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Based on observation, record review, interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the medical records for 20 of 20 sampled patients (Patients 1 - 20) had documentation indicating the staff provided the patient with a written statement, or in the case of an emergency department (ED) visit, a posted statement, explaining that there was not a doctor of medicine or osteopathy (MD or DO) present in the facility 24 hours per day, seven days a week (24/7). Also, the Critical Access Hospital failed to determine if all patients admitted to the facility had an advanced directive or provided information and/or assistance, if so desired by the patients, about how to obtain an Advanced Directive for seven of the 10 patients (Patients 11 - 13, 15 - 17, and 20). This deficient practice had the potential to affect all patients in the facility.

Findings Include:

Observation on 01/21/19, upon arrival at the facility revealed no postings in the ED for patients stating that a MD or DO was unavailable in the ED 24/7.

1. Review of medical records for Patients 1 - 20 lacked evidence the facility's staff provided a written notice to all inpatients, at the beginning of their stay, explaining that there would not be a MD or DO present at the CAH facility 24/7.

2. Review of medical records for Patients 9 - 13 (ED visits) showed there was no evidence the facility's staff provided a posted notification within the ED stating that a MD or DO was not present 24/7 for all patients entering the dedicated emergency department.

During an interview on 01/23/19 at 5:45 PM, Staff A, Hospital CEO stated that he did not know why the inpatients were not provided a written statement or why a written posting was not located within the ED regarding the unavailability of a MD or DO 24/7.

Document review of facility's policy, "Patient Rights," signed 09/07/98, showed the facility's staff failed to address how they would inform inpatients and ED patients about the unavailability of a MD or DO 24/7.

3. Medical record review determined that Patients 11 - 13, 15 - 17, and 20 lacked evidence that the patients were asked if they had an Advanced Directive or were offered information, and if so desired, assistance to formulate an advanced directive during their admission to the facility.

In an interview on 01/22/19 at 1:12 PM with Staff G, Certified Nursing Assistant (CNA) and on 01/23/19 at 2:00 PM with Staff A, Chief Executive Officer (CEO), it was confirmed that section 17 of the "Treatment Authorization and Privacy Acknowledgment" forms were blank. They had no explanation as to why these patients were not asked about Advanced Directives.

Document review of the facility's form, "Treatment Authorization and Privacy Acknowledgment" not dated, showed the facility failed to provide a written explanation within the form regarding the unavailability of a MD or DO 24/7 at the facility. In addition, the form stated, Advanced Directive Information: (complete for all patients including outpatients)." Followed by four questions; "Do you have a living will?, Do you have Medical Durable Power of Attorney (DPOA)?, If yes, is the living will or DPOA on file?, If no, were you given Advanced Directive Education Material? This form was to remain as part of the medical record. This section was blank in the seven medical records above.

A review of the facility's policies determined that there was no policy that address advanced directives.

Based on observation, interview, and policy review the Critical Access Hospital (CAH) failed to ensure that equipment and supplies commonly used in life saving procedures were readily available to emergency department (ED) staff. This practice had the potential to adversely affect all patients in the facility.

Findings Include:

Observation on 01/21/19 at 2:30 PM in the ED, Room One (trauma room with crash cart) showed numerous items used in life saving procedures were expired. The following was a list of type, number, and expiration date of the items:

Expired items located on counter or in drawers:

