HospitalInspections.org

Based on hospital document review, observations, and staff interviews, the CAH (critical access) failed to ensure the building was maintained in a manner to ensure safety and well being of patients.

Findings:
1. On the morning of 01/13/2015, surveyors toured the facility with Staff A and Staff B. Surveyors observed the following:

A waiting area that was designated for ED (emergency department) patients and visitors/family for inpatients. This was verified by Staff A, Staff B, and Staff C.

One entrance for ambulances and for walk up patients. This was verified by Staff A, Staff B, and Staff C.

The bone density room in the radiology department is designated for airborne isolation patients. This room is not a negative pressure (isolation) room. This room is not capable of monitoring the patient nor visualizing the patient by medical staff. This was verified by Staff A, Staff B, and Staff C.

2. On the morning of 01/13/2015, surveyors asked Staff A, Staff B, and Staff C if the bone density room in the radiology department is a negative pressure isolation room. Staff A, Staff B, and Staff C told surveyors it is not a negative pressure isolation room.

3. On the morning of 01/13/2015, surveyors requested the CAH policy and procedure regarding patients presenting to the ED with an suspected airborne disease.

4. On the morning of 01/13/2015, the DON provided surveyors with a policy titled, "Patients With Suspected Tuberculosis" that documented, "...Any patient with the following criteria will be escorted to a negative pressure room for isolation..."

5. On the afternoon of 01/13/2015, the DON verified that the CAH is not following the CAH's policy as specified above.

6. On the morning of 01/13/2015, Staff I, Staff N, and Staff W told surveyors that and inpatient room (101) is used for ED over flow patients frequently.

7. On the afternoon of 01/14/2015, hospital administration verified that inpatient room 101 is being used for ED over flow patients.

8. On the afternoon of 01/14/2015, surveyors requested to see the CAH's facility plans. The facility/plant manager brought facility plans to surveyors. The facility plans documented the ED waiting room was located elsewhere (where the vending machines reside by radiology) and has re-purposed areas of the CAH.

9. On the afternoon of 01/14/2015, the CEO and plant/facility manager did verify the ED wasting area (currently where vending machines were located by radiology).

10. On the afternoon of 01/14/2015, the findings were discussed at exit conference.

Based on hospital documents, credentialing file reviews and staff interviews, the CAH (critical access hospital) failed to ensure physicians that requested privileges were approved for the specific privileges requested. This occurred in five of nine credentialing files.

Findings:
1. On the morning of 01/13/2015, surveyors requested medical staff and governing body meeting minutes from 2013 to current.

2. Surveyors reviewed medical staff and governing body meeting minutes. There was no documented evidence that the 5 (V, CC, OO, PP, and QQ) of 9 physicians were granted privileges that they requested.

3. On the afternoon of 01/13/2015, surveyors reviewed nine (V, AA, BB, CC, LL, MM, OO, PP, QQ) of nine credential files requested. Five of nine credentialing files did not contain documented evidence that the governing body had approved them for the specific privileges requested.

4. On the afternoon of 01/14/2015, the HR administrator verified that five credentialing files did not contain documented evidence of specific privileges granted by the governing body.

5. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No further information was provided.

Based on hospital documents, observations, and staff interviews the CAH (critical access hospital) failed to:

a. ensure all patient care policies are consistent with applicable State law. See Tag C-0271;

b. ensure policies were developed with the advice of a group of doctors and mid-level practitioners. See Tag C-0272;

c. ensure policies and procedures were adopted and in place for health care services provided on site. See Tag C-0273;

d. ensure pharmaceutical services were in accordance with acceptable standards. See Tag C-0276;

e. have an ongoing infection control program to ensure a safe environment. See Tag C-0278;

f. ensure the nutritional needs of inpatients were met. See Tag C-0279

g. ensure policies are reviewed at least annually by the professional personnel. See Tag C-0280;

h. ensure inspections of radiology equipment were conducted and problems identified were corrected in a timely manner. See Tag C-0283;

i. maintain a list of all services furnished under arrangement or agreements. See Tag C-0291.

