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Based on observations, record reviews, interview, and review of the Critical Access Hospital's (CAH) policies and procedures, the CAH failed to provide documentation of preventative maintenance for scales, eyewash stations, and negative pressure devices in the CAH's Medical Surgical Unit (MSU) and Emergency Room (ER).

The findings are:

On 10/22/2019 at 2:00 PM, a tour of the MSU and ER revealed the CAH's preventative maintenance logs had no documentation that preventative maintenance for the scales, eyewash stations, and negative pressure room devices was performed. Director 1 verified the findings at 2:00 PM on 10/22/2019. On 10/23/2019 at 12:35 PM in an interview, the Maintenance Director verified the findings and stated, "Maintenance items fall under me."

On 10/22/2019 at 10:25 AM, review of the CAH's Quality Assurance Performance Improvement (QAPI) data and the CAH's Infection Control (IC) data for the CAH"S MSU and ER dated October 2018 to December 2018 revealed the preventative maintenance for equipment in ER and the MSU was not done for the Hoyer Lift, digital scales, portable scale, and infant scale, eyewash stations in the ER and MSU, preventative maintenance to the negative pressure devices in Room 55 on the MSU and ER 3. Review of the CAH's QAPI and Infection Control data for January 2019 to March 2019 and April 2019 to June 2019 revealed there was no documentation of preventative maintenance for the scales, eyewash stations, and negative pressure devices performed. The findings were verified by Director 1 at 2 PM on 10/22/2019.

On 10/22/2019 at 11:10 AM, review of the Medical Executive Committee (MEC) minutes dated 11/14/2018, 12/12/2018, 1/9/2019, 3/13/2019, 5/8/2019, 7/10/2019, and 9/11/2019 had no documentation of review of the preventative maintenance contracts and responsibilities to ensure all hospital equipment requiring preventative maintenance was performed per the contract. The finding was verified by Director 1 at 12:15 PM on 10/23/2019.

On 10/23/2019 at 8:53 AM, observations of the door to the CAH's designated negative pressure room on the MSU (Room 55) would not close and remain closed to allow the room to maintain a negative pressure. The finding was verified by Director 1 at 8:53 AM on 10/23/2019.

On 10/23/2019 at 10:25 AM, review of the CAH's maintenance contract revealed the negative pressure room devices were not included in the CAH's preventative maintenance contract. The finding was verified by Director 2 at 10:45 AM on 10/23/2019 who stated, "The negative pressure room maintenance falls under the Maintenance Director." On 10/23/2019 at 12:35 PM, the Maintenance Director verified that he/she is responsible for the maintenance of the negative pressure room devices.

On 10/23/2019 at 10:30 AM, review of the hospital's policies and procedures, titled, "Emergency Eye Wash Check and Log", stated, "Each station is flushed weekly every month. The information is logged and stored in the Eye Wash Weekly Log." The finding was verified by Director 1 at 10:30 AM on 10/23/2019.

On 10/23/2019 at 10:30 AM, review of the hospital's policy and procedure, titled, "IC Maintenance Department", stated, "Air pressure monitoring will be completed every month and logged in the negative pressure monitor test sheet/log. Manufacturer recommendations is for monitors to be recallibrated annually." The finding was verified by Director 1 at 10:30 AM on 10/23/2019.

Based on observations and interview, the Critical Access Hospital(CAH) failed to ensure foods observed in the CAH's dietary kitchen dry food storage area were not labeled, and raw chicken in the walk in cooler that had been placed in the walk in cooler 6 days previously to the survey.

The findings are:

Observations of the dry food storage on 10/21/19 at 12:46 PM revealed an opened box of onion soup mix in a plastic bag with no date when the box was opened or with a use by date, an opened bag of grits in a plastic bag no date when opened or a use by date, an opened package of gravy mix in a plastic bag with no opened date and no use by date, an opened pack of cream of chicken soup mix in a plastic bag that was sticky to touch with no opened date and no use by date. Observations of the CAH's walk in cooler revealed a metal bowl with thawed raw chicken legs dated 10/15/19. During an interview with the Dietary Manager on 10/22/19 2:00 PM, he/she revealed all opened foods should be labeled with the date the foods were opened and with a date that the foods should be used by.

Based on record reviews, interview, and review of the Critical Access Hospital's(CAH) policies and procedures, the CAH failed to ensure telephone verbal orders were authenticated per the CAH's policy within 48 hours by the ordering physician for 3 of 20 closed patient charts reviewed for verbal orders. (Patient #S2, #S3 and ED #7)

The findings include:

Review of Patient #S2's physician's orders on 10/22/19 at 11:00 AM revealed a telephone verbal order dated 10/17/19 at 10:40 AM for Thorazine 25 mgs(milligrams). The ordering physician did not authenticate the verbal telephone order until 10/21/19 at 1:04 PM which was 4 days after the verbal telephone order was written.

Review of Patient #S3's physician orders on 10/22/19 at 11:14 AM revealed a telephone verbal order for Fosamax 70 mgs dated 10/17/19 at 10:49 AM. The ordering physician did not authenticate the verbal telephone order until 10/21/19 at 1:04 PM which was 4 days after the verbal telephone order was written.

During an interview with Director of Nursing(DON) on 10/22/19 at 11:55 AM, the DON verified that the ordering physician did not authenticate the verbal orders within 48 hours after the verbal orders were written.




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Patient 7
On 10/23/2019 at 11:43 AM, review of Patient #ED7's chart revealed two verbal orders dated 7/18/2019 were not authenticated by the physician until 7/23/2019 which was 5 days after the verbal order was written. The finding was verified by RN #1 at 11:43 AM on 10/23/2019.

On 10/21/2019 at 2:38 PM, review of the CAH's policy and procedure, titled, "Verbal Orders", stated, "All verbal orders will be signed by the ordering physician within forty-eight hours of giving the verbal order." The finding was verified by Director #1 at 2:38 PM on 10/21/2019.

Based on review of patient charts, interview, and review of the Critical Access Hospital's (CAH) policies and procedures, the CAH failed to ensure the patient's Plan of Care (POC) was individualized and addressed identified problems for one of two current inpatient charts reviewed (Patient #A5).

The findings are:

Patient #A5
On 10/21/2019 at 1:15 PM, review of Patient #A5's chart revealed the patient was admitted on 10/18/2019 with a diagnosis of seizure and possible Cerebrovascular Accident (CVA). Review of the diet orders revealed the patient was to receive nothing by mouth (NPO) due to aspiration precautions, and the patient could not perform activities of daily living such as bathing. Patient #A5 POC failed to identify and assess the patient's needs related to seizure precautions, aspiration precautions, or the need for assistance with bathing and toileting. The finding was verified by Registered Nurse #1 at 1:44 PM on 10/21/2019.

On 10/22/2019 8:30 AM, review of the CAH's policies and procedures for developing the patient plan of care reads, "The POC shall be updated with revisions reflecting the reassessment of needs of the patient." The finding was verified by the Director #1 at 8:30 AM on 10/22/2019.