4 tablets of Carvedilol 25 mg with an expiration date of 6/26/2013, 1 tablet of Tamsulosin HCL 0.4 mg (a medication to treat symptoms of the prostate gland (a gland surrounding the neck of the bladder in males) with an expiration date of 4/20/2017, 2 bags of Potassium Chloride 100 ml (a mineral to treat low amounts of potassium in the body) with an expiration date of 6/2017, 4 capsules of Clindamycin 150 mg (an antibiotic used to treat infections) with an expiration date of 6/30/2017 and 1 capsule of Clindamycin 150 mg with an expiration of 12/1/2016, and 4 tablets of Gabapentin 100 mg (a nerve pain medication) with an expiration date of 7/2016.

Staff G, Pharmacy and Staff B, Administration interviewed on 8/14/2017 at 4:38 PM verified the expired medications in the Omnicell.


- Observation in the Nursing Lounge Patient Medication refrigerator on 8/14/2017 at 4:42 PM revealed 10 vials of Tdap 0.5 ml with an expiration date of 7/2017, 3 vials of Biorad Plus Control (to test urine for pregnancy) with an expiration of 6/14/2016, 1 vial of Flourenscein Sodium and Benoxinate Hydrochloride (a rapidly acting medication to numb the eye) with an expiration of 2/2017 and Acetylcysteine (a cough medicine) with an expiration date 3/2017.

Staff B, Administration interviewed in the nursing lounge on 8/14/2017 at 4:54 PM confirmed these expired medications in the patient medication refrigerator.

- The CAH's policy titled "Inventory" reviewed on 8/15/2017 directed ...drugs are checked monthly in all areas of the hospital. Outdated drugs are replaced ...

- Observation in ED room 2 on 8/14/2017 at 3:19 PM revealed 1 multi-dose vial of Xylocaine 1% 120 milliliter (ml) (a medication that can treat irregular heartbeats and relieve pain by numbing the skin) that failed to have a date documented when it was opened.

Staff F, RN interviewed in ED room 2 verified the multi-dose vial of Xylocaine did not have a date of when it was opened.

- Observation in the Nursing Lounge refrigerator on 8/14/2017 at 4:54 PM revealed 1 multi-dose vial of Humulin R (a short acting insulin) that failed to have a date when it was opened.

Staff B, Administration interviewed in the Nursing Lounge on 8/14/2017 at 4:54 PM verified the multi-dose vial of Humulin R did not have a date of when it was opened.

- The CAH failed to have a policy concerning the use of multi-dose vials.


The United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: if a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Medication vials should always be discarded whenever sterility is compromised or questionable.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure a system for identifying, investigating and controlling a sanitary environment in the facility kitchen concerning the wearing of hair nets around food preparation areas for 1 of 2 staff members, discarding expired food and ensuring an airgap system was installed in the kitchen sink for 1 of 2 sinks. Failure to ensure a safe and sanitary environment in the CAH's kitchen put all staff and patients at risk for food contaminated with bacteria, viruses, chemicals or poisonous metals resulting in potential food poisoning, illness and diseases. The CAH failed to ensure therapy equipment for 1 of 1 piece of stair training equipment had a cleanable surface and a bin of dried beans and bin of rice used for hand therapy was cleaned between patient use. Failure to ensure a clean environment for the therapy equipment put all patient at risk for acquiring and spreading bacteria, infection and communicable diseases. The CAH also failed to ensure equipment to provide a negative air pressure room for isolating patients with a communicable disease. Failure to ensure a negative pressure room for isolating patients with a communicable disease put all staff, visitors and patients at risk for acquiring communicable diseases, bacteria, viruses, and blood borne pathogens resulting in infection, illness and disease.

Findings include:

- Observation during the kitchen tour on 8/15/2017 at 1:46 PM revealed Staff H, Dietary staff failing to wear a hair net while touring throughout the kitchen areas.

Staff H, Dietary staff member interviewed in the kitchen area on 8/15/2017 at 2:51 PM confirmed they failed to wear a hairnet while touring throughout all kitchen areas.

