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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff maintain supplies and equipment to meet patient needs during an emergency for 3 of 3 emergency carts inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings Included:

1. Document review of the hospital policy and procedure titled, "Emergency Equipment Supply Preparedness," no policy number, last revised 08/01/19, showed that nursing staff will be responsible for checking emergency supplies and defibrillators daily. Emergency carts will be unlocked monthly and complete contents inventoried for outdates, missing items, or damaged/inoperable equipment.

2. On 05/04/21 between 11:00 AM and 12:00 PM, Surveyor #3 and the Nurse Educator (Staff #302) inspected the Acute Care Unit and Emergency Department's emergency carts. The observation showed the following:

a. Acute Care Unit - Adult Crash Cart had one package of pediatric Zoll defibrillation pads with an expiration date of 03/02/21 and one 500 ml intravenous bag of lidocaine with an expiration date of 04/21.

b. Broselow Pediatric Crash Cart with one tube of lubricating jelly with an expiration date of 02/26/21 and the specialized white module (containing various tubes and supplies) with an expiration date of 11/30/20.

c. Emergency Department - Adult Crash Cart with one 250 ml intravenous bag of Aggrastat (an antiplatelet medication frequently used to treat heart attacks) with an expiration date of 04/21 and one 500 ml intravenous bag of lidocaine with an expiration date of 04/21.

3. At the time of the observation, Surveyor #3 interviewed the Nurse Educator (Staff #302) about the checking of emergency carts. Staff #302 stated the emergency carts are checked daily and confirmed the expired items found by the surveyor.

4. On 05/04/21 at 11:45 AM, Surveyor #3 and the Nurse Educator (Staff #302) interviewed a Pharmacy Technician (Staff #303) about the expired medications found in the emergency carts. Staff #303 stated the intravenous bags of lidocaine were on back order and had not arrived yet. She stated the intravenous medication Aggrastat is ordered as needed just prior to its expiration date. She was unaware it was expired. It was later confirmed with the Director of Pharmacy (Staff #304) that the lidocaine was on a national wide shortage but acknowledged a label indicating that situation should have been applied to the item.
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Based on observation, interview and record review, the Critical Access Hospital failed to maintain all the emergency supplies on their cart for Malignant Hyperthermia (MH), (a potentially deadly, inherited disorder associated with the administration of certain general anesthesia drugs) as recommended by the Malignant Hyperthermia Association of the United States (MHAUS).

Failure to fully stock the MH cart with the recommended emergency supplies for MH places patients at risk for adverse outcomes, including death.

Reference: Malignant Hyperthermia Association of the United States, (MAHUS) https://www.mhaus.org/

Findings Included:

1.Review of the hospital policy titled, Malignant Hyperthermia, no policy number, last revised 10/08/20, showed that the facility would follow the MAHUS policy and protocol for assistance and treatment of MH.

2.On 05/04/21 at 1:30 PM, Surveyor # 3 and #10 conducted a tour of the surgical unit. During the tour the surveyors discovered that the MH cart was missing the following items as recommended by MHAUS:
-Urine Meter
-Nasogastric tube
-Central Venous Kits
-Transducer Kits
-Means for measuring core temperature
-Pressure Bags
-Test strips for urine analysis
-Insulin

3.Document review of the hospital's MH Cart supply/outdate inventory list, showed that the following items were not part of their checklist:
-Urine Meter
-Nasogastric tube
-Central Venous Kits
-Transducer Kits
-Means for measuring core temperature
-Pressure Bags
-Test strips for urine analysis

4. On 05/05/21 at 09:15 AM, Surveyor #10 interviewed the Operating Room Supervisor (Staff #1003). Staff #1003 verified that they follow MAHUS guidelines and protocol for MH and that some of the items missing were in the operating suite. Staff #1003 stated she was unaware they were missing some of the items listed by MHAUS. Staff #1003 verified the above listed items were not immediately available on the MH cart.
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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.
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Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff followed its policy for restraining patients for 1 of 2 patients reviewed (Patient #305).

Failure to approve policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital policy and procedure titled, "Restraint: Physical and Chemical Restraint," no policy number, last revised 02/06/20, showed that physical restraints are only used as a last resort to ensure the physical safety of the patient or others. Restraints are never for convenience and/or disciplinary purposes. All other means of dealing with a patient's condition must be exhausted before the use of restraints.