1. Iodine Swabsticks: expired 10/2017 x 1; expired 07/2018 x 1.
2. Vacutainer Tubes [blood collection tubes]: red tops - expired 09/2018 x 3; purple top - expired 12/31/18 x 1; green tops - expired 09/30/18 x 2; blue tops - expired 12/31/18 x 3; yellow tops - expired 10/31/18 x 3; gray tops - expired 11/30/18 x 3.
3. Hypodermic Safety Needles: 22G [gauge]x1 - expired 09/2018 x 5; 18G x 1 - expired 07/2016 x 3; 19G x1 - expired 11/2017 x 1.
4. Macro Bore Extension Set with Clave [used when starting intravenous access]: use by 11/2016 x 2; expired 06/2018 x 1; expired 12/31/18 x 2.
5. Intravenous (IV) SorbaView Shield (kits) [a one-step catheter securement system]: expired 07/2018 x 1.
6. Clave Adapter or Clave Connector [needle free connector for IV tubing]: expired 09/2018 x 4; were not dated x 2.
7. Central Venous Catheter (CVC) kit: expired 03/2017 x 1.
8. Endotracheal (ET) Tubes 7.5: expired 04/2018 x 2.
9. The Pediatric Broselow bag [a kit used in pediatric advanced emergency resuscitation that contains seven color coded bags that rapidly identifies and provides correct medication and equipment sizes for pediatric resuscitation]: All kits were expired.
10. Culture Swabs for aerobes and anaerobes [used for nasal and throat cultures]: expired 10/2018 x 3; expired 12/2018 x 1.
11. Stroke box for Activase contained Vacutainer Tubes [used for specific blood draws], all Tubes were outdated: red top - expired 08/2016 x 1; blue top - expired 10/2016 x 1; purple top - expired 08/2017 x 1; green top - expired 04/2017 x 1.
12. Nasopharyngeal Airway [used for intubation]: expired 01/2018 x 1; expired 02/2018 x 1; expired 03/2018 x 1; expired 07/2018 x 5; expired 08/2018 x 1; expired 01/2016 x 1.
13. Oxygen Supply Tubing: 2.1 m - expired 01/2018 x 2.

Opened items without date opened written on bottle, so expiration date could not be determined:
1. Povidone Iodine Topical Solution: one bottle.
2. Hydrogen Peroxide: one bottle.
3. Xylocaine 1% (anesthetic agent) multi dose vial: two vials.
4. ASA (Aspirin) & NTG (Nitroglycerin) multi dose bottles.

Observation on 01/21/19 at 3:40 PM in the ED showed that the medication room door, located off the ED/Acute floor nurses' station, was unlocked. Staff D, Registered Nurse approached the door and stated that Staff D was in the area of the medication room and had not locked the door since Staff D was close by.

Observation on 01/21/19 at 3:45 PM in the medication room showed that one medication, in the locked narcotic box, Phenobarbital with Belladonna Alkaloids Elixir 4-ounce bottle (used to reduce the symptoms of stomach and intestinal cramping), was opened for multi-use. The date that the bottle was opened was not written on the bottle, so an expiration date could not be determined.

During an interview on 01/21/19, Staff D, Registered Nurse, stated that she did not know why there were outdated items in ED room one. Staff D stated that she was not aware of why the open vial in the locked narcotic box was not dated when opened.

During an interview on 01/21/19, during observation of the ED, with Staff B, the Director of Nursing (DON), stated that Staff B had been employed at the facility for three months and was not aware of the numerous expired items in ED Room 1. Staff B stated that the Pharmacy Nurse was responsible for monitoring expired medications and Materials Management staff was responsible for changing out expired supplies.

During an interview on 01/23/19 at 10:30 AM, with Staff E, Materials Management Manager, stated that it was difficult for Staff E to keep up with expired supplies due to the loss of an employee in the Materials Management Department and the time that Staff E's other work assignments take away from materials management. Staff E stated that the Materials Management Department was not responsible for medications, a responsibility of the pharmacy or vacutainer tubes, a responsibility of the lab.

During an interview on 01/23/19 at 3:40 PM, Staff C, Pharmacy Nurse stated that Staff C was in control of the medications in the ED and acute floor but was not responsible for monitoring the medication in the crash cart. Staff C stated that a Consulting Pharmacist was on site one time a month and was also available by phone.