- The CAH's policy titled "Personal Hygiene" reviewed on 8/15/2017 directed " ...hair must be restrained, clean and neatly combed. A hair net is required while working around the food."

- Observation during the kitchen tour on 8/15/2017 at 1:46 PM revealed the following expired food items: 4 cans of low sodium chicken noodle soup with an expiration date of 8/6/2017, 1 container of cherry vanilla yogurt with an expiration date of 8/7/2017, 1 box of Bisquick with an expiration date of 5/28/2017, 1 box of Hungry Jack Pancake Mix with an expiration date of 3/7/2017, 1 box of Graham Cracker Crust with an expiration date of 5/9/2017, 1 box of Corn Flake Crumbs with an expiration date of 5/9/2017, 1 can of Cream Cheese Frosting with an expiration date of 6/18/2017, Mozzarella Cheese with an expiration date of 6/18/2017, 1 box of Granola cereal with an expiration date of 6/14/2017, 1 box of Cheerios with an expiration date of 4/14/2017, 1 box of Corn Crisps cereal with an expiration date of 1/30/2017, 1 box of Raisin Bran cereal with an expiration date of 6/6/2017, 1 box of Frosted Shredded Wheat cereal with an expiration date of 12/21/2016, 1 box of Gerber cereal with an expiration date of 5/25/2017, 1 can of Chili Fixins with an expiration date of 6/3/2017 and 3 packages of Chocolate Pudding (4 individual cups in a package) with an expiration date of 8/10/2017.

Staff H, Dietary and Staff C, Administration in the kitchen areas during the tour on 8/15/2017 at 1:46 PM confirmed the food had expired.

- The CAH failed to provide documentation of a policy related to discarding of food items past their expiration date.

- Observation during the kitchen tour on 8/15/2017 at 1:46 PM revealed the kitchen sink used in food preparation failed to have an airgap system installed to prevent the backflow of sewage, gas, or other contaminates.

Staff Y, Maintenance interviewed in the team conference room on 8/16/2017 at 9:44 AM verified the kitchen sink used for food preparation failed to have an airgap system installed in the sink.

- The CAH failed to provide documentation of policy concerning the prevention of backflow of food, sewage, gases and other contaminates in the kitchen sink.

According to the "2012 Kansas Food Code":

5-202.13 Backflow Prevention, Air Gap.
An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

5-202.14 Backflow Prevention Device, Design Standard.
A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device.


-Therapy Gym observation on 8/15/2017 at 11:35 AM revealed physical therapy equipment (one stair trainer) with wooden handrails in which the lacquer finish had worn off, exposing the porous wood, leaving the equipment un-cleanable.

Physical Therapy Staff Q interviewed on 8/15/2017 at 11:35 AM acknowledged the finish had worn off, saying, "We wipe it down. Yeah, it needs fixed."

- Document titled, "Decontamination of Work Surfaces" reviewed on 8/18/2017 at 1:10 PM directed, ...to decontaminate surfaces...that cannot be laundered, contact Environmental Services for more information.

- Document titled, "Cleaning Procedure" reviewed on 8/18/2017 at 1:15 PM directed, ...inspect your work. Inspect the room. Report any needed repairs.


-Therapy Gym observation on 8/15/2017 at 11:35 AM revealed physical therapy equipment (one bin with dried beans and one bin of dried rice) which therapy staff report is for hand therapy.

Physical Therapy Staff Q interviewed on 8/15/2017 at 11:40 AM reported the bins are used for hand therapies and fine motor skills, and are not single use. When asked about sanitation, cleaning and infection control, Staff Q stated, "we dump it periodically".



- Observation during a tour of the patient rooms with Maintenance staff on 8/16/2017 at 9:03 AM revealed the CAH failed to ensure a room with the proper equipment to provide negative air pressure for an isolation patient with a communicable disease.

Staff Y, Maintenance during the tour of patient rooms interviewed on 8/16/2017 at 9:15 AM verified the facility failed to ensure they have a room with the proper equipment to provide negative air pressure for an isolation patient with a communicable disease.

- The CAH failed to provide documentation of a policy concerning negative air pressure equipment, use and prevention in the case of a patient with a communicable disease.

