HospitalInspections.org

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The Critical Access Hospital (CAH) reported a census of 8 acute inpatients and 2 swing bed patients. Based on observation, staff interview and policy review the hospital failed to post signage of the EMTALA (Emergency Medical Treatment and Labor Act) laws in view of all patients for one of two Emergency Department entrances (ambulance entrance).

This failure placed patients at risk of not knowing their rights when seeking emergency treatment.

Findings include:

According to §489.20(q) [The provider agrees to the following:] In the case of a hospital as defined in §489.24 (b)-(1) To post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency department (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor; and (2) To post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX;


- The CAH Emergency Department ambulance entrance observed on 6/27/2016 at 10:35 AM lacked evidence of the EMTALA law signage for patient viewing.

Facility Administrator Staff A interviewed on 6/27/2016 at 2:30 PM acknowledged they do not have a sign regarding EMTALA law at the Emergency Ambulance entrance. Staff A mentioned they have the EMTALA law sign at the walk in Emergency Department entrance.

- Facility policy titled "Assessment and Triage of the Emergency Department Patient" reviewed on 6/29/2016 at 4:15 PM directed "... It shall further be the policy of CMH (Community Memorial Healthcare) that appropriate signage regarding EMTALA laws will be in view of all patients presenting to the ER informing them of their rights to have an appropriate Medical Screening..."

On 6/28/2016 at 9:00 a.m. the Administrator acknowledge the lack of signage at the ambulance entrance in the Emergency Department. A sign was observed posted on 6/29/2016.

The Critical Access Hospital (CAH) reported a census of 8 acute inpatients and 2 swing bed patients. Based on observations, staff interview, and policy review the CAH failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations for two of two labor/delivery rooms, the labor/delivery clean utility room, the labor/delivery medication room and one of six Post Anesthesia Care Unit (PACU) rooms (#717).

The failure of the facility to dispose of expired supplies places all patients at risk for receiving ineffective supplies or topical medications.

Findings include:

- PACU Room #717 observed on 6/27/16 at 11:15 AM revealed the following outdated supplies:
1) Two 22 gauge (the size of the needle) x 1 inch Intravenous needles (a needle that goes into the vein) with an expiration date of 3/2011.
2) Two 18 gauge x1¼ inch IV needles with an expiration of 11/2010.
3) Two 16 gauge x 1¼ inch IV needles with an expiration of 11/2013.
4) Two 14 gauge x 2 inch IV needles with an expiration of 5/2013.
5) Two 20 gauge x 2¼ inch IV needles with an expiration of 10/2010.
6) Eleven 20 gauge x 1.88 inch needles with an expiration of 1/2015.
7) Twenty one 18 gauge x 1.88 inch needles with an expiration of 2/2016.
8) Twenty 16 gauge x 1.77 inch needles with an expiration of 10/2015.
9) Twenty 14 gauge x 1.75 inch needles with an expiration of 1/2016.
10) Nine 22 gauge x 1 inch needles with an expiration of 3/2011.
11) Eleven 22 gauge x 1 inch needles with an expiration of 12/2011.
12) One 22 gauge x 1 inch needle with an expiration of 3/2014.
13) One 20 gauge x 1¼ inch needle with an expiration of 10/2013.
14) Fourteen 18 gauge x 1.88 inch needles with an expiration of 2/2016.
15) Fifty 18 gauge x 1¼ inch needles with an expiration of 2/2014.

16) Two packages of a Comfort Sampler Blood Gas System (a test that measures the amount of oxygen and carbon dioxide in the blood. It may also be used to determine the pH of the blood, or how acidic it is) with an expiration of 12/2015.

17) One package of a Cleansing Enema (a procedure in which liquid or gas is injected into the rectum, typically to expel its contents, but also to introduce drugs or permit x-ray imaging) Set with an expiration of 3/2016.

Registered Nurse Staff H interviewed on 6/27/16 at 11:15 AM acknowledged verification that the needles items 1-5 mentioned above were outdated.