During an interview on 01/23/19 at 2:35 PM, with Staff F, Laboratory Manager stated that Staff F began working at the facility during August 2018. Staff F stated that Staff F was not responsible for monitoring the expiration and re-stocking of the vacutainer tubes in the ED. Staff F stated that the "Draw Room" (a room set up to draw ambulatory patient's lab work and stocked with supplies [i.e. vacutainer tubes] was located down the hall from the ED and was fully stocked and closely monitored for expired supplies. Staff F stated that the vacutainer supplies in the "Draw Room" were available to all nursing staff 24 hours a day 7 days a week for immediate use or re-stocking the ED. Staff F removed the expired vacutainer tubes from ED Room One.

Document review of the facility's policy and procedure titled, "Crash Cart Maintenance," signed 08/24/10 showed that a Crash Cart was located in the Emergency Room. A par level of medications and IV's shall be maintained on this cart by the Materials Management Department. The Crash Cart shall be inspected by the Charge Nurse at least each month. The Charge Nurse shall inspect for missing medications, out-of-date medications, and discolored drugs. The facility's Charge Nurse was not following the policy.

Document review of the facility's policy and procedure titled, "Scope of Service (Pharmacy Department)," signed on 08/24/10 showed Licensed Nurses shall dispense medications, as needed, from the Pharmacy main storage room, and shall be responsible for removal of outdated medications with the exception of narcotics. The facility's nursing staff were not following the policy

Document review of the facility's policy and procedure titled, "Inspection of Nursing Units by The Consulting Pharmacist," signed on 08/24/10 showed the Consulting Pharmacist shall inspect nursing station medication centers every quarter for overseeing outdated medication review and that medication cabinets are kept locked. The facility's Consulting Pharmacist was not following the policy.

Based on observation, interview, and policy and procedure review, the Critical Access Hospital (CAH) failed to ensure that outdated patient medications on the Intermediate Swing Bed (ISB) Unit were not available for patient use. This practice had the potential to adversely affect all patients in the facility.

Findings Include:

Observation on 01/21/19 at 10:03 AM, of the ISB nursing station's medication refrigerator showed that the refrigerator contained a patient's medication (from an outside pharmacy) in the box which had been opened, taped up, and written on the tape was, "Do Not Use Wrong Dose". The medication was Tresiba Flextouch Pen, an insulin pen, with a prescription date of 12/05/17.

Observation on 01/21/19 at 10:20 AM of the ISB nursing station's medication cart showed that a medication, Docusate sodium (a laxative) had an expiration date of 08/16/18 and a fill date of 08/16/17. Two of the pill pockets did not contain a medication pill.

During an interview on 01/21/19 at 10:30 AM, Staff 2, Director of Nursing (DON) stated that the patient that had been prescribed the Tresiba Flextouch Pen was no longer an inpatient at the facility. Staff 2 did not know why the medication remained in the refrigerator and was not removed/discarded upon discharge. Staff 2 was requested to provide the facility's policy regarding the handling of expired medications.

During an interview on 01/23/19 at 3:40 PM, Staff 3, Pharmacy Nurse stated that Staff 3 was not responsible for the medications on the ISB Unit. Staff 3 explained that the town pharmacy supplied the medications for patients on that unit.

Document review of the facility's policy titled, "Scope of Service (Pharmacy)," signed on 08/24/10 showed, Licensed Nurses shall dispense medications, as needed, from the Pharmacy main storage room, and shall be responsible for removal of outdated medications with the exception of narcotics. Staff 2 failed to supply the requested policy regarding expired medications.

Based on medical record review and interview, the Critical Access Hospital (CAH) staff failed to properly execute an informed consent in two of 20 sampled records (Patients 14 and 20).

Findings Include:

A review of Patient 14 and Patient 20's medical records showed the informed consent document lacked dates from either the patient or the hospital representative to indicate when the informed consent was executed.

In an interview on 01/22/19 at 11:35 AM, Staff G, Certified Nursing Assistant (CNA) confirmed that the Informed consent form for Patient 14 and Patient 20 was not dated. Staff G had no explanation for the omission of the date the informed consent was executed.

