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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) failed to safely store hazardous chemicals for 2 of 3 days of survey (May 13, 2019 and May 15, 2019). Failure to safely store hazardous chemicals may result in cognitively impaired patients sustaining an injury.

Findings include:

- Observation of the CAH's second floor on 05/13/19 at 12:40 p.m. showed a door labeled "Beauty Shop." The door was unlocked and the room contained a hazardous chemical labeled "Barbicide."

Review of the safety data sheet (SDS) for Barbicide occurred on 05/15/19. This SDS, revised January 2014, stated, ". . . a concentrated germicidal detergent formulated with synthetic phenols, anionic surfactants and alcohol . . . causes severe skin burns and eye damage . . . flammable liquid . . . precautionary statements - storage store locked up. . . ."

- Observation of the CAH's second floor on 05/15/19 at 10:00 a.m. showed a chemical labeled "Master care bath Aire system disinfectant" in a free-standing cabinet located in a tub room (Room #17). The cabinet was locked with the keys present in the lock. The label on the chemical stated, "Corrosive. Causes irreversible eye damage and skin burns. Do not get in eyes, on skin or on clothing. . . . Harmful if swallowed. . . ."

During interview on 05/15/19 at 11:30 a.m., an environmental services staff member (#4) stated the facility does not have a policy on storage or locking of harmful chemicals.


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Based on review of bylaws, provider credentialing files, surgical log book, and staff interview, the Critical Assess Hospital (CAH) failed to ensure the re-appointment for 1 of 1 Certified Registered Nurse Anesthetist (CRNA #1). This resulted in CRNA #1 providing treatment without proper credentialing and placed the CAH's surgical patients at risk of receiving treatment/services from an unqualified licensed personnel.

Findings include:

Review of the "MEDICAL STAFF BY-LAWS" occurred on 05/15/19. These bylaws, adopted 04/12/13, stated, ". . . CATEGORIES OF THE MEDICAL STAFF . . . ALLIED HEALTH PROFESSIONALS Categories of health care professionals other than physicians, podiatrists, dentists and optometrists approved by the Board who are licensed or certified by their respective licensing or certifying agencies and who desire to provide professional services in the Hospital are eligible to practice as Allied Health Professionals. . . . Specific Qualifications: Only physicians, allied health professionals . . . who: a. are currently licensed to practice in this state; b. credentialed to provide services; c. possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the Hospital; d. can document their: i. background, experience, training and demonstrated competence; ii. adherence to the ethics of their profession; iii. good reputation and character, including the applicant's mental and emotional stability; iv. ability to work harmoniously with others sufficiently to convince the Hospital and all patients treated by them in the Hospital will receive quality care and that the Hospital and its Medical Staff will be able to operate in an orderly manner; shall be qualified for appointment to the medical Staff. . . ."

Review of the governing body's bylaws occurred on 05/15/19. These bylaws, dated 05/15/85, stated, ". . . Article VIII - Medical Staff; Section 4. . . . after receipt of a recommendation from the medical staff or an appropriate committee thereof concerning an applicant for medical staff appointment or concerning a medical staff appointee, the Board shall act in the matter. The Board retains the absolute discretion to take any action it deems in the best interest of the hospital and the decision of the Board shall be conclusive. . . ."

Review of a random sample of credentialing files occurred on 05/15/19 and identified CRNA #1's appointment period had expired in December 2017 with no reappointment completed.

Review of the surgical log book from January 2019 through 05/13/19 showed CRNA #1 provided anesthesia services in the operating room (OR) on 03/13/19, 04/10/19, and 05/08/19.

During interview on 05/15/19 at 11:30 a.m., the credentialing coordinator (#3) verified the CAH had not reappointed CRNA #1 since December 2017 and he/she had no knowledge CRNA #1 continued to perform anesthesia services in the OR.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner to prevent unauthorized access for 3 of 3 crash carts (located in the Emergency Department, at the nurse's station, and in the surgical department). Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

- Observation of the Emergency department (ED) and of the nursing unit on the afternoon of 05/13/19 and the surgical department the morning of 05/14/19 showed one crash cart in each department secured with a tab lock. An administrative nurse (#1) opened the carts by breaking the tab lock. Each crash cart contained medications used in the event of an emergency. Medications included Epinephrine (stimulant), Atropine (blocks nerve impulses), Enoxaparin (anticoagulant), Naloxone (reverses effects of narcotic drugs), and similar medications administered for emergency events.

During interview on 05/13/19 at 1:00 p.m., an administrative nurse (#1) stated only the pharmacist was able to place a new tab lock on the carts and confirmed the carts remain unlocked until the pharmacist returned to work.

During interview on 05/13/19 at 1:30 p.m., a pharmacist (#2) stated if staff opened the crash carts, the carts remained unlocked until the pharmacist's next working shift. The pharmacist (#2) stated the pharmacist hours are Monday through Friday from 8:00 a.m. to 4:30 p.m.

During interview on 05/14/19 at 8:50 a.m., an administrative staff member (#3) responsible for setting up badge access/security for staff confirmed most staff have badge access to the ED.

During interview on 05/14/19 at 4:30 p.m., an administrative nurse (#1) stated the facility did not have a policy regarding locking of the crash carts in the facility.

During interview on 05/14/19 at 2:15 p.m., a staff nurse (#5) confirmed if staff opened the crash cart at the nurses' station, the crash cart remained unlocked until the pharmacist's next scheduled working day.

During interview on 05/15/19 at approximately 10:15 a.m., an environmental services staff member (#4) confirmed housekeeping staff have access to the ED for daily cleaning.