Based on observation, staff interview, document and policy and procedure review the Critical Access Hospital (CAH) failed to ensure the nutritional needs of patients are met according to recognized dietary practices and failed to have a trained Dietary Manager. This deficient practice put all patients at risk for poor healing, illness and medical complications.

Findings include:

- Observation of the patient menus in the Dietary Manager's office on 8/15/2017 at 2:23 PM revealed the CAH failed to ensure printed weekly menus for patient meals

Staff H, Dietary Manager, interviewed on 8/15/2017 at 2:23 PM verified the facility failed to print and use weekly nutritional menus for patient meals. Staff H explained that meals are generally prepared for the hospital staff due to low census. Staff H further explained if they have a patient with a cardiac or diabetic diet they will take some of the food and alter it to meet the patient's dietary needs. When asked how they (Staff H) would ensure a patient received a 1,200 calorie Diabetic diet, they acknowledged they had no idea how to make a 1,200 calorie Diabetic diet. Staff H indicated that they did not have any training to be the Dietary Manager.

Staff I, Dietician interviewed over the phone in the team conference room on 8/16/2017 at 8:35 AM confirmed that the Dietary Manager failed to be trained for the position and that weekly menus were not used for patient meals.

- The CAH's job description for the Dietary Manger directed, ...responsible for food preparation for the patients ...keeps up to date on educational requirements ...studies with the Consulting Dietician in order to gain an understanding of the preparation of menus, general and modified and/or special diets, and assist with the preparation of the menus.

- The CAH's policy titled "Nutrition" reviewed on 8/17/2017 directed, ...all personnel under the supervision of the Dietary Consultant and the Manager of Food Service must have a working knowledge of how to set up standard recipes as to the number of servings needed, size of servings ...all dietary personnel must familiarize themselves with the basic principles of nutrition as related to meal planning, preparation, serving and storing of foods ...all diets must be followed, and only the substitutions as listed by the Food Service Supervisor may be used. All dietary personnel must gain knowledge of interchangeable foods ...special and modified diets as ordered by the physician such as diabetics, ulcer patients, coronary patients, etc. will be given the diet allowed by the physician.

Based on medical record review, staff interview, and document review, the facility failed to notify 1 of 5 swing bed patients (#3) of their resident rights. This deficient practice has the potential to place all swing bed patients at risk for exploitation.

Findings include:


- Patient #3's medical record review on 8/16/2017 at 3:00 PM revealed they were admitted to swing bed on 4/21/2017 and discharged on 4/28/2017. Medical record review revealed the facility failed to provide evidence the patient received their patient rights.


Nurse Manager Staff B interviewed on 8/16/2017 at 3:00 PM confirmed lack of documentation that patient #3 received their swing bed patient rights.


Director of Nursing Staff E interviewed on 8/17/2017 at 8:40 AM reported that it is expected for the nurses to ensure the patients receive the swing bed resident rights when they (the nurses) are completing the admission assessment, and for the patients to be given a copy.


- Policy titled, "Swing Bed Patient Bill of Rights" reviewed on 8/21/2017 at 12:44 PM directed, ...Each patient admitted to the facility: is fully informed, prior to, or at the time of admission and during stay...the patient is given the Patients' Bill of Rights/information.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include the rights regarding residents who perform services/work for the CAH in their Swing Bed rights for 4 of 5 swing bed medical records reviewed (Patient #1, #2, #4, and #5). Failure to provide notification puts all swing bed patients at risk for exploitation and inadequate compensation.


Findings include:


- Patient #1's medical record review on 8/16/2017 at 2:00 PM revealed they were admitted to swing bed on 3/15/2017 and discharged on 3/23/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the rights regarding residents who provide services for the CAH.

- Patient #2's medical record review on 8/16/2017 at 2:40 PM revealed they were admitted to swing bed on 4/7/2017 and discharged on 4/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the rights regarding residents who provide services for the CAH.

- Patient #4's medical record review on 8/16/2017 at 3:35 PM revealed they were admitted to swing bed on 5/8/2017 and discharged on 5/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the rights regarding residents who provide services for the CAH.

