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Based on record review, policy review, testing, and interview, the provider failed to instill in personnel that the facility and its belongings should be maintained in sound, clean, and safe operating condition, and that health care was provided in accordance with acceptable federal and state standards of practice. Findings include:

1. Refer to C-222 Regarding maintenance.

2. Refer to C-226 Regarding proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

3. Refer to C-229 Regarding provisons for an emergency fuel and water supply.

Based on random observation, testing, and interview, the provider failed to maintain the facility and its belongings in sound, clean, or safe condition. A facility tour revealed:
- Boxes of intravenous (IV) solutions and clean supplies were stored on the floor in the sterilization/supply room.
- A raw plywood shelf was laid on top of the clean linen cart, raw wooden two by fours were used to hold the grab bar in place on the tub, and a spray bottle of cleaner for the tub hung on the clean linen cart in the bathing room.
- Layers of dead bugs were found in the light shields of patient bathrooms 104, 106, and the labor room.
- The plaster and/or paint was cracked and/or eroded on the walls and/or ceilings in the following areas: patient rooms 104 and 106, the doctor's sleep room, the soiled utility room, the housekeeping closet, laundry, and the pediatrics bathroom.
- The flooring and/or ceiling was eroded, dirty, and or missing in the following areas: around the foot pedals of the x-ray table, around the toilet base in the labor room, patient room 105, the central supply room, the womens locker room, and the housekeeping closet.
- The labor room bathroom had a roll of toilet paper on the floor, and the toilet paper holder was missing from the wall unit.
- The soap dispensing handle for the liquid soap dispenser was missing in patient room 105.
- The sink basin had layers of caulk which covered an area the size of a coffee cup rim in patient room 106.
- The fill hose for the sink in the housekeeping closet and the shower hose in the patient shower room did not have vacuum breakers.
- A housekeeping chemical labeled Odor Eliminator was stored next to rolls of toilet paper on the shelf in the housekeeping closet.
- The main central supply room had raw wooden shelves with stains on them.
- The outside door in the small hallway between the main central supply room and the oxygen cylinder storage room had an approximate one inch gap under the door.
- Clean baby diapers were stored in old dirty milk crates in the small supply room in the single emergency room (ER) suite.
- The plastic cold water handle for the handwashing sink was taped with black electrical tape, and the cold water handle was missing from the hopper sink in the single ER suite.
- Raw wooden peg boards were used to hang clean and sterile supplies in the double ER and in the labor room.
- The outside window in the pharmacy was taped with layers of duct tape and had packages of packing foam pushed into the crevices around the air conditioner. The wall area around the window had large areas of chipped plaster and paint.
Findings include:

1. Random observation on 3/23/10 from 8:00 a.m. to 11:50 a.m. revealed:

a. Boxes of IV solutions and clean supplies sat on the floor in the sterilization/supply room (photo 14). Interview with the sterilization technician (ST) at the time of the observation confirmed that finding. She revealed she was aware the boxes of IV solutions and clean supplies were stored on the floor. She stated they had been in the process of moving some supplies around this past month. The ST stated she was aware the IV solutions and clean supplies should have been stored off the floor.

b. A raw plywood shelf approximately two foot by three foot was laid on top of the clean linen cart in the bathing room (photo 19). Two raw wooden two by fours were used as braces for the grab bar on the tub in the bathing room (photo 18). A spray bottle labeled Tub Cleaner hung on the clean linen cart in the bathing room (photos 52 and 53). Interview with the maintenance supervisor (MS) at the time of the observations confirmed those findings. He stated he was not aware of the plywood shelf but was aware it was not cleanable. He was not aware why the staff hung the disinfectant on the clean linen cart but confirmed it was not a good practice. The MS revealed he had installed the raw wooden two by fours and had not considered painting or sealing the raw wood to make it cleanable.

c. Layers of dead bugs were found in the bathroom light shields of patient rooms 104, 106, and the labor room (photos 21, 27, and 34). Interview with the MS at the time of the observations confirmed those findings. He stated he was not aware those light shields were dirty. He stated they should have been cleaned by housekeeping.

d. Plaster and/or paint was cracked and/or eroded on the walls and/or ceilings in the following areas:
1. Patient rooms 104 (photo 20) and 106 (photos 33 and 35).
2. The doctors' sleep room (photos 36, 37, and 38).
3. Under the wall border behind the hopper in the soiled linen room (photo 39).
4. Next to the sink in the housekeeping closet (photo 40).
5. Under the window in the laundry room (photo 45).
6. Behind and next to the toilet area in the pediatric bathroom (photo 17).
Interview with the MS at the time of the observations confirmed those findings. He stated he was not aware of the condition of the walls throughout the facility as he had not received any work orders.