Registered Nurse Staff L interviewed on 6/27/16 at 12:10 PM acknowledged verification that the needles items 6-15 mentioned above were outdated.

Registered Nurse Staff L interviewed on 6/27/16 at 3:15 PM acknowledged verification that items 16-17 mentioned above were outdated.

- Policy reviewed on 6/27/2016 at 4:00 PM revealed the CAH failed to develop a policy to ensure all expired supplies were not available for use.

- Labor/Delivery Room #1 observed on 6/27/2016 at 11:30 AM revealed the following outdated supplies:
1) One surgical glove size 6 ½ packet with expiration date of 1/2016.
2) One Insyte IV (Intravenous) catheter (needle placed in a vein) 20 gauge x1 1/4 inch found in the closet stored in a shoe holder with expiration date of 2/2016.


- Labor/Delivery Room #2 observed on 6/27/2016 at 11:40 PM revealed the following outdated supplies:
1) One Umbilical Cord Sterile Clamp (placed on Umbilical prior to cutting the infant's cord) packet with expiration date of 8/2015.
2) Two Surgical gloves size 7 and 8 with expiration dates of 6/2014 and 12/2014.


- Labor/Delivery Clean Utility Room observed on 6/27/2016 at 11:50 AM revealed the following outdated supplies:
1) One Ear/Ulcer Syringe (to irrigate ear or wound) with expiration date of 12/2015.
2) One box of Disposable tongue depressors (used to view back of throat) 100unit per box with expiration date of 7/2015.
3) Thirty Vitamin A and D ointment (to heal skin) individual packets with expiration date of 11/2015.

- Labor/Delivery Medication room observed on 6/27/2015 at 11:55 AM revealed the following outdated supplies:
1) Three Povidone Iodine (to disinfect skin) Prep pad with expiration dates of 3/2012 and 12/2013.
2) Two 4x4 dressing sponges in the Amniocentesis pack box with expiration dates of 3/2014 and 7/2015.
3) Three surgical gloves size 7, 7 ½, and 8 with expiration dates of 12/2014, 5/2015, and 3/2016.
4) Two cervical dilation kits size 7 and 8 with expiration dates of 12/2014 and 5/2015.

Registered Nurse Staff K interviewed on 6/27/2016 at 11:45 AM acknowledged the outdated supplies should have been disposed.

Based on observation, interview, record review and review of the Critical Access Hospital (CAH) policies and procedures the CAH failed to implement interventions to prevent infections and communicable diseases of patients and personnel as evidenced by:

1. Terminal Cleaning Procedure did not include the walls and the ceilings of the back-up Operating Room.

2. a. Equipment in the therapy room used by multiple patients was uncleanable due to tears and cracks in the material.
b. Layer of dust on a metal shelf.
c. Hydrocollator had build up on outside of the unit.

3. Sterile Equipment packages opened prior to need leaving them un-sterile.

4. Kitchen Equipment-airgaps had buildup of debris and trash and cutting boards had grooves in them leaving them un-cleanable.

5. Physical Therapy staff failed to perform hand hygiene between glove changes during a wound dressing change.

Failure to implement interventions to control infectious and communicable diseases potentially placed all patients and personnel at risk of illness.

Findings include:



1. The Procedure Room (also back-up Operating Room), observed on 6/27/16 at 3:25 PM, revealed Staff Q and Staff R performed the terminal cleaning (the process of disinfecting an operating room) at the end of the day. The walls and ceilings were not cleaned.

According to The Association of periOperative Registered Nurses (AORN) guidelines
for thorough cleaning and disinfection of surgical environments.
"Proper terminal cleaning protocol requires that cleaning staff wear proper
cleaning attire and personal protective equipment (PPE).

Proper protocol standards should also include special focus on high-touch
point cleaning of door handles, light switches, phones, keyboards, etc.,
utilizing the proper color-coded microfiber (colors designated for individual
areas of a facility) and hospital-grade disinfectant. Wall and ceiling areas
should be cleaned with a microfiber flat mop that is wet with sufficient
disinfectant solution and allowed proper dwell time. For floors, the area should
be flood mopped and, after proper dwell time, the solution recovered using a
wet/dry vacuum."