Based on policy and procedure review, medical record review, and staff interviews, the CAH (critical access hospital) failed to ensure all patient care policies are consistent with applicable State law.

Findings:

1. The Oklahoma State Board of Pharmacy regulation for multiple-dose containers [OAC 535:15-10-54 (f)] documented, "The BUD (beyond use dating) after initially entering or opening (e.g., needle-punctured) multiple-dose containers is 28 days unless an alternate time period is otherwise specified by the manufacturer..."

2. On the morning of 01/14/2015, a policy titled, "Multiple Dose Containers" provided by Staff G documented, "...Multiple dose vials are to be dated and initialed as of the first usage and returned to the Pharmacy after thirty (30) days and discarded...Multiple dose vials of insulin are to be dated and initialed as of the first usage and returned to the Pharmacy after ninety (90) days and discarded..."

3. On the afternoon of 01/13/2015, surveyors were told by multiple nursing staff that LPNs (licensed practical nurses) and paramedics triage ED (emergency department patients).

4. On the afternoon of 01/13/2015, surveyors were told by multiple nursing staff that LPNs conducts comprehensive initial assessments on admitted patients.

5. On the morning of 01/14/2015, Staff I told surveyors that LPNs and paramedics were triaging ED patients which was not in their scope of practice. Staff I told surveyors that RNs (registered nurses) were the only ones who should be triaging ED patents and had discussed this with nursing and ancillary staff in the hospital.

6. On the morning of 01/14/2015, Staff I verified that LPNs were conducting initial inpatient admission assessments of admitted patients.

7. Oklahoma State Board of Nursing Practice Act (OBN Policy/Guideline#P-14 Page 2 of 2, Revised 7/24/12) documented, "...Licensed practical nursing means the practice of nursing under the supervision or direction of a registered nurse..." and "...The Licensed Practical Nurse contributes to assessment of the patient by conducting focused assessment of the client through collecting data, comparing the data collected to the client's previous condition, and determining when, to whom and where to report the data collected..."

8. On the afternoon of 01/14/15, surveyors were given a document titled, "Admissions/ER" that documented, "RN will be responsible for all inpatient admission assessments. LPNs will be responsible for admission history, discharge planning summary and documenting of home meds of inpatients. On ER patients, the RN will initiate ER Triage and assessment and complete necessary documentation and then LPN/Paramedic will modify/add to the RNs assessment for completion."

9. The CNO (chief nursing officer) verified that LPNs and paramedics were conducting triage. The CNO verified that LPNs were conducting initial inpatient admission assessments.

10. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on policy and procedure review, medical staff and governing body meeting minutes review, and staff interviews, the CAH (critical access hospital) failed to ensure there were policies developed with the advice of a group of doctors and mid-level practitioners.

Findings:

1. On the afternoon of 01/13/2015, Staff B told surveyors that policies and procedures hospital wide had not been reviewed, revised, or updated by managers of each department and had not gone through medical staff or governing body for approval since 2013.

2. On the morning of 01/14/2015, Staff E told surveyors that she hasn't seen the Medical Director of her department in many years and that she typed up and put policies in her department manual.

3. Surveyors reviewed multiple department policy and procedure manuals that contained documentation that documented approval by a RN (registered nurse) and the CEO (chief executive officer) with a date of 01/13/2013.

4. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on policy and procedure review and staff interviews, the CAH (critical access hospital) failed to ensure that policies and procedures were adopted and in place for health care services provided on site.

Findings:
1. On the morning of 01/13/2015, surveyors were told that mobile ultrasound, mobile mammography, mobile MRI (magnetic resonance imaging) were services provided onsite at the CAH.

2. On the morning of 01/13/2015, surveyors requested all radiology policies and procedures for all radiology services provided at the CAH.

3. On the morning of 01/14/2015, administrative staff provided surveyors with a white binder that included policies and procedures from the contracted service that provide teleradiologists, radiology policies and procedures for services that the hospital did and did not provide.