e. The flooring and/or ceiling was eroded, missing, and/or dirty in the following areas:
1. Around the foot pedals under the x-ray table. The vinyl floor had receded around the pedals creating an area to harbor dirt and debris (photos 28 and 29). Interview with the x-ray technician (employee 11) at the time of the observation confirmed that finding. She stated the area around the pedals had been sealed with caulk, but the pedals had been repaired by a service company and the company had removed the caulk.
2. Around the toilet base in the labor room bathroom the floor tiles were cracked and broken (photo 22). Interview with the MS at the time of the observations confirmed that finding. He stated he was not aware of the condition of the floor.
3. Around the toilet base in patient room 105. A new toilet had been installed, but remnants of caulk and seal from the base of the old toilet laid in rings around the new toilet (photo 30). Interview with the MS at the time of the observation confirmed that finding. He stated he had installed a new toilet in that bathroom. He confirmed he should have cleaned the area where the old caulk and seal remained from the old toilet.
4. Behind the door and under all the shelves in the main central supply room. Layers of dirt, dust, fuzz, and debris that could be moved around and gathered with a shoe lay behind the door and under the shelves (photo 47). An area approximately fifteen inches long and six inches wide had been gouged from the cement floor. That gouged area had dirt and debris that had collected in the hole (photo 46). Interview with the MS at the time of the observations confirmed those findings. He confirmed the room should have been cleaned by the supply personnel, and the hole should have been filled to be cleanable.
5. Around the floor drain and by the handwashing sink in the women's locker room. The linoleum was eroded away from the floor drain leaving a raw edge of about one to two inches around the drain (photo 54). The linoleum had ripped at the seam by the handwashing sink and created a gap about one foot long and four to five inches wide (photo 55). Interview with the MS at the time of the observation confirmed those findings. He stated the floor had been in that condition since he had started to work at the facility about four years ago.
6. The ceiling vent grate in the housekeeping closet was filled with dirt and debris (photo 42).

f. The labor room bathroom had a roll of toilet paper on the floor and the toilet paper holder was missing from the wall unit (photo 23). Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware the holder was missing from the wall unit and had not received a work order.

g. The soap dispenser handle was missing from the soap dispenser in patient room 105 (photo 31). Testing of that dispenser at that time revealed soap could not be dispensed into the hand for proper handwashing. Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware that dispenser was broken nor had he received a work order to fix the dispenser.

h. The sink basin in patient room 106 had a layer of caulk applied to an area around the drain that measured the size of a coffee cup rim (photo 32). That layer of caulk was dirty and had crevices and ridges that were not cleanable. Interview with the MS at the time of the observation confirmed that finding. He stated he had applied the caulk to seal a hole in the sink. The MS confirmed that was not the proper way to fix the handwashing sink.

i. The fill hose directly attached to the laundry sink in the housekeeping closet did not have a vacuum breaker (photo 41). The end of that hose laid in the bottom of the laundry sink. Interview with the MS at the time of the observation confirmed those findings. The MS stated he was not aware that hose needed a vacuum breaker. The shower hose in the shower room did not have a vacuum breaker (photo 25). The old metal corner braces of the shower stall had peeled paint (photo 26). Interview with the MS at the time of the observation confirmed those findings. He stated a new shower hose had been installed a few months ago and a vacuum breaker had not been installed with the new shower hose. He stated he was not aware the paint had started to peel from the metal corner braces of the shower.

j. A housekeeping chemical labeled Odor Eliminator was stored directly next to rolls of toilet paper on the top shelf in the housekeeping closet (photo 43). Interview with the MS at the time of the observation confirmed that finding. He stated he was aware chemicals should not be stored with patient use items. He stated he did not supervise housekeeping but would let the supervisor know of the improper storage.

k. Approximately one third of the shelves in the main central supply room were not sealed or painted to be cleanable. Those shelves had stains from past supplies and housed clean liquid supplies. Interview with the MS at the time of the observation confirmed those findings. He confirmed the shelves should have been sealed or painted to be cleanable.

l. The outside door in the small hallway between the main central supply room and the oxygen cylinder storage room had a gap under the door of about one inch where daylight could be seen. Interview with the MS at the time of the observation confirmed that finding. He stated he had installed a door sweep a while back, but it apparently needed another one. (photo 12)

2. Random observation on 3/23/10 from 1:40 p.m. to 3:00 p.m. revealed:

a. Clean unprotected baby diapers were stored individually in a dirty blue plastic milk crate in the small supply room in the single ER suite (photo 44). Interview with the central supply coordinator at the time of the observation confirmed that finding. She agreed it was not a good practice to remove the clean diapers from the original protective packaging and store them unprotected.

b. The plastic cold water knob on the handwashing sink in the single ER suite was taped with black electrical tape (photo 13). Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware why the knob was taped but was aware it was not a cleanable surface. Continued observation of the ER suite revealed the cold water handle was missing from the hopper sink. Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware that handle was missing from the hopper.

c. Unfinished wooden peg boards with hooks were used to hold sterile instruments and supplies in the double ER and in the labor room (photos 49, 50 and 51). Interview with the MS at the time of the observations confirmed those findings. He stated he was not aware those peg boards could not be easily cleaned and disinfected and could not be used in procedure rooms.

d. The outside window in the pharmacy was taped with layers of duct tape above the air conditioner. The area beneath the air conditioner was stuffed with packages of packing foam. In addition the wall around the window had chipped and peeled plaster and paint (photo 56). Interview with the MS at the time of the observation confirmed those findings. He stated they had installed a new window air conditioner, but the slide vents were too small for the old opening so they had to seal the rest of the area with duct tape. The MS stated the wind blew through the old opening making the pharmacy cold. The pharmacy technician had placed the packages of packing foam under the window to help seal the opening.