2. On 05/06/21, Surveyor #3 and the Quality Manager/Infection Preventionist (Staff #305) reviewed the records of two patients who were restrained. The review showed the following:

a. Patient #305 was a 63-year-old admitted on 01/02/21 for a ground level fall and subsequent closed head injury. The patient was placed in two-point restraints on 01/06/21 at 12:40 AM for marked agitation, mental confusion, disorientation and delirium. The patient was removed from restraints at 4:45 AM. The provider order for physical restraint did not include a time that it was ordered.

b. On 01/06/21 at 3:15 PM, a provider wrote an order for Patient #305 to be placed in physical restraints for biting, kicking, throwing items and disorientation. The record showed the patient was placed in 2-point restraints at 4:00 PM and released from restraints at 4:30 PM. The nurse documented "Patient appears to be sleeping. Trial removal of restraints" at 3:00 PM, 4:00 PM, 5:00 PM and 6:59 PM.

c. On 01/07/21 at 2:45 PM, a provider wrote an order for Patient #305 to be place in physical restraints "prn" or as needed.

3. On 05/06/21 at 12:45 PM, Surveyor #3 interviewed the Quality Manager/Infection Preventionist (Staff #305) about restraint management in the Critical Access Hospital. Staff #305 stated that restraint orders should be dated and timed and that physical restraint orders cannot be written "prn" or as needed. Staff #305 also confirmed that the hospital policy does not allow for a trial removal of restraints.
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Based on observation, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure staff followed its policies for labeling and dating of insulin pens for 2 of 2 patients observed (Patient #301, #302).

Failure to label and date multidose insulin pens after removing from the automated dispensing machine risks medication errors and administration of unusable medications.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Management-High Risk Management," no policy number, last revised 03/11/19, showed that insulin products which are dispensed and stored in the patient medication drawer will be individually labeled with a specific patient name and an expiration date of 28 days from time of removal.

2. On 05/04/21 at 11:30 AM, Surveyor #3 observed a Registered Nurse (Staff #301) administer insulin to Patient #301. The surveyor observed that the insulin pen was not labeled with the patient's name nor dated when it was first removed from the refrigerator as required by policy.

3. On 05/04/21 at 11:30 AM, Surveyor #3 interviewed the Registered Nurse (Staff #301) about insulin pen labeling and dating requirements. Staff #301 stated that they are usually labeled with a patient sticker and dated when removed from the pyxis machine (automated drug dispensing machine). Staff #301 confirmed that Patient #301's insulin pen had not been labeled or dated.

4. Surveyor #3 asked Staff #301 if he had any other patient on insulin. Staff #301 unlocked Patient #302's medication drawer and showed the surveyor another insulin pen. Patient #302's insulin was labeled with a patient name (hospital sticker) but was not dated as required by hospital policy.
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Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure patients received a dietary consultation when ordered by the provider for 2 of 5 records reviewed (Patient #303, #304).

Failure to assess, plan, and provide nutritional care for patients with metabolic disorders risks malnutrition and delayed treatment.

Findings included:

1. Document review of the hospital policy and procedure titled, "Dietary Assessment and Recommendations," no policy number, last revised 08/01/19, showed that all patients will receive a dietary assessment and be reevaluated as needed by the dietician. Patient conditions which warrant consideration for a dietary referral include uncontrolled diabetes. Once a dietary referral is initiated, the dietician will utilize the nutrition screen and/or the nutritional therapy assessment and intervention record.

Document review of the hospital policy and procedure titled, "Registered Dietician Coverage," no policy number, last reviewed 03/09/20, showed that the hospital will contract with a registered dietician to provide nutritional consults as requested by the providers for hospital patients and swing bed patients. The dietician will be available by phone or email during normal work hours and throughout the week for urgent consults by facility nutritional services or the nursing staff.