1. The therapy center observed on 6/27/16 at 2:25 PM revealed a small trampoline had multiple tears on the foam edging, a chair by one of the treatment beds had a tear on the back plastic cushion, and a foam pad used in treatments had multiple cracks and a tear in the center that was taped up. These areas were not cleanable and multiple patients use these items.

2. The metal supply cart across from the black refrigerator was observed to have a white layer of dust. Several pieces of equipment was on the cart and used for patient treatments.

3. Director of Housekeeping, Staff Q interviewed on 6/27/16 at 3:35 PM revealed the walls were cleaned once a week and not nightly according to their policy and standards or practice.

4. Record Review on 6/29/16 at 1:35 PM revealed the Hydocollator cleaning completed on 2/5/2016, 2/18/2016, 3/8/2016, and 5/14/2016. The Hydrocollator had white build up on the outside of the unit.

The hospital Policy and Procedure reviewed on 6/29/2016 at 1:30 PM "Hydrocollator Pack" revealed ... Additional Points of Consideration 3. The unit should be cleaned once a month depending on usage. Drain the tank and clean with a mild disinfectant and soap. Do not use abrasives ...

According to the Hydrocollator User Manual it states, "Regularly clean and drain the tank (every two weeks). Failure to properly maintain the unit will cause premature wear and will void the warranty."

This failure to maintain the hydrocollator placed patients at risk for ineffective treatment.



1. The Recovery Room Area observed on 6/27/16 at 3:15 PM revealed Bay 4 had a sterile suction tubing package was opened and setting behind the suction machine. Bay 5 had the sterile suction tubing open and attached to the suction machine. This tubing was not tagged as to when it was open.

2. The Computerized Axial Tomography (CAT) scan room observed on 6/28/16 at 10:25 PM revealed a sterile suction tubing had been opened and attached to the suction machine.

3. Registered Nurse (RN), Staff L interviewed on 6/27/16 at 3:15 PM verified the suction tubing was a sterile use product and opened prematurely.

4. Radiology Technician, Staff U interviewed on 6/28/16 at 10:25 AM verified the suction tubing was a sterile use item and was opened prematurely.

Failure to maintain sterile packaging until use puts patients at risk for infection.



The Therapy Wound Treatment Area observed on 6/27/16 at 1:25 PM revealed wound care performed by Physical Therapist (PT) Staff O had multiple glove changes while removing an old dressing soiled with blood and yellow drainage and failed to perform hand hygiene between glove changes. This practice potentially could cause re-infection to the patient.

Director of Infection control, Staff C interviewed on 6/28/16 at 2:50 PM revealed they have a hand hygiene policy and procedure that should have been followed.

Policy and Procedure review on 6/28/16 at 2:50 PM "Infection Control-Hand Hygiene"...If hands are not visibly soiled, use an alcohol based hand rub for decontaminating hands in all other clinical situations. Examples:...After skin or mucous membrane contact..."

Failure to perform effective hand hygiene put patients and staff at risk for infections from cross contamination.



1. Observation of the facility kitchen on 6/27/2016 at 12:20 PM revealed that two airgaps had a build-up of dark green debris and trash. One airgap was located under a sink with the garbage disposal and the second airgap was located next to the steam craft oven.

Interview with the facility dietician on 6/27/2016 at 12:30 PM revealed the kitchen staff were responsible for cleaning the kitchen.

Interview with the maintenance staff member on 6/28/2016 stated the kitchen staff were unable to clean the airgaps due to not having the correct cleaners and equipment. Maintenance staff were assigned to cleaning the airgaps.


2. Observation of the facility kitchen on 6/27/2016 at 1:40 PM revealed that 3 of the white cutting boards had multiple cuts and no longer had a smooth surface that was cleanable.

Interview with the facility dietician stated the hospital had ordered new color coded cutting boards.




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The Critical Access Hospital (CAH) reported a census of 8 acute inpatients and 2 swing bed patients. Based on medical record review, staff interview and policy review the CAH failed to ensure medical records are closed within 30 days of discharge for one of twenty-two discharged patients reviewed (Patient #10).