Review of the facility policy titled Work Order Requests dated 1/1/02 revealed the policy statement was to "ensure a timely completion of facility maintenance projects within the Bennett County Healthcare Center." Number one under Procedures of that policy revealed: work order request forms must be submitted to the Maintenance Department for all repairs needed on medical and non-medical equipment. Number two revealed "Work order request forms must also be submitted to the maintenance department for repairs and modifications to the facilities or structures within the facility."

Interview with the director of nursing (DON) on 3/24/10 at 8:45 a.m. revealed she was aware of several environmental and housekeeping issues within the hospital that needed attention. She stated she had requested several times that those issues be addressed since she had started as DON a few weeks ago.

Interview with the administrator on 3/24/10 at 4:40 p.m. revealed he had placed a new director of maintenance, laundry, and housekeeping into effect February 12, 2010. He stated he had done that due to the lack of preventative maintenance and lack of work orders being introduced or completed. The administrator stated he had requested the new director to work on a preventative maintenance program and checklist for the facility. However, he had not given him a deadline to complete and engage the program and checklist.

Based on random observation, testing, interview, and policy review, the provider failed to maintain the following areas in good and/or working condition:
- One of four fluorescent lights in the sterilization room was not shielded.
- The labor room bathroom had no ventilation fan. The entire unit had been removed.
- The ventilation fan was not working in patient rooms 103, 104, 105, and 106.
- The energy efficient light bulb was not shielded over the sink in patient room 107.
- The incandescent light bulb in the small supply room by the single emergency room was not shielded.
- One of four fluorescent light bulbs was not shielded and two of four fluorescent light bulbs were missing end caps on the light shields in the single emergency room.
- The incandescent light bulb in laundry was not shielded.
Findings include:

1. Observation on 3/22/10 at 2:50 p.m. revealed one fluorescent light bulb in the sterilization/supply room was not shielded. Interview with the maintenance supervisor (MS) at the time of the observation confirmed that finding. He stated he was unaware that light was not shielded but was aware the lights must be shielded in the sterilization/supply room.

2. Observation on 3/23/10 from 8:40 a.m. to 11:50 a.m. revealed:

a. The ventilation fan in the labor room had been removed and the hole had been plugged with a piece of insulation (photo 24). Interview with the MS at the time of the observation confirmed that finding. He stated he had removed the fan as it had quit working and had not had it repaired yet.

b. The bathroom ventilation fan in patient rooms 103, 104, 105, and 106 would not work upon activation of the switch. Interview with the MS at the time of the observation confirmed those findings. He stated he was not aware those fans were not working.

c. The light globe was missing from the energy efficient light bulb in patient room 107. Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware the globe was missing but was aware the light bulb must be shielded.

d. The incandescent light bulb in the small supply room by the single emergency room was not shielded. Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware that light was not shielded but was aware light bulbs in clean supply rooms must be shielded.

e. One fluorescent light bulb was not shielded and two fluorescent light bulbs had missing end caps on the light shields in the single emergency room. Interview with the MS at the time of the observations confirmed those findings. He stated he was not aware those lights were not properly shielded but was aware light bulbs in treatment rooms must be shielded.
f. The incandescent light bulb in laundry was not shielded. Interview with the MS at the time of the observation confirmed that finding. The MS stated he had shielded the fluorescent light bulbs but had not considered the incandescent light bulb.

Continued interview with the MS at 11:55 a.m. on that same day revealed he was not aware of all the work that needed to be done in the facility. He had not received any work orders.

Review of the facility policy titled Work Order Requests dated 1/1/02 revealed the policy statement was to "ensure a timely completion of facility maintenance projects within the Bennett County Healthcare Center." Number one under Procedures of that policy revealed: Work order request forms must be submitted to the Maintenance Department for all repairs needed on medical and non-medical equipment. Number two revealed: "work order request forms must also be submitted to the maintenance department for repairs and modifications to the facilities or structures within the facility."

Based on document review and interview, the provider failed to implement a policy to provide potable water to the facility in times of emergency or loss of drinking water. Findings include:

1. Document review of the emergency water supply agreement revealed "The Martin Volunteer Fire Department agrees to supply water to the Bennett County Healthcare Center on a priority basis due to its life safety responsibilities. Drinking water will need to be gained by the Emergency Drinking Water Policy."

Interview with the administrator at 11:00 a.m. on 3/24/10 revealed he was not aware the emergency water supply agreement did not cover potable water. The administrator revealed there was no policy in place to provide potable water to the hospital when there would be a loss of normal water supply. He also stated he did not keep a supply of drinking water at the facility in case of loss of potable water.

Based on record review, interview, and policy review, the governing board failed to ensure quality health care was provided in accordance with acceptable standards of practice. Findings include:

1. Review of the undated governing board bylaws revealed the governing board had overall responsibility and authority for the operation and performance of the organization.

Interview with the administrator on 3/24/10 at 4:40 p.m. revealed he was the person responsible for reporting to the governing board. He stated the hospital did not have a formal quality assurance program at the time, and he did not have much to report regarding the facility and its operation. He stated he had not given direction on how reports should be maintained and delivered to QA and himself regarding the operation and supervision of the departments in the facility.

