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Based on document review, observation, and staff interviews, the hospital failed to ensure that all drugs and biologicals were stored in accordance with acceptable standards of practice and that outdated, mislabeled, and unusable drugs were not available for patient use.

Findings:

1. On the afternoon of 10/23/2014, surveyors toured the medication room with staff JJ. Surveyors observed four vials of multidose insulins (Novolin R, Humulin 70/30, Humalog, Lantus) that were opened, used, and not dated.

2. On the afternoon of 10/23/2014, surveyors observed one multidose vial of Novolin N that was opened, used, and not dated. The box of Novolin N had a label fixed to the box that documented an open date of 06/2014.

3. On the afternoon of 10/23/2014, staff JJ told surveyors that once insulin vials are opened there should be a sticker placed on the vial, dated it with an expiration date of 28 days from the day it is opened, and the person's initials who opened the insulin vial.

4. On the afternoon of 10/22/2014, staff LL told surveyors that she opens the insulin multidose vial and places a sticker on the vial, dated it with an expiration date of 30 days from the date it is opened.

5. On the morning of 10/24/2014, the drug room supervisor told surveyors that all insulin vials should be labeled with the expiration date of 28 days from the day it is opened and accessed as well as the person's initials who opened it.

6. On the morning of 10/24/2014, the drug room supervisor told surveyors that there was not a policy and procedure for labeling and storing insulin.

7. On the afternoon of 10/23/2014, surveyors requested a policy on labeling and storing insulin. None was provided.

Based on infection control policy and procedure review, infection control meeting minutes review, observation and staff interview, the Critical Access Hospital (CAH) failed to maintain a clean and sanitary environment to control infections and communicable diseases in patients and personnel.

Findings:

1. On the morning of 10/22/2014, surveyors reviewed infection control meeting minutes. There was no documentation that all chemicals and disinfectants used in the CAH had been reviewed and approved by the infection control practitioner, the infection control committee and the medical staff.

2. On the morning of 10/22/2014, Staff A told surveyors that Staff B was the infection control practitioner. There was no documentation that the Staff B had been designated in writing as the infection control practitioner.

3. There was no documentation that the infection control practitioner had conducted a hospital wide infection control risk assessment.

Observations:

1. On the morning of 10/22/2014, surveyors toured the CAH.

2. Surveyors observed an ice machine positioned behind the main nurse's station. The ice machine contained 2 ice scoops sitting on top of the machine. One scoop was in a bucket and one scoop was on top of a towel. The ice scoops were not protected with a cover. Staff B told surveyors the ice scoops should be covered.

3. Surveyors observed the physical therapy department. Surveyors observed clean linen stored on shelves within the department. The linen was not covered and was kept in a patient care area.

4. Surveyors observed a soiled utility room. The soiled utility room contained cabinets. Surveyors observed inside the cabinets a curling iron, water pick and hair dryer. Staff E told surveyors that these items were at one time used for patients.

5. Surveyors observed patient care rooms. Surveyors observed room 16 on the patient care unit. Room 16 had an un-repaired hole in the wall. Staff A told surveyors there had been a water leak. Staff A told surveyors that room 16 could be used for patient care.

Operating Room Observations:

1. On the morning of 10/23/2014, surveyors toured the operating room.

2. Surveyors observed the operating room suite. There was a blue surgical towel on the top of the anesthesia cart and one on top of the anesthesia medication cart. Staff E told surveyors the towels were not changed between each case. Staff E told surveyors the towels were changed at the end of the day.

3. Surveyors observed a metal stand that contained intubation supplies such as a laryngoscope blade and handle, and a oral airway. The supplies were covered with a green surgical towel. Staff E told surveyors the supplies stay on the stand. Staff E told surveyors the supplies are left throughout the day during all surgical procedures.

4. Staff E told surveyors that laryngoscope blades are cleaned after use with "DMQ" the main disinfectant used in the hospital. DMQ is not high level disinfection. Staff B told surveyors that the blades are cleaned using high level disinfection. The CAH had no policy and procedure to guide staff in the disinfection of laryngoscope blades.

5. Surveyors observed an office in the operating room department. The office contained 2 chairs that were upholstered. Upholstered furniture can not be terminally cleaned.

6. Surveyors observed the decontamination room. The decontamination room contained an automated scope reprocessing machine. The size of the decontamination room does not accomodate the automated scope reporcessing machine to prevent cross contamination.