4. On the morning of 01/14/2015, surveyors asked Staff E for policies and procedures specific to bone density services, MRI services, ultrasound services, and mammography services.

5. On the morning of 01/14/2015, surveyors received a binder that had policies and procedures from the mobile MRI contracted service.

6. On the morning of 01/14/2015, surveyors were told by Staff E that the mobile ultrasound and mobile mammography entities had not provided the CAH with their policies and procedures.

7. Staff E informed surveyors that there was not a policy and procedure manual for bone density.

8. Staff E told surveyors that the CAH is using the contracted teleradiology policies and procedures.

9. On the afternoon of 01/13/2015, surveyors reviewed medical staff and governing body meeting minutes for 2013 through current. There was no documented evidence that the CAH had adopted the MRI contracted service's company policies and procedures. There was no evidence the CAH had adopted the contracted teleradiology policies and procedures.

10. On the afternoon of 01/14/2015, Staff B verified that both teleradiology contracted services and mobile MRI contracted services policies and procedures were not adopted by the medical staff and governing body.

11. On the afternoon of 01/14/2015, Staff B verified that there were no policies and procedures for bone density, mobile ultrasound and mobile mammography.

12. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on policy and procedure review, observation, and staff interviews, the pharmacist failed to:

a. store drugs and biologicals in accordance with acceptable standards.

b. ensure all outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

c. review and revise policies and procedures governing provision of pharmaceutical services.

d. identify loss or diversion of all controlled substances.

e. participate in CAH (critical access hospital) decisions about emergency medication kits.

f. provide orientation, training, on-going education to the pharmacy technician and drug room supervisor.

Findings:
1. On the afternoon of 01/13/2015, surveyors toured the drug room with the drug room technician. Surveyors observed the following:

-Multiple cardboard boxes of intravenous fluids stacked approximately four feet (or taller) throughout the entire drug room with minimal space to walk. These boxes have direct contact with the floor and not on shelves.

-A large plant placed in a handwashing sink and a propagated plant sitting on a shelf near the hand washing sink which were both located next to the medication refrigerator.

-Large heaping pile of clutter with multiple coffee cups covering a work station/desk.

-A white oscillating fan that was turned on medium speed, blowing dust, dirt, and particles throughout the drug room.

-Large metal racks that contained multiple cardboard boxes of intravenous fluids, medication supplies, and a can of Lysol disinfectant spray.

-A portable small rack overloaded and stacked with cardboard boxes, plastic bins, opened drugs/medications/biologicals supplies that was in front of the large metal racks.

-Dirt stained medication storage shelves that contained drugs/biologicals/medications.

-Dirty counters and floors. Dirt and dust covered cardboard boxes that were sitting on shelving next to drugs/medications.

-Plastic yellow bins stacked approximately five feet with multiple drugs/biologicals/medications randomly stacked.

-Drugs/biologicals/medications stacked on a white particle board that is placed over the top of the plastic yellow bins stacked approximately five feet.

-A door that contained signage, "Expired Medications Do Not Enter" that was ajar with a brown door stopper to hold the door open about one inch. Upon entering this room, surveyors observed:

-Twelve (12) damaged cardboard boxes of intravenous fluids directly on the floor stacked taller than four feet in the storage room that was labeled for expired medications. These boxes have direct contact with the floor and not on shelves.

-Multiple cardboard boxes that contained medications/drugs/biologicals (identified by the drug room technician) stacked on the floor, counters, and on top of a filing cabinet.

-Multiple computer/printers, plastic bins, humidifier, coffee pots/coffee/coffee filters and condiments, a bar of soap sitting in a soap dish, papers, file folders, CDs (compact discs), medicine cups, binders, multiple cardboard boxes labeled "Discrepancies."

-Medications in stacked bins near the door (these medications were identified by the drug room tech as expired.) There was no specific signage placed on the bins.