2. Refer to C220, C222, C226, C229, C258, C270, C278, C279, C280, C283, C293, C304, C307, C330, C336, C337, C399, and the deficiencies cited in the life safety code survey conducted at the facility on 3/23/10.

Based on policy review, bylaw review, and interview, the provider failed to ensure the medical director and medical staff were actively involved in the development, approval, and review of seven of seven patient care related policy and procedure manuals. Findings include:

1. Review of the following patient care related policy and procedure manuals revealed no evidence of review or approval by the medical director or medical staff:
*Nursing services.
*Radiology.
*Laboratory.
*Emergency room.
*Obstetrics/Pediatrics.
*Swing bed.
*Dietary.

Review of the provider's revised September 2002 nursing service policy revealed the medical director would be responsible for the implementation of resident care and coordination of medical care in the facility.

Review of the unsigned 2004 medical staff bylaws revealed the following were duties of the medical staff:
*Continually seek to provide quality care for all patients and residents admitted to or treated in any of the departments or services of the facility.
*To participate in the overall hospital performance improvement program.
*To propose policies and procedures for adoption by the Board of Directors intended to achieve the provider's performance improvement goals.

Review of the medical staff meeting minutes for 2009 and 2010 revealed there was no mention of review or approval of any policies or procedures.

Interview with the administrator at 11:40 a.m. on 3/24/10 revealed policy and procedure manuals had not been taken to the medical staff for review or approval. He stated it would be a good practice to have them review all policy and procedure manuals.

Based on record review, testing, manual review, policy review, and interview, the provider failed to instill in personnel that the facility and its belongings should be maintained in a sound, clean, and safe operating condition; and the dietary department be operated within acceptable hygiene, food handling, and sanitation practices in accordance with acceptable federal and state standards of practice. Findings include:

1. Refer to C-278 Regarding a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

2. Refer to C-279 Responding to inpatient services and procedures that ensure that the nutritional needs of the inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients.

3. Refer to C-280 Regarding polices be reviewed at least annually by the group of professional personnel.

4. Refer to C-283 Responding to radiology services furnished at the CAH are provided as direct services by staff qualified under State law.

5. Refer to C-293 Regarding contracted services.

Based on observation, record review, policy review, manual review, label review, and interview, the provider failed to implement policies and correct procedures for the handling and sterilization of contaminated surgical instruments. The following was noted in the central sterilization room:
*A large paper drink cup with a straw.
*Two plastic tubs of soiled surgical instruments in the basin of the two compartment sink.
*The door to the autoclave was taped closed.
*Another drink cup and an opened bag of M&Ms.
*The biological testing had not been completed on the autoclave since 11/20/09.
*The cleaning solution for the soiled surgical instruments was not used according to manufacturer's directions.
Findings include:

1. Observation on 3/22/10 at 2:50 p.m. revealed:
a. A large paper drink cup with a straw on top of boxes of intravenous solutions (photo 14).
Interview with the sterilization technician (ST) at the time of the observation revealed she was aware she had drinks in the room. She stated she was also on the ambulance crew and she got tired during the day, so she had caffeine drinks to wake her up.
b. Two plastic tubs of soiled surgical instruments sat in the basin of the two compartment sink (photo 16). Interview with the ST at the time of the observation confirmed that condition. She stated she would clean and sterilize instruments from the emergency rooms one to two days per week.
c. The door to the autoclave was taped shut with blue masking tape (photo 13). Interview with the ST at the time of observation confirmed that condition. She stated they taped the door shut, because it would not stay shut, would swing open, and dust and debris could contaminate the inside. The ST revealed she was not aware she could close and shut the door using the hand lock used during sterilization without setting the autoclave for sterilization.

2. Observation on 3/23/10 at 11:00 a.m. revealed:
a. A large drink glass and an opened bag of M&Ms in the sterilization/supply room (photo 48). Interview with the ST at the time of the observation revealed she was aware she had drinks and M&Ms in the room. She stated she was also on the ambulance crew and she got tired during the day, so she had caffeine and chocolate to keep her energy up through the day.
b. The biological testing of the autoclave had not been done since 11/20/09. Interview with the ST at the time of the review of the biological testing records revealed she was aware she must do a biological test each month according to policy. She was also aware she was behind in the biological testing. Review of the undated Autoclave Testing policy revealed the word weekly had been crossed out and the word monthly had been replaced for the test of autoclaves. Review of the manual for the 3M Attest biological test indicators revealed the following for monitoring frequency: For optimal quality assurance of hospital-sterilized goods, we recommend that an Attest biological indicator be used to monitor every load of steam sterilized supplies. No log could be located to reveal the number of times the autoclave had been run since 11/20/09.
c. Label review of Metri enzymatic detergent on 3/23/10 at 1:00 p.m. revealed the detergent was not used according to label directions. The directions stated "Soak instruments and equipment immediately after use, until soil is dissolved and removed." Interview with the ST at the time of the observation revealed emergency room staff would leave the dirty instruments in the tubs for her in the sink. She then would start the cleaning and sterilization process one to two days per week when she had time.

