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Based on tour of the temporary mobile Magnetic Resonance Imaging (MRI) unit located outside the facility, review of the facility floor plan, review of the MRI Service Agreement, observation, and staff interview, it was determined the facility failed to provide an all-weather enclosure walk-way from the Critical Access Hospital (CAH) to the mobile unit located outside and adjacent to the emergency department. This failure poses the potential risk that patients may be exposed to the elements during transport which could affect their health and safety.

Findings include:

The CAH is providing MRI Services for inpatient and outpatient diagnostic testing.

Observation on 05/01/19 confirmed there was not an all-weather enclosed walkway from the hospital to the mobile MRI unit.

The MRI contract, dated 07/25/2007, revealed: "....the Client shall prepare and maintain a safe and suitable site for the MRI Unit which complies with the Manufacturers specifications..."

Employee #1 confirmed, during an interview conducted on 05/01/19, that there has never been an all-weather enclosed walkway from the hospital to the mobile MRI unit.

Employee #2 identified, during an interview conducted on 05/02/2019, s/he was not aware an all-weathered enclosed walkway was required.

Based on review of facility documents and staff interview, it was determined that the governing authority failed to ensure the medical staff bylaws and medical staff regulations were maintained as evidenced by, failure to review at least every 3 years; failure to update to include Surgical and Anesthesia Services, inclusive of pre-anesthesia and post-anesthesia assessment requirements by the medical staff. Failure to do so poses the risk of jeopardizing the delivery of quality health care in a safe environment.

Findings include:

Review of medical staff bylaws and medical staff regulations revealed 7/29/2013 as the most recent review or revision date. Additionally, the Surgical Center began operations on 8/16/2016 offering inpatient and outpatient Surgical Services with Anesthesia Services. However, no update to the medical staff bylaws or medical staff regulations were made to include either of these services.

Employee #4 and Employee #5 verified, in an interview conducted on 5/2/2019 at 0930 hours, the medical staff bylaws and the medical staff regulations have not been reviewed since 7/29/2013 or updated to include Surgical and Anesthesia Services.

Based on review of policies and procedures, observations, and staff interview it was determined that the nurse executive failed to ensure the staff maintained ongoing compliance with the requirements for the use of audible alarms per their policy and procedure related to continuous cardiac monitoring, as evidenced by the lack of audible alarms on the telemetry monitoring system within the inpatient unit. Failure to do so poses a potential risk of nursing staff not being alerted to a patient's change in cardiac rhythm or vital signs in a timely manner in order to provide intervention if required.

Findings include:

Review of the policy titled, "Continuous Cardiac Monitoring" revealed: "....H. Monitoring:...2. Alarm Settings and Parameters: a. Alarms are continuously on and audible with respect to distance and competing noise...."

During a tour of the facility, conducted on 4/26/2019 and 4/30/2019, the surveyor observed the absence of audible alarms from the inpatient cardiac monitoring system located in the nursing station. A sticker was on the bottom of each cardiac monitoring screen reminding the nursing staff to not turn the alarms off.

RN #1 and RN #5 identified, in an interview conducted on 4/26/2019, the cardiac monitoring system has never had audible alarms but should have this ability.

RN #6 confirmed, in an interview conducted on 4/30/2019 at 1500 hours, the cardiac monitoring system has never had audible alarms, and that it would be much better if the system was capable of this.

RN #1 identified, in an interview conducted on 4/30/2019, the hospital's IT staff was working on the cardiac monitoring system to determine if the system was capable of producing an audible alarm.

RN #1 identified, in an interview conducted on 5/2/2019, the audible alarms on the cardiac monitoring system were unplugged and subsequently have now been plugged in to allow for audible alarms.

Based on hospital policy, review of medical records, and interviews, it was determined that the facility failed to establish and document an activities program and calendar per facility policy for the swing bed program in order to provide physical and mental stimulation for patients who are confined to the hospital. Failure to provide an activities program to the confined patient has the potential risk of failing to promote physical and mental stimulation in the hospitalized patient.

Findings include:

Hospital policy titled: "Swing Bed: Activities & Recreation: Statement of Purpose: revealed"...based on patient preference, patient's physical and mental level of functioning...maintain space and supplies necessary to support activities....calendar will be established...Activities will be available seven days a week...Activities would be considered part of the patient's clinical treatment plan...."

Random selection of Swing Bed medical records between 01/01/19 through 05/02/19 revealed 4 of 4 swing bed patients (Patient #'s 1, 2, 3, and 4 did not have documentation of Activities/Recreational Services received by the above four (4) patients in their medical records. Additionally, there was no documentation in the medical records regarding an activity assessment provided to the patients.

Employee # 21 confirmed, during an interview conducted on 05/01/19, that s/he was hired in January 2019 as Director of Rehabilitation Services. The Director also confirmed s/he had hired an Activities Coordinator who has not started yet.

Employee # 1 confirmed during an interview conducted on 05/03/19 that the swing bed program is not robust. Employee # 1 confirmed there was no Activities documented in the Swing beds medical record.

Based on review of facility documents, an interview with the facility Physician owner it was determined, the facility failed to:

(E-0004) develop and maintain an EP plan that must be reviewed, and updated at least annually.

(E-0007) incorporate documentation on the EP plan to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations.

(E-0013) develop and implement emergency preparedness policies and procedures, based on the Emergency Plan.

(E-0015) develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients.