2. On the morning of 01/13/2015, surveyors toured the CAH. Surveyors observed expired medications in the following areas:

-ED (emergency department) crash cart contained six (6) boxes Atropine Sulfate 0.5 mg expired 1 January 2015. Staff G and Staff N verified that the medications were expired.

-ED/Med-Surg medication room contained eight (8) vials of insulins all opened and not dated. Staff G, Staff I, and Staff N verified that all 8 vials did not contain a date when opened.

-PACU (post anesthesia care unit) Cabinet A contained: Ephedrine Sulfate 50 mg/ml (1 vial) expired 04/2014, meperidine 25 mg/ml (4 vials) expired 11/2014), meperidine 50 mg/ml (11 carpujects) expired 1 May 2013. Staff F verified that the medications were expired.

3. On the morning of 01/13/2015, surveyors requested pharmacy policies and procedures. Pharmacy policies and procedures did not contain evidence that they were reviewed, revised, or updated by the pharmacist.

4. On the morning of 01/13/2015, surveyors reviewed the pharmacy policies and procedures. None of the policies and procedures contained documented evidence that they followed the standards of practice and recommended pharmaceutical guidelines.

5. On the morning of 01/14/2015, surveyors asked for the CAH (critical access hospital) use of multiple dose vials policy and procedure. Surveyors were provided with two different policies and procedures on use of multiple dose vials that were different. Neither policy contained documentation that the pharmacist, medical staff, and governing body approved them.

6. On the morning of 01/14/2015, a policy titled, "Multiple Dose Containers" provided by Staff G documented, "...Multiple dose vials are to be dated and initialed as of the first usage and returned to the Pharmacy after thirty (30) days and discarded...Multiple dose vials of insulin are to be dated and initialed as of the first usage and returned to the Pharmacy after ninety (90) days and discarded..."

7. On the morning of 01/14/2015, a policy titled, "Use of Multiple Dose Vials (MDVs)" provided by Staff F documented, "...The healthcare provider shall write the expiration date on the vial, when it is opened...This revised expiration date replaces the manufacturer's original expiration date unless the original expiration date occurs earlier than the 28-day date..."

8. On the morning of 01/14/2015, the drug room technician verified that the policy for Multiple Dose Containers was incorrect. The drug room technician told surveyors that she was unaware of the policy "Use of Multiple Dose Vials (MDVs)" and had not ever seen that.

9. On the morning of 01/13/2015, surveyors reviewed medical staff and governing body meeting minutes for 2013 through current. There was no documented evidence that the medical staff and governing body reviewed, revised, or approved pharmacy services policies and procedures.

10. On the morning of 01/14/2015, the drug room technician told surveyors once the CRNA (certified registered nurse anesthetist) checks out medications he needs, the OR (operating room) manager is responsible for tracking and monitoring the usage and wasting of narcotics.

11. On the morning of 01/14/2015, the OR manager told surveyors that he thought the pharmacy technician was checking all the medication that were in the surgical department.

12. On the afternoon of 01/14/2015, surveyors reviewed P&T (pharmacy and therapeutics) meeting minutes, medical staff and governing body meeting minutes. There was no documented evidence that narcotics were being monitored and tracked throughout the hospital.

13. There was no documented evidence that chart reviews were being reviewed to identify loss or drug diversion of all controlled substances.

14. There was no documented evidence in P&T meeting minutes, medical staff and governing body meeting minutes that the pharmacist participated in decisions about emergency medication kits throughout the CAH.

15. On the morning of 01/14/2015, surveyors asked Staff E where the emergency medication kit for adverse reactions was kept. Staff E opened a cabinet and pulled out a worn unsealed plastic bag that contained two (2) vials of benadryl 50 mg/ml.

16. On the morning of 01/14/2015, surveyors asked Staff G who decided what is included in emergency medicine kits throughout the hospital. Staff G told surveyors she did not know.

17. On the morning of 01/13/2015, surveyors asked the CEO and DON for the name of the drug room supervisor. The CEO told surveyors that the DON was the drug room supervisor. The DON was not aware she was the drug room supervisor.

