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Based on observations, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to create and implement an effective system to ensure staff detected when hot water temperatures exceeded the CAH's acceptable range for hot water (between 110 - 120 degrees Fahrenheit.

The CAH administrative staff reported a census of 1 inpatient at the beginning of the survey.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury related directly to the temperature and duration of exposure to the hot water. Exposure to hot water at 133 degrees Fahrenheit can cause a third-degree burn (destruction of the outer layer of skin and the entire layer beneath) to occur is 15 seconds, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit.

Findings include:

1. Observations on 4/10/23 to 4/13/23, during the surveying tour of the CAH's facilities with the Chief Clinical Officer (CCO) and the Medical Surgical/Emergency Room Manager, revealed the following hot water temperatures at the hand washing sinks in several areas of the CAH:

a. Public bathroom- Emergency Room - 130.8 degrees Fahrenheit.
b. Medical Surgical Room #270 - 122.5 degrees Fahrenheit.

2. Review of the policy "Maintenance and Monitoring of Water Systems," approved 3/2023 revealed in part, " ...The Domestic Hot water system will be monitored on a regular schedule for temperature. This is required to prevent complaints of water that may be too cold and or water that may be dangerously hot. The host water systems temperature should range between 110 to 120 degrees ...If any temperature are above 120 degrees the hot water system will need adjusted to maintain the correct temperature. If adjustments are needed perform water temperature testing the next day and every week for two weeks to confirm temp is below 120 degrees. Record all findings on PM or develop a work order to make corrections. "

3. Review of documentation from 1/10/21- 4/21/22 of the Hospital Boiler Room checks revealed the water temperatures were recorded daily at various locations throughout the CAH. However, the documentation of testing water temperatures discontinued after 4/21/22.

The administrative staff failed to have a process in place to test and record the water temperatures throughout the facility, thereby allowing the maintenance staff to detect abnormal water fluctuations allowing the CAH to maintain acceptable range for hot water temperatures.

4. During an interview on 4/12/2023 at 10:00 AM with the CCO, Quality & Compliance Specialist, and Facilities Director Plant Operations revealed the previous Environmental Service Manager (EVS) had been in charge of routine water temperature checks and testing. The EVS Manager resigned around February 2023. The new administrative staff were unaware the EVS manager was not attending to the issue with the hot water temperatures. The Facilities Director Plant Operations acknowledged the water temperatures exceeded the CAH's acceptable limit for hot water temperatures (120 degrees Fahrenheit). The Facilities Director Plant Operations contacted an engineering company to address the issue.

Based on document review and staff interviews the Critical Access Hospital (CAH) failed to approve policies for 2 of 3 contracted patient care services provided to CAH's patients (Therapies and Sleep Studies).

Failure to ensure policies and procedures are developed and approved by the medical staff and governing body could potentially result in miscommunication of expected practices and performances in the provision of patient care and result in patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm.

The CAH Administrative staff identified the facility had a census of one on entrance.

Findings based on:

1. Review of the policy "Policy Development and Approval Process", dated last Revised 11/2022, revealed in part..."all...departmental policies and procedures...will be approved by the Critical Access Hospital (CAH) Policy Committee...".

2. Review of the document "Policy Index", revealed the index lacked policies for two of the hospitals contracted services, [name of service] which provides physical therapy, occupational therapy, speech therapy and for [name of service] which provides sleep studies.

3. During an interview on 4/12/2023 at 8:45 AM, the Quality & Compliance Specialist verbalized the "Policy Index" was current and contained all the policies that had been approved through the CAH Policy Committee. The Quality & Compliance Specialist verbalized the therapy department and the sleep study service utilized their own company's policies for providing patient care services and these policies were not reviewed or approved by the CAH Policy Committee. The contracted services policies could only be accessed by contracted department staff and could not be accessed by other CAH staff as the policies are not published with the CAH's approved policies.

Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscopy procedures for each patient, in accordance with the manufacturer's directions.

Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient.

The hospital's administrative staff identified that an average of 13 endoscopy procedures per month perform per fiscal year from 07/01/2021to 06/30/2022.

Findings include:

1. Observations during a tour of the surgery department on 04/11/2023 at approximately 10:10AM with the Surgery Manager, Surgery RN A, and the Chief Clinical Officer (CCO) revealed 1 of 1 bottle B. Braun 1,500 mL bottle of sterile water for irrigation connected to the endoscopy equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions indicated in part, " ...After opening container, its contents should be used promptly to minimize the possibility of bacterial growth or pyrogen formation. Discard unused portion of irrigating solution since it contains no preservative ...Single unit container. Discard unused portion."