7. Surveyors observed paper and binders in the decontamination room on the cabinet beside the scope cleaning sink. The papers and binders were not protected from potential splashing from the scope cleaning sink.

8. Suveyors observed corrogated boxes throughout the operating room department. Corrogated boxes can not be terminally cleaned.

9. Surveyors observed an ultrasonic instrument cleaner in the central sterile area. An ultrasonic instrument cleaner is used to clean dirty instruments and is not a clean process. Surveyors observed a policy, The policy, titled, "Infection Control-Operating Room and Anesthesia," documented "..all instruments will be washed and placed in ultrasonic instrument cleaner before being sent to central service for packaging and sterilization..."

Radiology Observations:


1. On the morning of 10/22/2014 and the afternoon of 10/23/2014. Surveyors toured the radiology department with administrative staff.

2. On the afternoon of 10/23/2014, surveyors observed one bottle of Revital-Ox test strips with an expiration date of 11/23/2013, which was used to test the cleaning chemical Revital-Ox solution before and after cleaning the trans-vaginal ultrasound probe.

3. On the afternoon of 10/23/2014, the radiology manager verified that the Revital-Ox test strips had an expiration date of 11/23/2013 and were expired.

4. On the afternoon of 10/23/2014, surveyors observed a white canister with unknown solution with a date of 11/2014.

5. On the afternoon of 10/23/2014, the radiology manager was unable to verify what the solution was in the white canister. The radiology manager told surveyors that the container was suppose to contain a high level disinfectant that was used to clean the trans-vaginal ultrasound probe.

6. On the morning of 10/23/2014, surveyors requested a policy and procedure for cleaning, storing, and transporting the trans-vaginal ultrasound probe. The radiology manager told surveyors that there was not a policy and procedure for cleaning, storing, and transporting the trans-vaginal ultrasound probe.

7. On the afternoon of 10/23/2014, the radiology manager told surveyors that staff NN takes the trans-vaginal ultrasound probe with her.

8. On the afternoon of 10/23/2014, the radiology manager told surveyors he was unaware if the trans-vaginal probe was being cleaned before use.

9. On the afternoon of 10/23/2014, the radiology manager told surveyors that staff NN may have taken the log book (information that identifies the temperature of the high level disinfectant, if the solution passed or failed, and patient information).

10. On the afternoon of 10/24/2014, the radiology manager told surveyors that the log book was supposed to stay at the facility.

Laundry Service Observations:

1. On the morning of 10/23/2014, surveyors toured the linen room. Staff DD told surveyors that the housekeepers are in charge of washing the linen. Staff DD told surveyors that the housekeepers do not wear disposable gowns when handling all linen. Staff DD told surveyors that disposable gowns were worn when handling visibly soiled linen. A policy, titled, "BBP Exposure Control Plan: Laundry," documented, "...all laundry, other than dietary tablecloths, from this facility shall be treated as if contaminated..."

Based on document review, observation, and staff interviews, the hospital failed to ensure that the dietary needs of the patients were met. This occurred in seven (#6 through 9 and 11 through #13) of eight medical records reviewed.

Findings:

1. On the afternoon of 10/22/2014, surveyors reviewed patient #11's medical record that documented patient was admitted for a heart attack. Patient #11 has a past medical history of diabetes, anemia, high blood pressure, congestive heart failure, thyroid disease, gastroesophageal reflux disease, and cancer.

2. There was no documentation for patient #11 that the dietary manager or the dietician reviewed the patient's medical record. There was no documentation that the nutritional screen flagged the dietary manager or dietician.

3. The nutritional assessments for patient #11 and patient #12 were partially filled out and not complete.

4. Staff A identified the dietary manager as staff CC. Staff CC is not a dietician and is not a certified dietary manager.

5. On the afternoon of 10/23/2014, surveyors asked nursing staff how they contact the dietary manager/dietician. Staff BB told surveyors they can fax the dietician if they need to.

6. On the afternoon of 10/23/2014, nursing staff verified that patient #11 should of had a dietary consult based on the patient's medical history.

7. On the afternoon of 10/23/2014, nursing staff verified that patient #11 and 12's nutritional assessment were not completed.

8. On the afternoon of 10/23/2014, Staff A verified that the nutritional screening and assessment policy and procedure was not being followed.

Based on document review, observation, and staff interviews, the hospital failed to ensure that all radiological services were provided in accordance with acceptable standards of practice and met professionally approved standards for safety.