18. On the morning of 01/13/2015, the CEO informed surveyors that there was a drug room technician who ran the drug room.

19. On the morning of 01/13/2015, surveyors asked the DON if she had any orientation and training by the pharmacist for the drug room. The DON said she did not have any orientation or training for the drug room at all.

20. On the morning of 01/14/2015, surveyors asked the drug room technician if she had any orientation and training by the pharmacist for the drug room. She said she had not but she had worked in the drug room for years.

21. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff to include all hospital services;

b. Develop and enforce surveillance/monitoring to ensure infection control policies and procedures are uniform and followed throughout the facility.

c. Analyze the infection preventionist (IP) surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

The hospital did not have a current infection control plan that detailed what, how and how often surveillance would occur.

Except for listing of multi-drug organisms, the hospital/community-wide risk assessment did not identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital, so that disinfectants and precautions could be identified.


Observations:
1. On the morning of 01/13/14, while touring the surgical services, the surveyor noted multiple disinfectants, including but not limited to, Opticide-TB, Prospay Wipes, Micro-Kill + wipes, and Sanotex wipes. Staff F told the surveyor that they also used Percept and Virex-256. Sanotex wipes did not contain approval by the environmental protection agency for stated disinfection effectiveness.

2. Staff SS stated on 01/13/14 that she would use the Micro-Kill + to clean between patients who had colonoscopy procedures. The container she indicated, the red-toped container, is not effective against Clostridium difficile (C-diff), the organism most prevalent with this type of procedure.

3. On 01/14/14, Dietary staff and Staff WW and XX, housekeeping staff, identified they usually used GC 2 or Micro-Kill + disinfectants. When asked Staff WW and XX stated they would use a different Micro-Kill disinfectant, "the blue top", if a patient had C-diff.

4. Radiology staff identified Micro-Kill + as the disinfectant used.

5. On the afternoon of 01/14/14, the hospital had three patients with contact isolation precautions. There was also an isolation cart outside, between the two emergency rooms. Only one of the four isolation carts had a list of what items were to be included in the cart. None of the carts contained all the items listed as required for the isolation cart. Isolation gowns were not included in three of the carts.

6. On the afternoon of 01/14/14, Staff Z entered Room 105, one of the contact isolation rooms, without appropriate personal protective equipment (PPE). When asked, she told the surveyor that she knew she needed an isolation gown, but the hospital did not any. Two of the other isolation carts observed contained isolation gowns. The surveyor also noted the supply room and one of the emergency rooms contained packets of isolation gowns.

7. On the morning of 01/14/14, Staff E told the surveyor that nursing staff did not disinfect the intravenous (IV) adaptor hubs/connectors before hooking the patient up to the power injector in the radiology department. In an interview with Staff Z on 01/14/14, the nurse did not verbalize the correct cleaning process - she only told the surveyor she would clean the top of the cap.


Surveillance/Monitoring:
1. Review of surveillance activities provided to the surveyors did not demonstrate the following were monitored:
a. disinfectant application, for all departments/areas of the hospital;
b. isolation - including appropriate isolation precautions, stocking of isolation carts, and correct PPE being utilized;
c. review of processes for all department to ensure they are following standards of practice and infection control policies.

2. On the afternoon of 01/14/14, Staff H stated she had made a calendar schedule of departments to visit/monitor, but that she was just starting this process.

3. Review of surveillance data provided showed:
a. only hand hygiene had been monitored since November 2014.
b. hand hygiene was not monitored between May and November 2014.
c. the last time isolation was monitored, in any way was April 2014.
d. no other monitoring of services/processes were provided.
e. Staff H told the surveyor there was not other data available.
f. Staff K, stated that he did not have any evidence of process observations for the surgery department.


Meeting minutes:
1. Staff H, the staff identified as responsible for infection control told the surveyors on 01/14/14 that infection control business (review of activities and concerns, analysis and plans of action with follow-up review) was part of the super committee meeting minutes. Those meeting minutes for 2014 were reviewed.