3. During an interview at the time of the tour, Surgery Manager, Surgery RN A, and CCO reported the surgery staff opened the bottles of sterile water for irrigation each day for endoscopy procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscopy procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscopy procedures. The Surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

4. During an interview on 04/11/2023 at approximately 10:10 AM, the Surgery Manager reviewed and confirmed the manufacturer's directions for the bottles of sterile water for irrigation. The Surgery Manager acknowledged the manufacturer's documentation did not support using the bottles of sterile water for irrigation for more than one patient.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physician notification for the occurrence of a medication error for 5 of 10 medication errors reviewed. (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5).

Failure to notify the physician of medication errors could potentially result in the practitioner not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the practitioner making a medical decision without the knowledge of the medication error, potentially resulting in inappropriate treatment or even a fatal reaction.

The CAH administrative staff identified a census of 1 patient at the beginning of the survey.

Findings include:

1. Review of CAH policy, "Occurrence Reporting Patients and Visitors," approved 4/2023, revealed in part, " ... notify the attending provider of any occurrence affecting the care of the patient."

2. Review of medication errors from May 13, 2022 to February 10, 2023 revealed the practitioner was not notified in the following medication error records:

a. The nursing staff administered Metformin (used to lower blood sugar levels) after Patient #1 had received Cat Scan (CT) Contrast (a special dye used with a series of x-ray images) on 5/13/22 at 5:00 AM. Metformin should be stopped at the time of or prior to CT studies with IV Contrast, and withheld for 48 hours after the procedure due to potential for kidney damage. Patient #1's medication error lacked documentation of the date and time of discovery of the medication error and that the practitioner responsible for Patient #1's medical care was notified.

b. The nursing staff administered the wrong dose of medication on 8/10/22 at 9:30 AM which involved Patient #2. Patient #2's medication error lacked documentation of the date and time of discovery and that the practitioner responsible for Patient #2's medical care was notified.

c. The nursing staff administered medication at the wrong time on 12/13/22 at 5:00 AM which involved Patient #3. The error was discovered on 12/13/22 at 8:00 AM. Patient #3's medication error information lacked documentation of the date and time that the nursing staff notified the practitioner responsible for Patient #3's medical care.

d. The nursing staff administered the wrong medication dose on 12/13/22 at 3:00 AM which involved Patient #4. The error was discovered on 12/13/22 at 8:30 AM. Patient #4's medication error information lacked documentation of the date and time that the nursing staff notified the practitioner responsible for Patient #4's medical care.

e. The nursing staff administered the wrong medication dose on 2/10/23 at 12:32 PM which involved Patient #5. The error was discovered on 2/10/23 at 1:51 PM. Patient #5's medication error information lacked documentation of the date and time that the nursing staff notified the practitioner responsible for Patient #5's medical care.

3. During an interview on 4/11/23 at 10:35 AM, the Pharmacy Manager acknowledged that the medication errors had not been reported to the practitioner immediately upon discovery.

Based on medical record review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the development of a care plan for 10 of 10 sampled patients (Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14).

Failure to develop and keep current a care plan that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible.

The CAH administrative staff identified a census of 1 patient on entrance.

Findings include:

1. Review of CAH policy "Care Plans," approved 09/2022, revealed in part, "...all patient/residents ...have an individualized, comprehensive care plan that includes measurable objectives and time lines to meet the medical, nursing, mental, and psychosocial needs of each patients/residents as identified in the admission comprehensive assessment."

2. Review of closed acute inpatient medical records revealed the following:

a. The CAH staff admitted Patient #6 to skilled nursing status from 1/27/2023 - 2/3/2023 for strengthening due to blood lost and post-surgery from another facility. Patient #6's medical record lacked evidence of any nursing care plan that had been developed since Patient #6's admission.

b. The CAH staff admitted Patient #7 to skilled nursing status from 10/28/2022 - 11/1/2022 for strengthening due passing out and fracturing the collar bone. Patient #7's medical record lacked evidence of any nursing care plan that had been developed since Patient #7's admission.

c. The CAH staff admitted Patient #8 to skilled nursing status from 10/28/2022 - 11/1/2022 for strengthening due electrolyte imbalance (occurs when you have too much or not enough of certain minerals in your body) requiring electrolyte replacement. Patient #8's medical record lacked evidence of any nursing care plan that had been developed since Patient #8's admission.

d. The CAH staff admitted Patient #9 to skilled nursing status from 2/21/2023 - 2/24/2023 for strengthening due stroke like symptoms. Patient #9's medical record lacked evidence of any nursing care plan that had been developed since Patient #9's admission.