Based on observation, testing, record review, policy review, and interview, the provider failed to comply with proper food handling practices, instill appropriate food safety guidance and hygienic practices to food service workers, and maintain food service equipment in clean and good condition. Findings include:

1. Observation on 3/22/10 from 3:20 p.m. to 5:30 p.m. and again on 3/23/10 from 5:00 p.m. to 5:45 p.m. revealed the following in the kitchen:

a. The ceiling in the food storage room (photo 1), above the dishwasher, over the serving line and around the automatic sprinkler head (photo 3), and over the dish cart by the walk-in cooler (photo 9) had cracked plaster and peeled paint. Interview with the dietary manager (DM) at the time of the observations confirmed those findings. She stated the ceiling was damaged throughout the kitchen, because the roof leaked. The DM stated maintenance had tried to fix the ceiling, but every time they got a lot of snow or rain it damaged the ceiling. Interview with the maintenance supervisor at that same time also confirmed the statement by the DM. He said they had the roof repaired about a year , but apparently the roofer did not do a very good job.

b. Two of two light shields in the food storage room were hanging loose, did not fit tight against the frame, and were cracked and broken. No shield was provided for one of two fluorescent light bulbs above the dishwasher. The incandescent light bulb in the utility/supply closet in the kitchen was not shielded nor shatterproof. The fluorescent light bulbs above the stove were not shielded nor were they shatterproof. The light shield was broken above the milk cooler. Interview with the DM at the time of the observation confirmed those findings. She stated the fixtures were so old that maintenance had a hard time trying to repair them and could not order new covers.

c. The ceiling air conditioner grate in the kitchen above the office window was covered with a layer of lint and debris (photo 2). The light globes above the stove and deep fat fryer were layered with old grease and had dripped grease onto the equipment below (photo 7). Interview with the DM at the time of the observation confirmed that finding. She stated she had trusted the night shift to follow the cleaning schedule for the kitchen, but it appeared they had not done their jobs.

d. The table mounted can opener had different colored layers of dried food debris on the blade and on the wheel. The Kitchen Aide mixer next to the can opener on the same table had different colored layers of dried food on the splash area. Interview with the DM at the time of the observation confirmed that finding. She stated the can opener and the mixer were to be cleaned after each use. She had the can opener and mixer cleaned at that time.

e. The pass through sliding door on the commercial dishwasher was taped with duct tape on the outside edge of the door (photo 4). Interview with the DM at the time of the observation confirmed that finding. She stated the service company who worked on the dishwasher had cut a larger hole in the door to gain access to the dishwasher. After the door had been cut it created a very sharp edge, so staff had covered it with duct tape to avoid being cut. The DM agreed it did not create a cleanable surface, and the layers of duct tape would harbor food debris. The DM removed the duct tape at that time.

f. The wall by the mop sink in the utility closet had cracked and peeled plaster and paint. The fan in the utility closet was not working upon activation of the light switch. Interview with the DM at the time of the observations confirmed those findings. She was aware the wall was in disrepair, and the fan was not working. She stated she had told maintenance but had not filled out a work order.

g. The walk-in freezer had a mound of ice on the floor approximately the size of a basketball in circumference and height (photo 8). Interview with the DM at the time of the observation confirmed that finding. She stated the mound of ice occurred regularly from the fan dripping condensation. The DM stated they had a company try and fix the problem a few months ago. It was better, but it still would drip condensation and freeze on the floor.

h. The floor drain under the tilt kettle was layered with dirt, mop strings, and debris (photo 6). Interview with the DM at the time of the observation confirmed that finding. The DM had the drain cleaned at that time. She stated she had trusted the night shift to follow the cleaning schedule for the kitchen, but it appeared they had not done their jobs.

i. The splash area of the milk machine under the nozzles had several dried spots and splashes of dried milk. Interview with the DM at the time of the observation confirmed that finding. The DM had the splash area cleaned at that time. She stated the milk machine was to be cleaned after each meal.

j. Packages of sliced ready-to-eat bologna, salami, and cheese were wrapped in butcher paper and were stored in a pan in the walk-in cooler. Those packages were covered in what appeared to be wet blood (photos 10 and 11). Interview with the DM at the time of the observation confirmed that finding. The DM confirmed the red liquid on the packages appeared to be wet blood. The DM discarded the ready-to-eat foods in the garbage. She stated it appeared the packages had come with other packages of frozen meat from the butcher shop in town. Staff then removed those sliced ready-to-eat foods from the box and placed them in the walk-in cooler to thaw without checking the integrity of the packages.

k. A cardboard box of cooked fry bread was stored directly next to and in contact with rolls of raw hamburger on the bottom shelf in the walk-in cooler. Interview with the DM at the time of the observation confirmed that finding. The DM stated she and staff were aware ready-to-eat foods could not be stored on the same shelf as raw meat. The DM discarded the fry bread in the garbage.

l. Wiping cloth solutions with sanitizer were not provided in the food preparation areas. Interview with the DM at the time of the observation confirmed that finding. She stated staff were aware they must have sanitizer available whenever they were doing food preparation in the kitchen throughout the day.

m. Two light shields over incandescent bulbs under the hood were layered with old grease that had dripped grease onto the equipment below. Interview with the DM at the time of the observation confirmed that finding. She stated she had trusted the night shift to follow the cleaning schedule for the kitchen, but it appeared they had not done their jobs.

