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Based on record review, observation and interviews, the Critical Access Hospital (CAH) failed to ensure that bed linens used for patients were clean and in good repair (Patients 1, 2, 3, 4 and 5). This had the potential to affect all patients in the CAH. Census at the time of entrance was 4. Findings include:

A. Observation and inspection with the DON (Director of Nursing) on 10/24/12 at 9:00 AM found 9 of 18 licensed beds in the CAH had stained and disrepaired patient linens: Examples include:

1. Room 3, bed A - observed the fitted sheet on the bed was worn and had discolored threads;
2. Room 4, bed A - had a pillowcase and bedspread observed with hair on it;
3. Room 4, bed B - holes were observed in the fitted sheets;
4. Room 5, bed B - holes were observed in the fitted sheets and bedspread;
6. Room 6, bed A - a dried black substance was observed on the flat sheet and holes were observed in the fitted sheet;
7. Room 10, bed A - holes were observed in the fitted sheet;
8. Room 11, bed A - holes were observed in the fitted sheet;
9. Room 12, bed A - holes were observed in the fitted sheet.

Further observation of the clean utility room with the DON on 10/24/12, where clean linens are stored for patient use, revealed the following:

1. 4 of 4 flat sheets had an unidentified dried black substance along the edges;
2. 3 of 4 bath blankets had an unidentified dried black substance along the edges.

B. Interview with the DON while inspecting the clean linens stated: "the linens were not acceptable for patient use". The DON had no idea what the black substance was; that housekeeping staff were responsible for cleaning and changing the rooms and beds upon patient discharges, and the nurse assigned to the patient was responsible to change bed linens on a daily basis while doing patient ADLs (Activities of Daily Living).

C. Interview with RN-1 (Registered Nurse) 10/25/12 revealed the patient's family member was given a copy of patient rights and the procedure of how to file a complaint. This was indicated with a signature on the consent to treat form. RN-1 acknowledged that the family member was upset because hair was found in the bed (failed to identify exactly how much hair was on the bed). RN-1 stated, "I offered them linens and remember thinking it strange they didn't want them after bringing this up--didn't want the patient disturbed--and wanted staff to post a sign on the door so housekeeping would not disturb the patient. I did not see hair on the bed--things quieted down after the sign was posted on the door. Had no more complaints--thought it was a fairly easy night--I could not deal with complaints/grievances and would talk to charge nurse--did not feel there was a complaint." The family member mentioned it and then nothing more was said." Patient 3 was discharged in stable condition on 10/02/12, with no adverse effects of the hair on the bed to Patient 3.

Record record review on 10/24/12 at 12:30 PM revealed that the patient (Patient 3) was escorted to the ED (Emergency Department) with family per pedis on 10/01/12 at 18:22 (6:22 PM) MDT with a primary diagnosis of asthma. Patient 3 was admitted into acute care and placed in Room 8, a negative pressure room. Orders included Albuterol 2.5 mg (milligrams) PRN (as needed) for wheezing; Essonite-formoterol, INH BID (inhalant, twice a day); Montelukast 5 mg, 1 tab chewed QPM (every evening), and Cetirizine (liquid) 5 mg PO (by mouth) daily.

D. Interview with the Director of Plant Engineering on 10/24/12 at 2:30 PM revealed that the CAH contracts out the laundry/linen services. Review of the contract, effective 10/01/09, revealed orders are placed on weekly basis and the laundry is delivered in sealed plastic wrap. Interview further revealed that there was a problem with hair on the linens about 5 years ago. The company was notified and said they would turn up the heat on the dryers, and since then there has not been a problem with the linens. The Director of Plant Engineering along with the Lead Environmental Services personnel checked all linens throughout the facility (including all departments) and found a large percentage of linens to be unacceptable. The Director of Plant Engineering contacted the contracted linen service and immediate arrangements were made for the delivery of clean linens. These linens were delivered to the facility later in the afternoon on 10/24/12. It was also noted that the contracted linen service recently had an employee strike, and the issue with the dried black substance was the result of a broken seal used in the circular cylinder washing process. No explanation was provided as to where the hair found on the patient linens came from. Review of the Quality Improvement and Infection Control reports lacked documentation of linens being an issue, or of them resulting in of adverse events to patient care or welfare. Interview with 2 patient family members and 3 patients revealed no issues or complaints with the care and treatment or linens the CAH provided.