- Patient #5's medical record review on 8/16/2017 at 4:15 PM revealed they were admitted to swing bed on 6/7/2017 and discharged on 6/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the rights regarding residents who provide services for the CAH.

Director of Nursing Staff E interviewed on 8/16/2017 at 9:40 AM acknowledged the facility's swing bed bill of rights lacked this right.

- Document titled, "Swing Bed and Skilled Nursing Patient Bill of Rights and Responsibilities" reviewed on 8/16/2017 at 9:15 AM revealed the document lacked the rights for residents who work.

- Policy titled, "Swing Bed Patient Bill of Rights" reviewed on 8/21/2017 at 12:44 PM directs, " ...These patients' rights and procedures ensure that, at least, each patient admitted to the facility ...is not required to perform services for the facility that are not included for the therapeutic purposes of his plan of care; patients are not used to provide a source of labor for a facility against their will or against their physician's orders ..."

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include visitation rights in their Swing Bed rights for 4 of 5 swing bed medical records reviewed (Patient #1, #2, #4, and #5). Failure to provide notification put all swing bed patients psychosocial well-being at risk.


Findings include:


- Patient #1's medical record review on 8/16/2017 at 2:00 PM revealed they were admitted to swing bed on 3/15/2017 and discharged on 3/23/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the visitation rights requirement.

- Patient #2's medical record review on 8/16/2017 at 2:40 PM revealed they were admitted to swing bed on 4/7/2017 and discharged on 4/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the visitation rights requirement.

- Patient #4's medical record review on 8/16/2017 at 3:35 PM revealed they were admitted to swing bed on 5/8/2017 and discharged on 5/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the visitation rights requirement.

- Patient #5's medical record review on 8/16/2017 at 4:15 PM revealed they were admitted to swing bed on 6/7/2017 and discharged on 6/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the visitation rights requirement.

Director of Nursing Staff E interviewed on 8/16/2017 at 9:40 AM acknowledged the facility's swing bed bill of rights lacked the visitation rights requirement.

- Document titled, "Swing Bed and Skilled Nursing Patient Bill of Rights and Responsibilities" reviewed on 8/16/2017 at 9:15 AM revealed the document lacked the visitation rights requirement.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include the right to retain and use personal possessions in their Swing Bed rights for 4 of 5 swing bed medical records reviewed (Patient #1, #2, #4, and #5). Failure to provide notification put all swing bed patients at risk to access and use of personal possessions, effecting adjustment and psychosocial well-being.


Findings include:


- Patient #1's medical record review on 8/16/2017 at 2:00 PM revealed they were admitted to swing bed on 3/15/2017 and discharged on 3/23/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the right to retain and use personal possessions requirement.

- Patient #2's medical record review on 8/16/2017 at 2:40 PM revealed they were admitted to swing bed on 4/7/2017 and discharged on 4/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the right to retain and use personal possessions requirement.

- Patient #4's medical record review on 8/16/2017 at 3:35 PM revealed they were admitted to swing bed on 5/8/2017 and discharged on 5/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the right to retain and use personal possessions requirement.

- Patient #5's medical record review on 8/16/2017 at 4:15 PM revealed they were admitted to swing bed on 6/7/2017 and discharged on 6/14/2017. Medical record review revealed the facility provided swing bed rights to the patient during their admission, however the facility's swing bed rights lacked the right to retain and use personal possessions requirement.

Director of Nursing Staff E interviewed on 8/16/2017 at 9:40 AM acknowledged the facility's swing bed bill of rights lacked the right to retain and use personal possessions requirement.

- Document titled, "Swing Bed and Skilled Nursing Patient Bill of Rights and Responsibilities" reviewed on 8/16/2017 at 9:15 AM revealed the document lacked the right to retain and use personal possessions requirement.

- Policy titled, "Swing Bed Patient Bill of Rights" reviewed on 8/21/2017 at 12:44 PM directed, " ...The patient is allowed to retain personal clothing and possessions as space permits..."