Based on medical record review, policy review, review of bylaws and staff interviews, the Critical Access Hospital's (CAH) supervising physician failed to co-sign a mid-level practitioner's orders for six of 10 sampled medical records (Patients 11 - 15, and 20) in keeping with the basic standard of care. This practice had the potential to adversely affect all patients receiving medical orders by mid-level practitioners in the facility.

Findings Include:

Medical record review for Patient 11 showed seven discharge orders entered by Staff I, Physician Assistant (PA) on 01/10/19 at 2:40 PM. The co-signatures of the supervising physician were still pending 13 days after they were written. Orders included discharge, follow-up, monitoring instructions for infection, return if worse, dressing care and Ibuprofen (a non-steroidal anti-inflammatory used for pain relief, fever, and inflammation.).

Medical record review for Patient 12 showed 13 orders entered by Staff I on 01/12/19 at 5:56 PM. The co-signatures of the supervising physician were still pending 12 days after they were written. Orders included blood sugar check, discharge, follow-up, rest, drink 3 liters of water per day, heat for spasms, use narcotics sparingly, Aspirin (a salicylate used for pain, fever, and inflammation), take diabetes medication as prescribed, light stretch of neck and shoulders 5 minutes per day, Accucheck (blood from a finger stick used for blood sugar level), Lidocaine Topical patch 5% (an anesthetic is used to prevent and to treat pain.), Cyclobenzaprine (a muscle relaxer), Ketorolac Injections (a non-steroidal anti-inflammatory drug used to treat moderate to severe pain).

Medical record review for Patient 13 showed 17 orders entered by Staff I on 01/13/19 between 3:33 AM and 5:00 AM. The co-signatures of the supervising physician were still pending as 11 days after they were written. Orders included, discharge home, follow-up, rest, drink 3 liters of water per day, return to ER for SOB, CP or other concerns, Aspirin, Afrin (an eye decongestant used to treat eye redness caused by minor irritations), CPK a blood test for Creatine Phosphokinase enzyme), multiple other labs, chest X-ray.

Medical record review for Patient 14 showed the following admission orders: "Obs [Observation] - headache - IV [Intravenous] fluids 1 L[liter] over 3 hours - 30mg Toradol (a non-steroidal anti-inflammatory drug used to treat moderate to severe pain) IV - 10mg Regan (a medication used to treat people with slow emptying of the stomach and intestinal tract) IV - 25mg Benadryl (an antihistamine used to treat the symptoms of an allergic reaction) IV." These orders had no signature of the ordering practitioner or the time or date they were ordered.

Medical record review for Patient 15 showed eight orders entered by Staff J, PA on 11/13/18 at 4:26 PM. The co-signatures of the supervising physician were still pending 2 months and 9 days after they were written. Computer orders included multiple orders for admission including medication orders for Aspercream with lidocaine cream (topical cream used to treat minor aches and pains of the muscles/joints), and Bentyl (used to treat bowel problems including irritable bowel syndrome).

Medical record review for Patient 20 showed 27 orders entered by Staff N, PA on 07/26/18 between 7:06 AM and 8:33 PM. The co-signatures of the supervising physician were still pending as of almost 6 months after they were written. This patient arrived via ambulance to the Emergency Department (ED) unresponsive. Patient 20 was admitted to inpatient medical with a diagnosis of Diabetic Keto Acidosis (DKA). Computer orders included multiple orders for admission as well as medication orders for IV NS (intravenous normal saline: a mixture of sodium chloride in water), Regular Insulin Drip (a fast-acting intravenous insulin used for DKA), D5 ½ (Intravenous fluid with 5% dextrose (sugar) and normal saline), and Acetaminophen (a pain reliever used to treat mild pain and fever.).