(E-0018) develop and implement a policy and procedure for tracking of on-duty staff and sheltered patients in the facility's care during an emergency in the emergency plan.

(E-0024) develop and implement a policy and procedure for the use of volunteers in an emergency.

(E-0025) develop and implement a policy and procedure for having arrangement with other facilities.

(E-0026) develop and implement emergency preparedness policies and procedures to describe the ASC's role in providing care at alternate care sites during an emergency.

(E-0029) develop and implement an emergency preparedness Communication Plan that complies with Federal, Sate, and local laws and must be reviewed and updated at least annually.

(E-0032) identify a primary and alternate means of communication during an emergency.

(E-0033) develop and implement a method for sharing information and medical documentation for patients under the ASC'S care, as necessary, with other health care providers to maintain the continuity of care.

(E-0034) develop a means to sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction.

(E-0036) develop a facility based emergency planning, training and testing program.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Establishment of the Development of an Emergency Preparedness Plan, which poses a high potential risk to the health and safety of patients and staff related to potential harm if staff and patients are not aware of what to do during an emergency situation.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop and maintain an Emergency Plan that must be reviewed, and updated at least annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potentail risk that all required revisions to the plan will not be recognized and revised as needed.

Findings include:

The Plant Services Manager, Manager of Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The facility did not have an Emergency Plan that was reviewed, and updated at least annually. The facility also failed to include emerging infectious diseases as part of it's Emergency Plan.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, there was no Emergency Plan that should have been reviewed, and updated at least annually.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Preparedness Plan on May 01, 2019. The facility was unable to locate any documentation addressing the needs of the patient population or a delegation of authority within the current written plan .

The Chief Executive Officer and key hospital staff acknowledged during a exit conference on May 01, 2019, the facility did not have documentation addressing the needs of the patient population or a delegation of authority within the current written plan.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on the required Emergency Plan that must be reviewed and updated at least annually. Failure to develop policies and procedures during an emergency could cause harm to staff and patients.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the Emergency Plan on May 01, 2019. The facility did not include emergency preparedness policies and procedures, as part of the requirements for and EP plan and based on the Emergency Plan that must be reviewed and updated at least annually.

The Chief Executive Officer and key hospital staff acknowledged in the exit conference on May 01, 2019, that the facility did not include emergency preparedness policies and procedures, based on an Emergency Plan that must be reviewed and updated at least annually.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergeency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the Emergency Plan on May 01, 2019. The facility did not include emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistenence needs for staff and patients.

The Chief Executive Officer and key hospital staff acknowledged in the exit conference on May 01, 2019, that the facility did not include emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistenence needs for staff and patients.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a policy and procedures for tracking of on-duty staff and sheltered patients in the facility's care during an emergency in the emergency plan. Failure to develop a policy and procedure for tracking on-duty staff and patients may cause harm to the patients and staff during an emergency.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include a policy and procedures for tracking of on-duty staff and sheltered patients in the facility's care during an emergency in the emergency plan.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the Emergency Plan did not include a policy and procedures for tracking of on-duty staff and sheltered patients in the facility's care during an emergency in the emergency plan.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined the facility failed to develop and implement a policy and procedure for the use of volunteers in an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include policies and procedures to address the use of volunteers in an emergency.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility Emergency Plan did not include policies and procedures to address the use of volunteers in an emergency.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined the facility failed to develop and implement a policy and procedure for having arrangement with other facilities. Failure to have arrangements with other facilities could adversely impact patient care during an emergency.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include policies and procedures for having arrangements with other facilities.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility Emergency Plan did not include policies and procedures for having arrangements with other facilities.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement an emergency preparedness Communication Plan that complies with Federal, Sate, and local laws and must be reviewed and updated at least annually. Failure to develop a Communication Plan could delay the process for treatment of patients and staff during an emergency.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include emergency preparedness Communication Plan that complies with Federal, Sate, and local laws and must be reviewed and updated at least annually.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility Emergency Plan did not include emergency preparedness Communication Plan that complies with Federal, Sate, and local laws and must be reviewed and updated at least annually.

Based on review of the facility Emergency Plan, record review, and staff interview, it was determined the facility failed to have a primary and alternate means of communication during an emergency. Failure to have a primary and alternate means of communication during an emergency could lead to harm to both patients and staff.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The Emergency Plan did not identify a primary and alternate means of communicating staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility Emergency Plan did not identify a primary and alternate means of communicating staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement a method for sharing information and medical documentation for patients under the CAH's care, as necessary, with other health care providers to maintain the continuity of care. Failure to have a method for sharing information and medical documentation could delay treatment to patients.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include a method for sharing information and medical documentation for patients under the CAH's care, as necessary, with other health care providers to maintain the continuity of care.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, the facility Emergency Plan did not include a method for sharing information and medical documentation for patients under the CAH's care, as necessary, with other health care providers to maintain the continuity of care.

Based on review of the Emergency Plan, record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in residents not receiving care and services as needed.

Findings include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The Emergency Plan did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

The Chief Executive Officer and key hospital staff acknowledged during the exit interview on May 01, 2019, the Emergency Plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to develop a facility based emergency planning, training and testing program. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Plant Services Manager, Manager Infection Prevention, and the surveyor reviewed the facility's Emergency Plan on May 01, 2019. The plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

The Chief Executive Officer and key hospital staff confirmed during an exit conference on May 01, 2019, the Emergency Plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.