Findings include:

- Patient #10's medical record reviewed on 6/28/2016 revealed an admission date of 4/2/2016 for Pneumonia (infection in one or both lungs). The CAH failed to ensure the physicians, Staff V and Staff W signed their records within thirty days after the patient was discharged from hospital.

Director of Health Information Staff F interviewed on 6/29/2016 at 8:30 AM acknowledged the medical records should have been closed within 15 days after patient was discharged from the hospital per their policy.


- Medical Staff Rules and Regulations reviewed on 6/29/2016 at 4:00 PM directed " ...Medical records are to be completed within 15 days after the record becomes available to the physician ... "

The Critical Access Hospital (CAH) reported a census of 8 acute inpatients and 2 swing bed patients. Based on medical record review, staff interview and policy review the CAH failed to ensure the physician completed the discharge summary within thirty days after patient discharge for one of twenty-two discharged patients records reviewed (patient #10). This deficient practice had the potential for inadequate follow-up care.

Findings include:

- Patient #10's medical record reviewed on 6/28/2016 revealed an admission date of 4/2/2016 for Pneumonia (infection in one or both lungs). The medical record failed to contain a completed discharge summary within thirty days after the patient's discharge date.

Director of Health Information Staff F interviewed on 6/29/2016 at 8:30 AM acknowledged the physician did not have their discharge summary on the chart within 30 days of the patient being discharged.

Policy reviewed on 6/29/2016 revealed the CAH failed to develop a policy to ensure the physician completed their discharge summary within 30 days of a patient's discharge.

Based on interview and record review the facility failed to ensure the implementation of 30 day notices for 1 of 3 swing-bed patients reviewed (Patient #10) or notices as soon as practicable before swing-bed residents were transferred or discharged.



Findings include:



Review of patient #10's medical record revealed there was no 30 day notice or a notice as soon as practicable before discharge for this swing bed patients with a stay longer than 30 days.


Interview with the facility case manager on 6/29/2016 at 3:50 p.m. stated the hospital did not have a 30 day notice form for transfers or discharges to provide to swing bed patients.







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Based on interview and record review the facility failed to develop and implement a system to thoroughly investigate past histories of all potential employees to ensure they are fit for duty. Failing to investigate potential employees' history to rule out convictions of being found guilty of abusing, neglecting or mistreating resident(s) by a court of law or had a finding entered into the State nurse aide registry placed all Swing-bed patients at risk for potential abuse, neglect or mistreatment.


Findings include:


Review of 6 employee files lacked evidence thorough background checks to rule out history of convictions were conducted prior to employment.


Interview with the Administrative team on 6/29/2015 revealed background checks were only conducted on staff members who worked in a home health setting. Staff members that provided care and services to Swing-bed patients did not have background checks conducted.

Based on interview, record review and hospital documents, the Critical Access Hospital (CAH) failed to provide evidence of the patient being encouraged to participate in care planning meetings for 2 of 3 swing bed records review (#22 and #23). Failure to encourage patients to attend their care plan meeting does not promote the patient's rights to make decisions concerning their care, including the right to refuse care and to assure services are furnished to attain and maintain the patient's highest practical physical, mental and psychosocial well-being.

Findings include:

Record review on 6/28/16 at 3:55 PM of swing bed patients #22 and #23 failed to provide documentation of the patients being encouraged to attend weekly care plan meetings.

Registered Nurse (RN) Staff X interviewed on 6/28/16 at 3:55 PM acknowledged there was no evidence swing bed patients had been encouraged to attend the care plan meetings.

Hospital Document reviewed on 6/28/16 at 3:55 PM "Community Memorial Healthcare Swing Bed Resident Rights"...#17. Is aware that one and one's family are encouraged to participate in the planning of one's care including discharge planning. Residents and their representatives are encouraged to participate in the care plan meeting which is held every Tuesday at 11:30 AM. The Discharge Planner will make every attempt to contact one's family regarding participation in the planning of one's care.