Findings:

1. On the morning of 10/22/2014 and the afternoon of 10/23/2014. Surveyors toured the radiology department with administrative staff.

2. On the afternoon of 10/23/2014, surveyors observed one bottle of Revital-Ox test strips with an expiration date of 11/23/2013, which was being used to test the cleaning chemical Revital-Ox solution before and after cleaning the trans-vaginal ultrasound probe.

3. On the afternoon of 10/23/2014, the radiology manager verified that the Revital-Ox test strips had an expiration date of 11/23/2013 and were expired.

4. On the afternoon of 10/23/2014, surveyors observed a white canister with unknown solution with a date of 11/2014.

5. On the afternoon of 10/23/2014, the radiology manager was unable to verify what the solution was in the white canister. The radiology manager told surveyors that was the container is suppose to contain a high level disinfectant that was used to clean the trans-vaginal ultrasound probe.

6. On the morning of 10/23/2014, surveyors requested a policy and procedure for cleaning, storing, and transporting the trans-vaginal ultrasound probe. The radiology manager told surveyors that there was not a policy and procedure for cleaning, storing, and transporting the trans-vaginal ultrasound probe.

7. On the afternoon of 10/23/2014, the radiology manager told surveyors that staff NN takes the trans-vaginal ultrasound probe with her.

8. On the afternoon of 10/23/2014, the radiology manager told surveyors he is unaware if the trans-vaginal probe is being cleaned before use.

9. On the afternoon of 10/23/2014, the radiology manager told surveyors that staff NN may have taken the log book (information that identifies the temperature of the high level disinfectant, if the solution passed or failed, and patient information).

10. On the afternoon of 10/24/2014, the radiology manager told surveyors that the log book is supposed to stay at the facility.

Based on document review and staff interviews, the hospital failed to maintain a list of all services provided through arrangements, contracts or agreements describing the nature and scope of services provided.

Findings:

1. On the morning of 10/22/2014, surveyors requested a list of contracted services including scope of services.

2. On the afternoon of 10/22/2014, administrative staff provided a list of contract services. The document containing contracted services did not list all services provided (several contracted services missing including but not limited to: organ procurement organization, pest control service, pathology, contracted physicians, telemedicine services, credentialing service, and badge reading company).

3. On the afternoon of 10/23/2014, the CEO (chief executive officer) verified the contracted list of services was incomplete.

Based on hospital document review and staff interview, the hospital failed to ensure all contracted services and shared services comply with the Critical Access Hospital (CAH) conditions of participation.

Findings:

1. On the morning of 10/22/2014 , staff A told surveyors that the CAH does not evaluate all contracted and shared services.

2. On the afternoon of 10/23/2014, staff A told surveyors that the contracted/shared service list was not complete.

3. On the morning of 10/22/2014, surveyors requested a list of all contracted and shared service agreements to include what services were provided. A contracted service list was provided.

Based on operating room medical record review and staff interview, the Critical Access Hospital (CAH) failed to:
a. Ensure a qualified physician evaluated each patient prior to a surgical procedure to determine the risk of the procedure to be performed.
b. Ensure a qualified physician evaluated each patient after a surgical procedure to determine a proper anesthesia recovery.
This occurred in 3 of 5 (# 1, 2, & #3) operating room medical records reviewed.
Findings:
1. On the morning of 10/23/2014, Staff E told surveyors that a physician performed conscious sedation on the endoscopy procedures and a nurse performed conscious sedation on the eye procedures. Staff E told surveyors this was based on the ASA score (American Society of Anesthesiologist's physical status classification system) given to the patient before the procedure.
2. On the afternoon of 10/24/2014, surveyors reviewed 5 (#1, 2, 3, 4, & #5) operating room medical records. Two (#4, & #5) operating room medical records reviewed were endoscopy procedures. Three (#1, 2, & #3) operating room medical records reviewed were eye procedures.
3. Three (#1, 2, & #3) operating room eye procedure records reviewed did not contain documentation of a pre-anesthesia evaluation by a qualified physician to include an ASA score. Three (#1, 2, & #3) operating room eye procedure records reviewed did not contain documentation of a post-anesthesia evaluation by a qualified physician.
4. On the afternoon of 10/24/2014, Staff V told surveyors that the eye procedures do not
recieve a pre and a post anesthesia evaluation by a qualified physician.