n. The wooden shelf above the stove had several areas of chipped paint and splintered wood. Interview with the DM at the time of the observation confirmed that finding. She stated she was aware of the condition of the shelf. She had not requested it to be repaired. She would like a stainless steel shelf that was easier to clean.

o. Layers of food and grease debris, cups, forks, and what appeared to be mouse feces were found on the floors under the shelves and behind the equipment throughout the entire kitchen (photo 5). Interview with the DM at the time of the observation confirmed that finding. She stated she had trusted the night shift to follow the cleaning schedule for the kitchen, but it appeared they had not done their jobs. The DM stated she had set traps as they had mice off and on in the kitchen. She had not been told by the staff there were mouse feces under the shelves.

p. Two boxes of potatoes and two five gallon containers of cooking oil were stored on a pallet on the floor next to the two compartment sink. In addition a spray bottle of Comet with bleach was stored directly between the boxes of potatoes and containers of cooking oil with the nozzle turned toward the potatoes. Interview with the DM at the time of the observation confirmed that finding. She stated staff were aware cleaners and chemicals were to be stored in the utility closet and not near food or food preparation areas. The Comet was moved at that time.

q. A glass of ice water was noted in the food preparation area on the serving table by the stove. The volunteer kitchen staff person was noted to take a drink from the cup with her gloved hands and then return to work. Interview with the DM at the time of the observation confirmed that finding. The DM stated staff were supposed to keep drinks at the desk by the office and drink cups must be covered. Continued observation for approximately ten minutes of the volunteer staff person revealed she routinely talked on her cell phone, placed the cell phone in her mouth and in and out of her pocket, and then returned to work. That same staff person kept the same gloves on her hands throughout the above observation. The DM talked to the volunteer kitchen staff person at that time about the use of her cell phone. Policy review titled Telephones and Cell Phones dated 10/31/01 revealed the following information under number 3: Employee personal calls may only be made and/or taken while the employee was on authorized 1/2 hour meal and 1/4 hour break periods. That included all calls made on facility phones and/or personal cell phones.

r. The final rinse water on the low temperature commercial dishwasher indicated a reading of 200 parts per million (ppm). Interview with the DM at the time of the observation and testing confirmed the results of the tests. Continued observation at that time revealed the wash water temperature was 95 degrees Fahrenheit (F), and the rinse water temperature was 110 F. She stated she was not aware the dishwasher was not working properly. She stated she had the dishwasher service company turn down the water temperature as the wash water a few months ago was too sudsy. The DM did not realize the face plate on the commercial dishwasher stated the wash and rinse water temperature should both be at 120 F. She stated staff checked the sanitizer concentration and water temperature for each meal. Review of the dishwasher sanitizer concentration and temperatures record sheet for March 2010 revealed 19 of 23 days had a sanitizer concentration reading of 200 ppm and 20 of 23 days had 100 ppm. The criteria listed at the top of the sheet stated the dishwasher concentration would be at 50 ppm. Interview with the DM at the time of the record sheet review confirmed the above findings. She stated she was not aware the dishwasher sanitizer was not working correctly. She also stated she was not aware the service company had turned the water temperature down too low in accordance with instructions on the face plate of the machine. The DM revealed she was not aware if the service company for the dishwasher was authorized to work on the machine.

s. The night cook tested food temperatures in the steam table for the evening meal on 3/23/10. The night cook tested the hot food and then placed the probe thermometer in a glass of ice water. When questioned by the surveyor why he placed the thermometer in a glass of ice water he stated the thermometer needed to cool down between temperature checks of hot food. When the surveyor questioned if the probe thermometer had been calibrated, the night cook was aware it must be placed in ice water, but was unsure of the complete method to calibrate the thermometer. Testing at that time by the surveyor of the probe thermometer in a glass of slushy ice water revealed the probe thermometer used by the night cook registered at 25 F. The thermometer should have registered at 32 F. Continued interview with the night cook revealed he was not aware that particular probe thermometer was off by a negative 7 degrees. The surveyor requested that probe thermometer be placed out of service and another probe thermometer be placed in use. Another probe thermometer was located in the kitchen and placed in service at that time.

Interview on 3/24/10 at 11:00 a.m. with the DM revealed she had training every pay period in a variety of topics, but the kitchen and dietary staff just did not seem to get it. She stated she had put trust in her staff to know what they were doing, to do the cleaning, and she should not have trusted them.

Based on record review and interview, the provider failed to annually review and revise policies as needed for seven of eight policy and procedure manuals. Findings include:

1. Review of the following policy and procedure manuals revealed:
*The acute care services manual was reviewed and approved by the chairman of the board of directors on 8/1/06.
*The emergency room manual had no review or approval date. The most recent revisions on some policies occurred in October 2007. Some policies dated back to 1995.
*The obstetrics/pediatrics manual had no review or approval date.
*The laboratory manual had no review or approval date.
*The radiology manual was reviewed and approved by the chairman of the board of directors in June 2000.
*The swing bed manual was reviewed and approved by the administrator in June 2004.
*The dietary manual was reviewed and approved by the administrator on 7/27/07.

Interview on 3/24/10 at 9:45 a.m. with the director of nursing confirmed the above policy and procedure manuals had not been reviewed and approved on an annual basis. Further interview revealed she was aware the policy and procedures should have been reviewed on an annual basis.