A review of the facility's policy, "Telephone/Verbal Orders Handling" revised 05/29/15, showed no reference to the facility's requirement for the supervising physician's co-signature attesting to the review and acceptance of the PA's orders.

A review of the facility's "Medical Staff Bylaws and Rules and Regulations" dated 11/14/16 by the Chairperson of the Board of Trustees and 2/16/17 by the Chief of Medical Staff, showed no reference to the facility's requirement for the supervising physician's co-signature attesting to the review and acceptance of the PA's orders.

A review of the facility's "Hamilton County Hospital Board of Directors Bylaws" revised 07/17, showed no reference to the facility's requirement for the supervising physician co-signature attesting to the review and acceptance of the PA's orders.

In an interview on 01/22/19 at 3:00 PM, Staff A, Chief Executive Officer (CEO) stated, "There is nothing in the bylaws and we have no policy regarding the documentation of medications or the time frame for the supervising physician to review and co-sign the PA's orders. I thought there was, but we can't find anything."

Based on interview and review of facility documentation, the facility failed to ensure compliance with the Establishment of an Emergency Program as evidenced by the failure to 1) document a review and update the emergency preparedness plan (EPP) annually; 2) have an EPP based on a facility Risk Assessment; 3) develop policies based on a facility and community Risk Assessment, and documentation the policies were reviewed and updated annually; 4) establish policies and procedures to address subsistence needs for staff and patients during an emergency or disaster; 5) to establish policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency, a method to document the specific name and location of the receiving facility or other location; 6) to establish policies and procedures to address evacuation procedures in the event of an emergency; 7) to establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency; 8) ensure the contact information had a documented annual review and update; 9) to develop a written training and testing program based on the emergency plan and ensure that the training and testing program was reviewed and updated at least annually; 10) failed to develop initial training for new and existing staff, individuals providing services under arrangement, and volunteers. Provide training annually and maintain documentation of training. These failures had the potential to affect the all facility in-patients and/or swing bed patients, and/or out-patients receiving care in the facility, and potentially hindered the facility's ability to prepare for potential emergency situations and keep patients, staff, and visitors safe during an emergency event.

Findings Include:

1. The facility failed to ensure the Emergency Preparedness Plan (EPP) was evaluated and updated on an annual basis. Refer to tag E-0004.
2. The facility failed to provide an all-hazards risk assessment that was reviewed and updated annually. Refer to tag E-0006.
3. The facility failed to ensure that their Communication's Plan was reviewed and updated annually. Refer to tag E-0013.
4. The facility staff failed to establish policies and procedures to address subsistence needs for staff and patients during an emergency or disaster situation Refer to tag E-0015.
5. The facility staff failed to establish policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency, a method to document the specific name and location of the receiving facility or other location. Refer to tag E-0018.
6. The facility staff failed to establish policies and procedures to address evacuation procedures in the event of an emergency. Refer to tag E-0020.
7. The facility staff failed to establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency. Refer to tag E-0023.
8. The facility staff failed to ensure that all contact information has been reviewed and updated at least annually. Refer to tag E-0030.
9. The facility staff failed to develop a written training and testing program based on the emergency plan and ensure that the training and testing program was reviewed and updated at least annually. Refer to tag E-0036.
10. The facility staff failed to develop initial training for new and existing staff, individuals providing services under arrangement, and volunteers. Provide training annually and maintain documentation of training. Refer to tag E-0037.

Based on document review and interview, the Critical Access Hospital's (CAH) staff failed to ensure that their Emergency Preparedness Plan was reviewed and updated annually. Failure to keep the EPP up-to-date has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked evidence that the plan had been reviewed and updated on an annual basis. The current written plan, "Hamilton County Hospital Emergency Operations Plan" was dated 12/15/2011. There were parts of an electronic copy of the facility's Emergency Operations Plan that had been updated but the latest update was 12/15/17.