2. On 05/06/21, Surveyor #3 and the Quality Manager/Infection Preventionist (Staff #305) reviewed five inpatient medical records. The review showed the following:

a. Patient #303 was a 38-year-old admitted on 03/31/21 for diabetic ketoacidosis with marked hyperglycemia and acute kidney injury with a history of chronic kidney disease. The patient had a dietary consult ordered on 03/31/21, 04/01/21,04/02/21 at 9:25 AM, and again on 04/02/21 at 3:07 PM. The patient was discharged on 04/09/21 without being seen by a dietician during their hospitalization (a period of 10 days).

b. Patient #304 was a 68-year-old admitted on 02/23/21 for diabetic ketoacidosis. A dietary consult was ordered on 02/24/21. The patient was discharged on 02/26/21 without being seen by a dietician during their hospitalization.

3. On 05/06/21 at 11:00 AM, Surveyor #3 interviewed the Quality Manager/Infection Preventionist (Staff #305) about nutritional screening and the dietary consultation/referral process. Staff #305 confirmed the findings above and acknowledged that a dietary consultation should have been completed during the patients' hospitalization.
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Based on medical record review and interview the Critical Access Hospital failed to ensure that the anesthesilogist properly executed Informed Consents for Anesthesia for 4 of 4 records reviewed (Patient #1001, #1002, #1003 and #1004).

Failure to obtain a properly executed informed consent for anesthesia risks patients having anesthesia without full understanding of the interventions, risks, and benefits.

Findings included:

1. Document review of the Critical Access Hospital's policy and procedure titled, "Informed Consent-Surgical Patients," no policy number, last revised 10/08/20, showed that if patients are to receive any type of anesthesia, a fully executed Informed Consent will be fully and properly completed.

2. On 05/06/21, Surveyor #10 and the Interim Director of Nursing/Nurse Educator, (Staff #1005) reviewed the medical records of 4 surgical patients. The surveyor found that none of the 4 patients reviewed showed a date or time of when the anesthesia provider counseled the patient on the anesthesia consent form.

3. On 05/07/21 at 8:30 AM, Surveyor #10 interviewed the Operating Room Supervisor (Staff #1003) regarding the missing dates and times. Staff #1003 verified the findings and confirmed the document should have dates and times.
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Based on medical record review and interview, the Critical Access Hospital failed to ensure an updated history and physicals (H&P) were properly signed, dated and/or timed on the date of service, for 4 of 4 patients reviewed (Patient #1001, #1002, #1003, #1004).

Failure to ensure properly signed, dated, and timed medical records risks medical errors and adverse patient outcomes.

Findings included:

1.Document review of the hospital's policy and procedure titled, "Medical Record Documentation" no policy number, last reviewed 11/23/20 showed the following:

a. H&P shall be completed within the first 24 hours of admission.

b. The date of the H7P examination must be recorded and the entry authenticated by the provider.

c. Signature by the provider can be either handwritten or by electronic signature.

2. On 05/06/21, Surveyor #10 and the Interim Director of Nursing/Nurse Educator (Staff #105) reviewed medical records of 4 patients who underwent a surgical procedure. The review showed the following:

a. Patient #1001 was admitted for a Colonoscopy on 04/27/21. Closed medical record review showed an updated H&P was signed by the provider on 04/29/21 at 6:32 (two days after the procedure instead of at the time of the review). The electronic signature did not provide the time of the signature, nor if it was AM or PM.

c. Patient #1003 was admitted on 03/22/21 for the removal of a Melanocytic nevus on the right inner thigh. An updated H&P was signed 03/24/21 at 11:27 (2 days after the procedure instead at the time of review). The electronic signature did not provide the time of the signature, nor if it was AM or PM.

d. Patient #1004 was admitted on 04/23/21 for hardware removal. Closed record review showed an updated H&P was not dated or timed.

e. Patient #1002 was admitted for a Lipomatous Removal on 05/04/21. An open chart medical record review showed that the updated H&P was not signed, dated, or timed prior to the scheduled procedure.

f. On 05/04/21 at 11:45 AM, Surveyor #10 interviewed the Operating Room Supervisor (Staff #1003). Staff #1003 verified the finding and stated that the provider should have signed, dated, and timed the updated H&P prior to surgery.

2. On 05/06/21 at 9:45 AM, the Interim Director of Nursing/Nurse Educator, (Staff # 1005) verified the above findings for Patients #1001, #1003, and, #1004.
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Item #1
Based on observation, document review and interview, the Critical Access Hospital staff failed to prevent cross contamination of equipment in the Emergency Department (ED).