Based on interview and document review, the provider failed to ensure a credentialed member of the medical staff supervised the radiology services. Findings include:

1. Interview with the administrator (SM) 15 on 03/24/10 at 09:38 a.m. revealed there was not a credentialed member of the medical staff supervising the radiology services.

Review of the medical staff meeting minutes between January 2009 and January 2010 did not reveal a credentialed member of the medical staff had been appointed for supervisory oversight of the radiology department.

Review of the radiology policy manual failed to reveal a policy indicating a member of the medical staff would have supervisory oversight of the radiology department.

Review of the governing board minutes between January 2009 and January 2010 failed to reveal a credentialed member of the medical staff had been appointed for supervisory oversight of the radiology department.

Based on record review and interview, the provider failed to ensure the contracted laundry service met the federal and/or state regulations for proper handling of facility laundry. Findings include:

1. Record review of the document titled Textile Rental Agreement between Servall and the provider revealed the agreement gave:
*The description of textiles rented.
*The number of textile pieces and the unit price of each piece.
*Delivery and special delivery charges.
*Payment and credit terms.

No other information was provided to ensure the company followed federal and/or state regulations for the proper handling of soiled and clean laundry.

Interview with the administrator at 11:00 a.m. on 3/24/10 revealed he had not requested nor had the company provided any information for the handling and processing of soiled and clean linen. The administrator revealed he was unaware what disinfecting process the company used, how the soiled linens and bio-hazardous linens were transported, and how the clean linens were handled and transported back to the facility.

Based on record review, policy review, and interview, the provider failed to ensure:
*Informed consent forms were properly executed for 13 of 32 (1, 4, 5, 7, 8, 11, 21, 23, 24, 27, 30, 31, and 32)sampled open and closed patient's records reviewed.
*Discharge summaries were completed for 3 of 11 (23, 24, and 28) sampled acute care patient's closed records reviewed.
Findings include:

1. Review of informed consents on the medical records for patients 1, 4, 5, 7, 8, 11, 21, 23, 24, 27, 30, 31, and 32 revealed 1 was not signed by the patient or representative, 4 were not dated, and 13 were not timed.

Review of the provider's revised January 2003 consent and refusal forms policy revealed the informed consent form was to include:
*The date and time the consent was completed.
*The signature of the patient or the person empowered to give consent.

Interview with the director of nursing (DON) at 9:45 a.m. on 3/24/10 revealed it was her expectation all informed consents should have been signed, dated, and timed. She acknowledged there was a designated space on the informed consent form for each of those items to have been entered.

2a. Review of patient 23's medical record revealed she had been admitted on 10/21/09 and left against medical advice on the same day. No discharge summary was found in her chart.

b. Review of patient 24's medical record revealed she had been admitted on 2/21/10 and was discharged on 2/24/10. No discharge summary was found in her chart.

c. Review of patient 28's medical record revealed he had been admitted on 2/7/10 and was discharged on 2/12/10. No discharge summary was found in his chart.

Interview with the DON at 9:45 a.m. on 3/24/10 revealed it was her expectation discharge summaries should have been on the chart as soon as possible after discharge. She further revealed she felt no more than 15 days should have passed between discharge and the completion of discharge summaries.

Review of the provider's unsigned 2004 medical staff bylaws revealed medical records must have been completed within 30 days after discharge.

Both the above interview and bylaws review apply to findings 2, 3, and 4.

Based on record review and interview, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 159 medical record entries revealed 91 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 68 written physicians' orders during review of medical records on all patient care areas revealed 16 were not dated, and 25 were not timed.

2. Review of 10 telephone physicians' orders during review of medical records on all patient care areas revealed 2 were not timed.

3. Review of 55 physicians' progress notes during review of medical records on all patient care areas revealed 1 was not signed, 4 were not dated, and 22 were not timed.

4. Review of 24 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 2 were not signed, 5 were not dated, and 14 were not timed.

5. Interview with the director of nursing at 9:45 a.m. on 3/24/10 revealed she was aware all entries should have been signed, dated, and timed. Further interview revealed the provider did not have a policy regarding dating and timing of the above entries within the medical record.

Based on record review, observation, and interview, the provider failed to ensure quality assurance (QA) activities were effectively implemented by:
*Establishing an annual plan for the QA program.
*Conducting utilization review activities
*Adopting a QA program through input from the medical staff and obtaining approval of the governing board.
*Creating a person responsible for reporting and creating an effective preventative maintenance program for maintenance and housekeeping.
*Creating a person responsible for reporting the direction, organization, and operation of sanitary food handling practices throughout the dietary program.
Findings include:

1. Review of the quality assurance committee minutes and interview on 3/24/10 at 4:40 p.m. with the administrator revealed the provider had not implemented an annual plan for the QA program.
Refer to C-336, finding 1.

2. Review of medical staff meeting minutes, governing board minutes, and interview on 3/24/10 at 1:40 p.m. with the administrator revealed there were no utilization review activities conducted for acute care services provided in the hospital.
Refer to C-336, finding 2.

3. Review of medical staff meeting minutes, governing board minutes, and interview on 3/24/10 at 1:40 p.m. with the administrator revealed the medical staff and governing board had not been provided information about or participated in QA activities.
Refer to C-337, findings 1 through 4.