In an interview on 01/23/19 at 10:00 AM, Staff E stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." It was explained that Staff E was responsible for Materials Management and Maintenance for the whole hospital, plus the Emergency Preparedness plan. Staff E's support staff for Maintenance of the hospital has been reduced from three employees to none leaving Staff E sole responsibility for hospital maintenance. Additionally, Staff E's support staff for Materials Management had been reduced to one. Staff E was told by administration to limit attendance of the monthly Local Emergency Planning Committee (LEPC) and SHERT ([SH] Emergency Response Team) due to cost. Staff E stated, "I just have not had the time to work on the Emergency Preparedness plan and they do not want to pay over time."

Based on document review and interview, the Critical Access Hospital's (CAH) staff failed to provide an all-hazards risk assessment for their Emergency Preparedness Plan (EPP) that was reviewed and updated annually. Failure to use an all-hazards approach for the EPP has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that their risk-assessment was based on an all-hazards approach specific to the geographic location of the facility that encompasses all potential hazards or was updated annually. The written plan, "Hamilton County Hospital Emergency Operations Plan" was dated 12/15/11. The electronic copy of the facility's Emergency Operations showed the latest file update on 12/15/17.

In an interview on 01/23/19 at 10:00 AM, Staff E stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." It was explained that Staff E was responsible for Materials Management and Maintenance for the whole hospital, plus the Emergency Preparedness plan. Staff E's support staff for Maintenance of the hospital has been reduced from three employees to none leaving Staff E sole responsibility for hospital maintenance. Additionally, Staff E's support staff for Materials Management had been reduced to one. Staff E was told by administration to limit attendance of the monthly Local Emergency Planning Committee (LEPC) and SHERT ([SH] Emergency Response Team) due to cost. Staff E stated, "I just have not had the time to work on the Emergency Preparedness plan and they do not want to pay over time."

Based on document review and interview, the Critical Access Hospital's (CAH) staff failed to ensure that their Communication's Plan was reviewed and updated annually. Failure to keep the communication plan up-to-date has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that their Communication's Plan was updated annually. The written plan, "Hamilton County Hospital Emergency Operations Plan" was dated 12/15/11. The electronic copy of the facility's Emergency Operations showed the latest file update on 12/15/17.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." Staff E explained that some of the people and contact numbers are no longer active due to a change in staffing and administration. Staff E was told by administration to limit attendance of the monthly Local Emergency Planning Committee (LEPC) and SHERT ([SH] Emergency Response Team) due to cost. Staff E has multiple responsibilities i.e., Materials Management and Maintenance for the whole hospital, plus the Emergency Preparedness plan and therefore, has not had the time to devote to the plan that's required. Staff E stated, "I just have not had the time to work on the Emergency Preparedness plan and they do not want to pay over time."

Based on document review and interview, the Critical Access Hospital's (CAH) policies and procedures failed to address subsistence needs (such as adequate energy sources, emergency lighting, fire detection, extinguishing, alarm systems, sewage and waste disposal, or generator maintenance guidance) for staff and patients during an emergency or disaster situation. Failure to address subsistence needs has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that the facility's policies and procedures addressed subsistence needs for staff and patients during an emergency or disaster. Such needs would include adequate alternate energy sources necessary to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions; emergency lighting, fire detection, extinguishing, and alarm systems. Further, there were no policies to address the provision for sewage and waste disposal. It was determined that the facility did have an emergency generator but there was no policy that addressed the operation or maintenance of the generator during a disaster or how long the generator can remain in operation. There was no policy and procedure to address the provision for sewage and waste disposal.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I never considered the need for sewage and waste disposal." Staff E confirmed their policy did not address the subsistence needs.

Based on document review and interview, the Critical Access Hospital's (CAH) Emergency Preparedness Plan failed to address a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency, or a method to document the specific name and location of the receiving facility or other location. Failure to address a system to track the location of staff and sheltered patients has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that the facility's staff had policies and procedures to address a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency, or a method to document the specific name and location of the receiving facility or other location.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." Staff E explained that they have forms but no policy or procedure to outline a process to use the forms or a method to track the location of on-duty staff and sheltered patients in the facility's care during an emergency.

