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Based on observations, review of policies and procedures, and staff interviews, the facility failed to implement a process for ensuring all areas of the operating room were disinfected and cleaned routinely. In addition the facility failed to develop policies and procedures for cleaning and disinfecting the wall vents and ceilings for 2 of 2 operating rooms. The findings were:

Operating room cleaning technician #1 was observed performing terminal cleaning for 2 of 2 operating rooms on 2/28/18 from 6 AM to 7:30 AM. During the observation the technician did not clean and disinfect the ceilings and wall vents. Interview at that time revealed the technician cleaned both operating rooms every morning, even though one of the two rooms was primarily used for storing equipment. She further stated she had not been instructed to routinely clean and disinfect the wall vents and ceilings. Interview with the surgery supervisor on 2/28/18 at 7:30 AM revealed she was not aware of a schedule for cleaning the vents; and she thought staff were cleaning and disinfecting the ceilings when they cleaned the walls. She further stated she had not revised the policy and procedure, or implemented a process to ensure the walls and vents were routinely cleaned and disinfected. Observation during the interview showed, the surgery supervisor wiped the wall vents with a disposable disinfection cloth and removed dust and lint from both vents. Review of the policy and procedure titled, "Cleaning in Operating, Recovery, and all Other Surgical Work Areas Procedure," revised May 2017, revealed cleaning the wall vents and ceilings was not addressed.

Based on review of policies and procedures, and staff interview, the facility failed to develop policies and procedures for administration of all drugs and biologicals that adhered to accepted standards of practices. The findings were:

Review of policies and procedures revealed none had been developed that addressed acceptable standards of nursing practice for medication administration in the following areas:
a. Self-administration of medications.
b. Assessment/monitoring of patients receiving medications.
c. Scheduling for time-critical medications.
d. Identified parameters within which nursing staff are allowed to use their own judgement regarding rescheduling of missed or late doses; and when notification of the practitioner responsible for the care of the patient is required prior to doing so.
e. Medications or categories of medications eligible and not eligible for scheduled dosing times, based on the nature of the medication and its clinical application, to ensure safe and timely administration.
f. An annual review of each standing order and process for identification and timely completion of any requisite updates, corrections and modifications or revisions based on changes in nationally recognized, evidence-based guidelines

During interviews on 2/28/18 at 2:40 PM with the registered pharmacist and on 2/28/18 at 3 PM with the director of patient care services, both verified the lack of the above required policies and procedures.

Based on staff interview, review of facility provided mortalities rates, and review of the Donor Alliance Organization contract, the facility failed to ensure the Organ Procurement Organization (OPO) was notified in a timely manner for individuals whose death was imminent or who died in the critical access hospital (CAH). The findings were:

1. Review of the hospital mortalities data showed the facility had 69 deaths from 2015-2017. Further review showed 5 deaths during that timeframe were not reported in a timely manner to the Donor Alliance Organization.

2. Interview with the utilization review nurse on 2/28/18 at 2:40 PM revealed she was unaware of the significance of not reporting to the OPO in a timely manner. Further, she stated "I didn't understand the full process," and if an issue came up the nurses were re-educated about calling in a timely manner.

3. Review of the contract between the CAH and the OPO, executed 8/22/13 and renewed annually, showed: "Duties of the Donor Hospital; Provide timely referral to Donor Alliance of all imminent deaths... Referrals are made within a timely manner so that an on-site evaluation can be conducted to determine the medical, legal, and behavioral suitability of the referral..."

Based on staff interview, review of facility provided mortalities rates, and review of the Donor Alliance Organization contract, the facility failed to ensure qualified individuals designated by the CAH initiated the request for organ donation with family members. The findings were:

1. Review of the hospital mortalities data showed the facility had 69 deaths from 2015-2017. Further review showed for 2 deaths during that timeframe requests with families for organ and tissue donations were initiated by persons who were not designated requestors.

2. Interview with the utilization review nurse on 2/28/18 at 2:40 PM revealed when an issue came up, the nurse who improperly initiated the requests was re-educated and reminded they were not authorized to complete those requests.

3. Interview with the infection control nurse on 2/28/18 at 1:15 PM confirmed the CAH had 6 representatives on staff that had completed the Designated Requestor training and were authorized to contact potential donor families.

4. Review of the contract between the CAH and the OPO, executed 8/22/13 and renewed annually, showed: "1. Definitions: ... d. Designated Requestor-refers to a hospital representative who has completed training by Donor Alliance regarding the methodology for approaching Potential Donor Families..."

Based on employee record review, staff interview, and policy and procedure review, the facility failed to ensure pre-employment screening was completed for 3 of 15 employee files reviewed (Certified Nursing Assistant (CNA) #1, #2, #3). The findings were:

1. Review of the employee record for CNA #1 showed a date of hire of 3/9/16. Further review showed no evidence a State nurse aide registry screening was completed at the time of hire.

2. Review of the employee record for CNA #2 showed a date of hire of 2/1/11. Further review showed no evidence a criminal background check was completed at the time of hire.

3. Review of the employee record for CNA #3 showed a date of hire of 1/18/2000. Further review showed no evidence a criminal background check was completed at the time of hire.

4. Interview with the human resources manager on 2/28/18 at 3:03 PM confirmed she was unable to locate criminal background checks for CNA #2 and CNA #3. She stated "I had to re-run the checks today." Further, she confirmed she had not completed a State nurse aide registry screening for CNA #1.

5. Review of the policy titled "Background Investigations", last reviewed 9/16, showed: "... During the selection process the applicant will be informed that the Human Resources Department will conduct a background investigation prior to hiring...a. The Human Resources Director, or designee will access the Office of Healthcare Licensing and Surveys to ascertain if the Certified Nursing Assistant (CNA) has any abuse claims against him/her..."