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4. Observation, testing, policy review, manual review, label review, and interview revealed the preventative maintenance program and housekeeping program had not been overseen by administration.
Refer to C-220.

5. Observation, testing, policy review, label review, and interview revealed the dietary program had not been directed, organized, and operated according to federal and state guidelines.
Refer to C-270.

6. Interview with the administrator on 3/24/10 at 4:40 p.m. revealed:
*He, along with the past and the current director of nursing (DON), had created no written expectations regarding a QA program for the hospital.
*He expected the 15 different department heads to report to the monthly QA meetings, but not all of them reported.
*The prior DON had revealed to the administrator before she had left earlier this year that all department heads should be included in the hospital QA. The past DON and the administrator agreed they had been focused on the attached nursing home and they should focus on the hospital.

Based on record review and interview, the provider failed to ensure:
*There was an annual plan for the quality assurance program.
*There were utilization review activities conducted for the hospital.
*Medication error reports were incorporated into the quality assurance program.
Findings include:

1. Review of the 11/10/09 handwritten minutes of the quality assurance committee revealed a note stating an end-of-year report was to be prepared for the administrator by 12/1/09.

Interview on 3/24/10 at 4:40 p.m. with the administrator revealed:
*The end-of-year report had not been prepared.
*It had been the intention of the administrator to use the end-of-year report to prepare the annual quality assurance plan for the January 2010 meeting of the quality assurance committee.
*Not all of the individual departments had developed quality assurance plans to be included in the annual quality assurance plan.

2. Review of the minutes of six medical staff meetings from 1/11/09 through 2/24/10 and the minutes of eleven governing board meetings from 2/3/09 through 2/24/10 revealed:
*Utilization review activities were not included as an agenda item.
*There was no discussion of utilization review to evaluate the quality and appropriateness of diagnoses and the treatments furnished by the provider.
*There were no utilization review reports.

Interview on 3/24/10 at 1:40 p.m. with the administrator revealed:
*There was no appointed utilization review committee.
*There had been no utilization reports to the medical staff or the governing board for acute care services provided by the hospital.
*The provider had a contract with the state quality improvement organization (QIO) to perform utilization review.
*The QIO had not conducted any acute care utilization review activities for the provider.
*The provider had contacted the QIO about conducting utilization review for emergency room cases as a part of a plan of correction for a federal Emergency Medical Treatment and Active Labor Act (EMTALA) complaint.
*The QIO had recommended a different physician to conduct those reviews.
*The provider had used the different physician to complete the EMTALA reviews.
*The provider had plans to have the newly appointed chief medical officer establish an utilization review process for the provider.

3. Interview on 3/24/10 at 11:00 a.m. with the director of nursing (DON) revealed there had been fourteen medication errors reported in 2009. The DON stated:
*Medication errors were discussed during the pharmacy and therapeutics meetings.
*Those meetings also included the same people who attended the medical staff meetings.
*The medication errors were not included as a part of the quality assurance program.
*The provider did not have a system to rank the severity of the medication errors.
*There was no tracking or trending of medication errors as a part of the quality assurance process.

Based on record review and interview, the provider failed to ensure quality assurance data was provided to the medical staff and the governing body. Findings include:

1. Review of the provider's undated medical staff bylaws revealed:
*The medical executive committee was to participate in the adoption of an overall hospital quality assurance program.
*The overall quality assurance program was to be approved by the governing board.
*There was to be an utilization review committee that met at least quarterly. The duties of the committee was to monitor and improve the appropriateness and utilization of patient services in a cost effective manner.

Review of the minutes of six medical staff meetings from 1/11/09 through 2/24/10 revealed the quality assurance program was not an agenda item. There was no discussion of the quality assurance program to evaluate patient care services or other services provided.

Review of the minutes of eleven governing board meetings from 2/3/09 through 2/24/10 revealed the quality assurance program was not an agenda item. There was no discussion of the quality assurance program to evaluate patient care services or other services provided.

Interview on 3/24/10 at 1:40 p.m. with the administrator revealed:
*Review of quality assurance data was not an agenda item for medical staff meetings. There might have been times when the director of nursing discussed quality assurance items as part of her report.
*The governing board had not reviewed the results of quality assurance programs as a part of its meetings.
*The governing board did not have the expectation it should have been reviewing quality assurance data.

Based on record review and interview, the provider failed to ensure a discharge summary was completed for one of four sampled patient's (26) swing-bed closed records reviewed. Findings include:

1. Review of patient 26's medical record revealed she had been admitted to a swing-bed on 3/1/10 and was discharged on 3/3/10. No discharge summary was found in her chart.

Interview with the director of nursing (DON) on 3/24/10 at 9:15 a.m. confirmed:
*The discharge summary should have been in patient 26's chart.
*The discharge summary was not in the medical record department.
*She did not know where that record was, but thought it might have been dictated and not yet transcribed.
*At times pieces of patient's medical records had gotten lost.

Interview with the DON on the above date at 4:40 p.m. confirmed:
*The provider did not have a policy and procedure concerning swing-bed discharge summaries.
*She was in the process of revising all of the swing-bed policies.