Based on document review and interview, the Critical Access Hospital's (CAH) Emergency Preparedness Plan failed to address evacuation procedures in the event of an emergency. Failure to address evacuation procedures has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that the facility's staff had policies and procedures to address evacuation procedures in the event of an emergency. Specifically, at a minimum, the safe evacuation from the facility, including care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

A review on 01/23/19 of the, "Hamilton County Hospital Emergency Operations Plan" dated 12/15/11 stated, "Lines of Authority, Roles, and Responsibilities (MGRS)...Each department head should maintain access to the following: ... Evacuation Chairs/Sleds." There was no explanation of how safe evacuation from the facility, including care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance would be achieved.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." Staff E explained that they have forms to use for evacuation procedures but no policy or procedure to outline a process.

Based on document review and interview, the Critical Access Hospital's (CAH) Emergency Preparedness Plan failed to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency. Failure to address the confidentiality of patient records in the event of an emergency has the potential to place patients personal health information at risk for unauthorized access.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked documented evidence that the facility's staff had established policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." Staff E explained that they have no policies to address securing and maintaining availability of patient records, patient information, or protecting confidentiality of patient information in the event of an emergency.

Based on document review and interview, the Critical Access Hospital's (CAH) staff failed to ensure that all contact information in their Emergency Preparedness Plan had been reviewed and updated at least annually. Failure to keep contact information up-to-date has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked evidence that the plan had been reviewed and updated on an annual basis including all contact information. The current written plan, "Hamilton County Hospital Emergency Operations Plan" was dated 12/15/11. There were parts of an electronic copy of the facility's Emergency Operations Plan that had been updated but the latest update was 12/15/17.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "I have not done an annual review this year and last year I was only able to update some of the parts that needed to be updated." Staff E explained that some of the people and contact numbers are no longer active due to a change in staffing and administration. Staff E has multiple responsibilities i.e., Materials Management and Maintenance for the whole hospital, plus the Emergency Preparedness plan and therefore, has not had the time to devote to the plan that's required. Staff E stated, "I just have not had the time to work on the Emergency Preparedness plan and they do not want to pay over time."

Based on document review and interview, the Critical Access Hospital's (CAH) staff failed to develop a written training and testing program based on their Emergency Preparedness Plan (EPP) and ensure that the training and testing program was reviewed and updated at least annually. Failure to provide EPP training and testing and keep it up-to-date has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked evidence that the staff had developed a written training and testing program based on their emergency plan or ensure that the training and testing program was reviewed and updated at least annually. The current written plan, "Hamilton County Hospital Emergency Operations Plan" was dated 12/15/11. There were parts of an electronic copy of the facility's Emergency Operations Plan that had been updated but the latest update was 12/15/17.

In an interview on 01/23/19 at 10:00 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "We have not developed any emergency preparedness training for the staff yet." Staff E confirmed there was no evidence of an existing training or testing program and therefore, nothing established to review or updated annually.

Based on document review and interview, the Critical Access Hospital's (CAH) staff had no evidence of developing a program for emergency preparedness training or receiving annual emergency preparedness training. Failure to provide staff EPP training and keep staff up-to-date has the potential to place patients, staff, and visitors at risk in the case of an emergency.

Findings Include:

A review on 01/23/19 of the facility's Emergency Preparedness Plan lacked evidence that the staff had developed a written training and testing program based on their emergency plan or that staff received emergency preparedness training at least annually.

In an interview on 01/23/19 at 10 AM, Staff E, Emergency Preparedness Coordinator (EPC) stated, "We have not developed any emergency preparedness training for the staff yet." Staff E confirmed there was no evidence of an existing training or testing program and therefore, nothing established to review or update annually.