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Based on policy and procedure manual review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel annually review the CAH's health care policies and procedures in 2017 for 9 of 10 policy and procedure manuals (Nursing, Cardiac Rehabilitation, Physical and Occupational Therapy, Respiratory Therapy, Laboratory, Radiology, Surgery, Anesthesia, and Central Supply) reviewed. Failure to have the required group of professional personnel annually review the policies and procedures limited the CAH's ability to ensure the policies and procedures were current and followed regulations and standards of practice.

Findings include:

Review of the CAH's policy and procedure manuals occurred on all days of the survey. The following manuals lacked evidence of annual review in 2017 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel): Nursing, Cardiac Rehabilitation, Physical and Occupational Therapy, Respiratory Therapy, Laboratory, Radiology, Surgery, Anesthesia, and Central Supply. The following manuals lacked evidence of annual review in 2017 by a physician (a required member of a group of professional personnel): Nursing, Physical and Occupational Therapy, Respiratory Therapy, and Anesthesia.

During interview on 6/27/18 at 11:15 a.m., an administrative staff member (#4) confirmed the CAH had failed to have the required group of professional personnel annually review the CAH's health care policies and procedures in 2017.

Upon request on 6/27/18, the CAH failed to provide a policy requiring annual review of their health care policies and procedures by the required group of professional personnel.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure a sanitary environment in 1 of 1 kitchen. Failure to ensure sanitary conditions in the food preparation area and the walk-in freezer may result in the spread of foodborne illness within the CAH.

Findings include:

Observation in the kitchen occurred on 06/25/18 at 8:00 a.m. with a dietary staff member (#1) and identified the following:
* Two large chunks of ice (approximately 6 inches by 2 inches) on the floor in the walk-in freezer - observation showed a build-up of ice on the light fixture on the ceiling, water dripping from the light fixture, and deterioration of the ceiling at the edges of the light fixture with portions of the ceiling loose and flaking off
* Rust accumulation in three steel drawers containing utensils used for food handling - observation showed the paper lining in the drawers torn and exposing the rusted areas
* Serving bowls and baking pans stored upright on open shelves creating the potential for dust, insects, etcetera to accumulate in the bowls/baking pans

When interviewed during the observations, a dietary staff member (#1) confirmed the deteriorating ceiling in the freezer and the rust accumulation in the drawers and stated staff should store bowls and pans facing downward to avoid contamination.

Based on observation, review of facility menus, and staff interview, the Critical Access Hospital (CAH) failed to follow recognized dietary practices during meal service for 1 of 2 meals observed (lunch on 06/26/18). Failure to ensure staff served appropriate portion sizes for food limited the CAH's ability to ensure patients received the recommended daily nutritional requirements.

Findings include:

Observation of food service occurred on 06/26/18 at 11:30 a.m. with a dietary manager (#1) and a cook (#3). The cook (#3) dished mixed vegetables onto patient trays using a slotted spoon. When asked what serving size the spoon provided, the staff member (#3) stated "about 1/2 cup." Observation of the spoon failed to identify a serving size. The staff member (#3) then placed a beef roll-up on each patient's tray and served gravy from a 1/2 cup ladle by filling the ladle and pouring gravy over two to three roll-ups then refilling the ladle and repeating the process. When asked the serving size for the gravy, the dietary manager (#1) stated the cook "should have used a 1/4 cup ladle."

Review of the CAH menu for the noon meal occurred on 06/26/18 and identified the serving size for the vegetables as 1/2 cup and the gravy as a #30 scoop which provides 1/8 cup.