Failure to prevent cross contamination during the cleaning process places patients and staff at risk of infection.

Findings included:

1. Document review of the hospital's policy and procedure titled, " Emergency and Outpatient Room Cleaning," no policy #, last reviewed 12/02/20, showed no procedures for making beds.

Document review of the Critical Access Hospital's policy and procedure titled, " Bed Cleaning," no policy #, last reviewed 12/02/20, showed that staff are required to wipe the entire be with germicide solution.

2. On 05/04/21 between the hours of 9:30 AM and 10:30 AM, Surveyor #1 observed a registered nurse (RN) (Staff #101) turn over an ER room. During observation, Staff #101 wiped down the foot of the bed with a disinfectant wipe, then she preceded to move the pillows from the head of the bed (contaminated area) to the foot of the bed thereby re-contaminating the foot of the bed.

3. On 05/07/21 between the hours of 9:00 AM and 10:00 AM, Surveyor #1 interviewed the Infection Control Officer (Staff # 102) which confirmed that there's no discharge cleaning policy for the ED department.

Item #2
Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable diseases.

Reference: "Guidelines for Hand Hygiene in Healthcare Settings" (Centers for Disease Control and Prevention, 2008). "Recommendations: Indications for handwashing and hand anti-sepsis... After contact with contaminated surfaces".

Findings included:

1. Document review of the hospital's policy and procedure titled, "Hand Hygiene," no policy number, last reviewed 05/29/20, showed Hand Hygiene should be performed after contact with inanimate objects.

2. On 05/04/21 between the hours of 9:30 AM and 10:30 AM, surveyor #1 and #4 observed an Environmental Services staff (EVS) (Staff #103) do a daily clean of a patient room, room 20. During the observation, Staff #103 cleaned the toilet then immediately grabbed the toilet paper roll to tear off a piece of toilet paper to flush the toilet. Staff #103 did not remove gloves and do hand hygiene after cleaning the toilet and before touching the toilet paper roll.

3. On 05/07/21 between the hours of 9:00 AM and 10:00 AM, Surveyor #1 interviewed the Infection Control Officer (Staff # 102) which confirmed the finding.
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Based on interview and document review, the Critical Access Hospital failed to inform Swing Bed Residents of their right to be free from restraints.

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1.Document review of the hospital's pamphlet "Understanding Your Swing Bed Stay" no policy number, no date, showed that the residents' right to be free from physical and chemical restraints was not listed.

2.On 05/06/21 at 2:30 PM, Surveyor #10 interviewed the Chief Nursing Officer (Staff #1002). Staff #1002 verified that the pamphlet did not contain the required information on restraints.
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Based on document review and interview the Critical Access Hospital failed to develop policies and procedures for the hospital's emergency preparedness plan to include provisions for food for patient, staff, and visitors in an event of an emergency.

Failure to provide provisions for food, places patients, staff, and visitors at risk of harm during an emergency event.

Findings included:

1. Document review of the hospital's Emergency Safety Plan, no policy number, last reviewed 2019 showed no provisions for food.

2. On 05/06/21 between the hours of 1:00 PM and 3:30 PM, Surveyor #1 and #10 interviewed and reviewed the hospital's emergency safety plan with the hospital's Chief Financial Officer (Staff #104). Staff #104 was unable to provide policy and procedures for provisions for food as required in CMS regulation.
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Based on document review and interview, the Critical Access Hospital failed to provide initial emergency preparedness training for 1 of 12 records reviewed, (contractor #105).

Failure to train all staff on how to respond during emergencies places patients and staff at risk of injury and/or death in the event of a internal and/or external disaster.

Findings included:

1. Document review of the hospital's Emergency Safety Plan, no policy number, last reviewed 2019 showed no policy and procedures for initial training for contractors.

2. On 05/06/21 between the hours of 1:00 PM and 3:30 PM, Surveyor #1 and #4 interviewed and reviewed the hospital's emergency safety plan with the hospital's Chief Financial Officer (Staff #104). Staff #104 was unable to provide documentation that the hospital's contracted registered dietitian (Staff #105) had initial emergency preparedness training.
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