2. Meeting minutes did not demonstrate the hospital had an active on-going infection control program that reviewed all areas/services of the hospital. Staff B and H told the surveyors on 01/13 and 14/14 that the hospital had just hired a new infection control practitioner and they were just starting.

3. Meeting minutes did not demonstrate the disinfectants used throughout the hospital had been review and analyzed and approved for use by the committee. This findings was reviewed and verified by Staff H on 01/14/14.

4. Although the most current meeting minutes contained patient infections, the minutes did not reflect evaluations and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

5. Meeting minutes did not reflect employee illnesses and immunizations were part of the program.

Review of personnel files, including contract, student scrub techs, and physician and allied health files did not show complete immunizations as recommended by CDC and its advisory committee (ACIP). Examples include, but are not limited to:
a. the hospital did not maintain complete health files on contract staff and students that provided care to patients.
i. the hospital did not have health files for Staff P, CC, ZZ, CCC, DDD, GGG and scrub tech students EEE and FFF.
ii. the hospital did not have evidence of current immunizations for Staff AAA of influenza and tuberculosis.
iii. the hospital did not have evidence of Staff YY's immunity to measles, mumps, rubella and varicella, nor documentation that immunization to Hepatitis B had been offered.

b. Staff PP's credential/health file did not contain a current tuberculin questionnaire to assess for possible tuberculin exposure.

c. Staff BBB's health file did not contain evidence of immunity to measles, mumps, rubella and varicella, nor documentation that immunization to Hepatitis B had been offered.

Based on staff interview, hospital document review, and medical record review, the Critical Access Hospital (CAH) failed to ensure that the nutritional needs of inpatients were met. This occurred in 4 of 4 inpatient medical records reviewed where the patient condition would require a nutritional assessment.

Findings:

1. On the morning of 01/13/2015, administrative staff told surveyors that staff AAA was the consultant dietician and staff BBB was the dietary manager/supervisor.

2. On the morning of 01/14/2015, staff BBB told surveyors that she would only do nutritional assessments on the swing bed residents. Staff BBB told surveyors that if any other patient needed a nutritional screening/assessment the dietician would do those screenings. Staff BBB told surveyors that she was only supposed to conduct nutritional screenings on the swing bed residents.

3. On the morning of 01/13/2015, surveyors reviewed the job description of the dietary manager. The job description documented "...reviews patient diet information and discusses requests, changes, and inconsistencies with patient, professional staff and consulting dietician." Staff BBB told surveyors that she was unaware of any other patients other than swing bed patients that required nutritional screenings.

4. On the morning of 01/13/2015, staff I told surveyors that the nursing staff would perform an initial nutritional screening on the patient in the electronic health record. Staff I told surveyors that she was unaware if the information from the nursing nutritional screening was given to the dietary manager or the dietician. Staff I told surveyors that the dietary manager did not have access to the electronic health record and she was unaware if the dietician had access to the electronic health record.

5. On the morning of 01/14/2015, staff GG, a floor nurse told surveyors that the nursing staff was able to document in their daily nursing assessments a "dietary consult" note. Staff GG told surveyors that nurses would document allergies or likes and dislikes.

6. Staff GG told surveyors that if a patient had a diet order of Nothing Per Mouth (NPO) that she would not document any need for a nutritional screening. Staff GG told surveyors that the dietary department received diet orders daily.

7. Staff GG told surveyors that if a patient was on tube feedings she would not document a need for a nutritional screening. Staff GG told surveyors that the dietary department provided the diets and the dietary department received diet orders daily.

8. On the afternoon of 01/14/2015, surveyors reviewed 18 inpatient medical records. There was no documentation of any nutritional screenings on any inpatient medical record reviewed.

9. The medical record of patient # 19 documented the patient had pneumonia, and shortness of breath. There was no documentation of any nutritional screening done.