e. The CAH staff admitted Patient #10 to skilled nursing status from 1/3/2023 -1/12/2023 for strengthening due a recent fall. Patient #10's medical record lacked evidence of any nursing care plan that had been developed since Patient #10's admission.

f. The CAH staff admitted Patient #11 to acute inpatient care from 11/25/2022 - 12/1/2022 for altered mental status. Patient #11's medical record lacked evidence of any nursing care plan that had been developed since Patient #11's admission.

g. The CAH staff admitted Patient #12 to acute inpatient care from 12/26/2022 - 12/29/2022 for pneumonia. Patient #12's medical record lacked evidence of any nursing care plan that had been developed since Patient #12's admission.

h. The CAH staff admitted Patient #13 to acute inpatient care from 12/18/2022 - 12/20/2022 for symptoms of difficulty breathing, cough and respiratory problems. Patient #13's medical record lacked evidence of any nursing care plan that had been developed since Patient #13's admission.

i. The CAH staff admitted Patient #14 to acute inpatient care from 3/23/2023 - 3/27/2023 for shortness of breath and atrial fibrillation (is a quivering or irregular heartbeat). Patient #14's medical record lacked evidence of any nursing care plan that had been developed since Patient #14's admission.

3. During an interview on 4/12/2023 at 2:39 PM, with the Medical Surgical Manager, Chief Clinical Officer (CCO) and Chief Executive Officer (CEO) revealed that these patients did not have a care plan developed. Medical Surgical Manager verified that during his examination of the patient charts it appeared that care plans have not been done on any of the patients.

Based on review of policies, medical records, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation (rehab) services for 5 of 5 swing bed patients (Patients #6, Patient #7, Patient #8, Patient #9, and Patient #10).

Failure to ensure a physician ordered specialized rehab services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition.

The CAH administrative staff identified a census of 1 inpatient at the beginning of the survey.

Findings include:

1. Review of policies/procedures revealed the lack of a policy/procedure that addressed orders for specialized rehab services for swing bed patients were written by a physician.

2. Review of the closed medical records revealed:

a. Patient #6 was admitted for swing bed services on 1/27/2023 for strengthening due to blood lost and post-surgery from another facility. An electronic order entry dated 1/27/23 at 3:01 PM revealed Physician B, ordered Physical Therapy and Occupational Therapy Evaluation & Treatment. The documentation lacked evidence that Occupational Therapy ever performed an evaluation or treatment on Patient #6.

b. Patient #7 was admitted for swing bed services on 10/28/2022 for strengthening due passing out and fracturing the collar bone. An electronic order entry dated 10/28/22 at 2:12 PM revealed Hospitalist C, Physician Assistant (PA), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 10/28/19 at 2:43 PM revealed Hospitalist C, PA, ordered Occupational Therapy and Evaluation & Treatment.

c. Patient #8 was admitted for swing bed services on 10/28/2022 for strengthening due electrolyte imbalance (occurs when you have too much or not enough of certain minerals in your body) requiring electrolyte replacement. An electronic order entry dated 3/5/23 at 3:03 PM revealed Hospitalist D, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 3/5/23 at 3:03 PM revealed Hospitalist D, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

d. Patient #9 was admitted for swing bed services on 2/21/2023 for strengthening due stroke like symptoms. An electronic order entry dated 2/21/23 at 7:55 PM revealed Hospitalist D, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 2/21/23 at 7:55 PM revealed Hospitalist D, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

e. Patient #10 was admitted for swing bed services on 1/3/2023 for strengthening due a recent fall. An electronic order entry dated 1/4/23 at 12:47 PM revealed Hospitalist D, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/4/23 at 12:47 PM revealed Hospitalist D, ARNP, ordered Occupational Therapy and Evaluation & Treatment. An electronic order entry dated 1/4/23 at 12:47 PM revealed Hospitalist D, ARNP, ordered Speech Therapy and Evaluation & Treatment. Documentation for Patient #10 lacked evidence that a Speech Therapy Evaluation was performed.

3. During an interview on 4/12/2023 at 2:39 PM, with the Medical Surgical Manager, Chief Clinical Officer (CCO) and Chief Executive Officer (CEO) revealed they were unaware that ARNP's and PA's could not write orders for therapies for swing bed patients.

During an interview on 4/12/2023 at 8:45 AM, with the Quality & Compliance Specialist acknowledged the lack of a policy/procedure that addressed orders for specialized rehab services for swing bed patients were written by a physician.