Based on medical record review, interview and document review, the Critical Access Hospital (CAH) failed to ensure 2 of 5 swing bed patients (Patient #3 and #4) received a dietary screening by nursing or a dietary assessment by the consultant dietician, despite the presence of a physician's order for a therapeutic diet. This deficient practice has the potential to cause harm to all patients regarding healing, weight loss, and management of chronic medical conditions including diabetes.


Findings include:


- Patient #3's medical record review on 8/16/2017 at 3:00 PM revealed the patient was admitted to swing bed on 4/21/2017 with a diagnosis of debility (physical weakness as a result of an illness) and discharged on 4/28/2017. Medical record review revealed the patient was ordered a diabetic diet, however the record lacked evidence of a nursing nutritional screen or a dietary assessment from the consultant dietician.


- Patient #4's medical record review on 8/16/2017 at 3:35 PM revealed the patient was admitted to swing bed on 5/8/2017 with a diagnosis of need of rehabilitation and discharged on 5/14/2017. Medical record review revealed the patient was ordered a diabetic diet, however the record lacked evidence of a nursing nutritional screen or a dietary assessment by the consultant dietician.


Director of Nursing Staff E interviewed on 8/17/2017 at 8:40 AM acknowledged the assessments were missing and communicated that there is a place in the medical record to complete the screening by nursing and it should be done during their swing bed stay.


- On 8/17/2017, the facility failed to provide a policy regarding dietary screenings or consultant dietitian assessments pertaining to swing bed patients.

Based on medical record review and interview, the Critical Access Hospital (CAH) failed to ensure occupational therapy (OT) staff followed orders for evaluation and treatment for 2 of 5 swing bed medical records reviewed (Patient #1 and #2). This deficient practice has the potential to affect the rehabilitation and quality of life for all swing bed patients.


Findings include:


- Patient #1's medical record review on 8/16/2017 at 2:00 PM revealed they were admitted to swing bed on 3/15/2017 and discharged on 3/23/2017. Medical record review revealed the physician's orders included OT evaluation and treatment. The medical record lacked evidence of occupational therapy evaluation or occupational therapy treatments were completed as ordered.


- Patient #2's medical record review on 8/16/2017 at 2:40 PM revealed they were admitted to swing bed on 4/7/2017 and discharged on 4/14/2017. Medical record review revealed the physician's orders included OT evaluation and treatment. The medical record lacked evidence of occupational therapy evaluation or occupational therapy treatments were completed as ordered.


Nurse Manager Staff B interview on 8/16/2017 at 2:40 PM acknowledged patient #1's and patient #2's medical records lacked evidence of occupational therapy evaluations and/or treatments.


- Policy titled, "Physician's Orders" reviewed on 8/21/2017 at 1:15 PM directed, ...The license nurse is responsible for verification of physician's orders and the implementation and completion of the physician's directives.

Based on staff interview, documents and policy and procedure review the Critical Access Hospital (CAH) failed to ensure written policy and procedures regarding the visitation rights of patients in regards to informing each patient of his or her visitation rights, including any clinical restriction or limitations and their right, subject to their consent to receive visitors and their right to withdraw or deny such consent at any time. This deficient practice to ensure patient visitation rights are respected puts all patients at risk for being in an environment that fails to ensure their decision making over who they will see or not see during their care and treatment at the CAH.

Findings include:

- The CAH's policy titled "Visiting Regulations" reviewed on 8/17/2017 failed to provide documentation concerning informing patients of their visitation rights, including any clinical restriction or limitation and their right, subject to their consent to receive visitors and their right to withdraw or deny such consent at any time.

- The CAH's document titled "Patient's Bill of Rights and Responsibilities" reviewed on 8/17/2017 failed to provide documentation concerning patient rights concerning informing them of their visitation rights, including any clinical restriction or limitation and their right, subject to their consent to receive visitors and their right to withdraw or deny such consent at any time.

Staff E, Administration interviewed in the team conference room on 8/17/2017 at 12:00 PM acknowledged the facilities Patient's Bill of Rights and Responsibilities and policy titled "Visiting Regulations" lacked documentation of visitation rights, including any clinical restriction or limitation and their right, subject to their consent to receive visitors and their right to withdraw or deny such consent at any time.