10. The medical record of patient # 5, a 3 year old child with a low potassium level contained no documentation of a nutritional screening done.

11. The medial record of patients # 6 & # 7 documented the patient had pneumonia. There was no documentation of any nutritional screenings done.

Based on policy and procedure review, medical staff and governing body meeting minutes, and staff interviews, the CAH (critical access hospital) failed to ensure policies are reviewed at least annually by the professional personnel.

Findings:
1. On the morning of 01/13/2015, surveyors reviewed medical staff and governing body meeting minutes from 2013 through current. There was no documented evidence that policies and procedures were reviewed, revised, and updated hospital wide.

2. On the afternoon of 01/13/2015, the CEO verified that policies and procedures had not been reviewed and approved since 2013.

3. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on hospital documents, observations, and interviews, the CAH (critical access hospital) failed to ensure radiologic equipment had policies and procedures in place to ensure inspections of radiology equipment were conducted and problems identified were corrected in a timely manner.

Findings:
1. On the morning of 01/14/2015, surveyors toured the radiology department. Surveyors observed a power injector (used for injected contrast for a computed tomography scan) without documented evidence that it was inspected and safe for patient use.

2. On the morning of 01/14/2015, Staff E told surveyors she was unsure if the power injector was inspected.

3. On the afternoon of 01/14/2015, surveyors requested the preventative maintenance documentation on the power injector.

4. On the afternoon of 01/14/2015, the safety officer provided the last preventative maintenance documentation on the power injector which was dated 11/2013.

5. The safety officer verified that the power injector had not been inspected and did not know if it was safe for patient use.

6. On the morning of 01/14/2015, surveyors reviewed the physicist report which was dated 26 March 2014 that documented, "Fluoroscopy pulse mode doesn't adequately compensate for patient thickness..." and "...Mag 1 indicator light is out..."

7. On the morning of 01/14/2015, surveyors asked the radiology manager for the preventative maintenance invoice/work order showing the completed work for the fluoroscopy pule mode and mag 1 indicator. None was provided.

8. On the morning of 01/14/2015, the radiology manager told surveyors it had not been fixed.

9. On the morning of 01/14/2015, the CEO verified that the fluoroscopy pulse mode and Mag 1 indicator had not been fixed.

10. On the morning of 01/14/2015, surveyors asked the radiology manager who the supervising radiologist was over the department. The radiology manager told surveyors that there was not a supervising radiologist over the department.

11. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on medical staff and governing body meeting minutes and staff interviews, the CAH (critical access hospital) failed to maintain a list of all services furnished under arrangement or agreements.

Findings:
1. On the morning of 01/13/2015, surveyors requested a list of all contracted services that was furnished under arrangements or agreements. None was provided.

2. On the afternoon of 01/13/2015, the CEO told surveyors he would get the list.

3. On the morning of 01/14/2015, surveyors again requested a list of all contracted services. None was provided.

4. On the afternoon of 01/14/2015, surveyors again requested a list of all contracted services at exit. None was provided.

Based on medical record review and staff interviews, the CAH (critical access hospital) failed to ensure the medical record system correctly identified the author of every medical record entry.

Findings:
1. On the morning of 01/14/2015, surveyors reviewed 7 (#1 through #7) of 7 medical records all that originated from the emergency department. All 7 of the medical records contained entries where the authors could not be identified by title.

2. On the afternoon of 01/14/2015, surveyors asked the IT manager how to determine the employee's discipline (MD, DO, PA, RN, LPN, paramedic, CNA, etc.). The IT manager was not able to.

3. On the afternoon of 01/14/2015, the IT manager confirmed that he did not enter employees' disciplines on the electronic health record but would fix it.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure medical records contained:

a. complete pre-operative orders for intravenous (IV) feedings. This occurred in six of six (Records #8, 9, 10, 11, 12, and 13) surgical records review.

b. complete documentation concerning IV fluids. This occurred in six of six (Records #8, 9, 10, 11, 12 and 13) surgical records reviewed.

c. narcotic medication/drug orders signed by an authorizing physician or a certified nurse anesthetist with narcotic permits to do so. This occurred in Records #8, 13 and 14.

Findings:

1. The pre-operative order for Records #8, 9, 10, 11, 12 and 13 did not contain the amount of IV fluids to be started in the pre-operative area or the rate of flow. In addition, for Record #11, no type of IV was documented.

2. Pre-operative nursing staff did not documented the amount of fluid hung when the IV was started. This occurred in Records #8, 9, 10, 11, 12 and 13.

3. Intraoperative notes did not always indicate the amount of fluids received or whether an additional IV fluids were started.

4. Post-operative nursing notes did not consistently document the amount of fluids left hanging when they received the patient, what number of IV bag was in place when the patient was received, or the amount of fluid left in the bag when the IV was discontinued or it the IV catheter was intact. For example, but not limited to:
a. Record #8 - Although the post-operative nurse documented she had 30 milliliters (ml) left to count, she did not indicated the total amount of fluid, or if this was still the first bag of fluids that was hanging.
b. Record #9 - The nurse did not document if the IV catheter was intact at the time of discontinuation or the total amount infused.

5. In Records #8, 13 and 14, the nurse anesthetist administered narcotic medications. The nurse anesthetist does not have the appropriate narcotic State and Federal permits to order such medications. The records did not contain an order by the surgeon for the medications or a co-signature authorizing the medications.

6. The findings were reviewed with Staff HHH during the medical record review on 01/14/14 and again during the exit conference on 01/14/14. No additional information was provided.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure post-anesthesia evaluations contained a review of the patient's pulmonary status, including the patient's lung sounds. This occurred in six of six (Records #8, 9, 10, 11, 12 and 13) surgical records reviewed where the patient received general anesthesia.

Findings:

1. The hospital's anesthesia policies documented the patient's post-anesthesia evaluation would include the review of the patient's pulmonary status.

2. The post-anesthesia evaluations for Records #8, 9. 10, 11, 12 and 13 did not contain a full evaluation of the patient's pulmonary status. The entry contained the patient's vital signs and oxygen saturation, but did not demonstrate an evaluation of the the patient's lung sounds had been performed.

3. This was confirmed with Staff HHH during chart review on the afternoon of 01/14/14.

Based on medical staff and governing body meeting minutes and staff interviews, the CAH (critical access hospital) failed to evaluate its total program.

Findings:
1. On the morning of 01/13/2015, surveyors requested the CAH's annual program evaluation.

2. On the afternoon of 01/13/2015, administrative staff provided the annual program evaluation. The CAH's annual program evaluation did not evaluate contracted services, health care policies and procedures, a sample of active and closed records, identifying loss and diversion for narcotics, medication errors, and root cause of medication errors.

3. On the afternoon of 01/14/2015, the CEO confirmed that the annual program evaluation did not evaluate all CMS requirements.

4. On the afternoon of 01/14/2015, the findings were discussed at exit conference. No additional information was provided.

Based on hospital document review, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to provide an ongoing program of activities for Swing Bed residents that was designed to meet the needs of each swing bed resident based on a comprehensive assessment to include the resident's interests, and the physical, mental, and psychosocial well-being of each resident.
This occurred in 5 open swing bed resident's medical records reviewed (#16, 17, 21, 22 & #23) and in 1 closed swing bed resident's medical record reviewed (#20).

Findings:

1. On the morning of 01/13/2015, administrative staff told surveyors that staff JJJ was the swing bed activities director.
2. On the morning of 01/14/2015, staff I told surveyors that the CAH does not provide the swing bed residents with a schedule of daily activities.
3. On the afternoon of 01/14/2015, surveyors reviewed 5 open swing bed resident's medical records (#16, 17, 21, 22, & #23) and 1 closed swing bed resident's medical record (#20). All 6 swing bed resident's medical records reviewed contained no documentation of an activities assessment.
4. The activities director was not available during the time of the survey for interview.