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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on March 4, 2020, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on March 4, 2020, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 4, 2020.

A. Based on document review, observation, and interview, it was determined that for 2 of 3 patients ( Pt #1 & Pt #2) observed for intravenous (IV) fluid infusion and/or medication administration, the Hospital failed to ensure that care was provided in accordance with the patients' needs by not properly labeling the start time of the IV fluid infusion and the IV antibiotic administration.

Findings include:

1. On 2/24/20, the Hospital's policy titled "IV Administration Set (tubing) Change," (revised 1/28/2020), was reviewed and required "...label the administration set and solution container with the date of initiation or the date when the change is necessary..."

2. On 2/24/20 at 9:30 AM, an observational tour was conducted on the In-Patient Unit. At approximately 9:45 AM, Pt #1 was noted to have IV (intravenous) fluids infusing into his arm, and the IV solution bag was not labeled with the date or time the infusion was initiated.

3. On 2/24/20 at approximately 9:50 AM, Pt #2 was noted to have an IV infusing into her arm. Pt #2's IV solution bag and IV antibiotic medication bag were not labeled with the date or time the IV infusions were initiated.

4. On 2/24/20 at 10:10 AM, an interview was conducted with the Registered Nurse (E #6). E #6 stated that the IV bags and tubing should be labeled with the initiation time.

B. Based on document review and interview, it was determined that for 1 of 1 patient's (Pt #5) record reviewed for blood transfusion, the Hospital failed to ensure that the care was provided in accordance with the patient's needs by not assessing vital signs in a timely manner after completion of the blood transfusion.

Findings include:

1. On 2/24/20, the Hospital's policy titled, "Blood and Blood Product Transfusion," (revised 11/10/2019), was reviewed and required, "...At the completion of blood product administration, obtain the patient's vital signs and compare them with baseline measurements to detect signs of a possible transfusion reaction..."

2. On 2/24/20, Pt #5's clinical record was reviewed. Pt #5 was admitted to the Hospital on 2/19/20 with the diagnosis of "strengthening". Pt #5's clinical record indicated that Pt #5 received a blood transfusion on 2/18/20. Pt #5's "Blood Administration Flowsheet Data," dated 2/18/2020, included that the transfusion completion time was 5:38 PM. However, Pt #5's vital signs were not documented until 10:40 PM (5 hrs and 2 minutes after the completion of the transfusion) blood pressure 112/62, temperature 97.7, pulse 60 and respirations 16.

3. On 2/24/20 at approximately 11:00 AM, an interview was conducted with the Charge Nurse (E #4). E #4 stated that Pt #5's vital signs should have been taken within 90 minutes after the blood transfusion was completed.

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Room Physician (MD #1), the Hospital failed to employ methods for preventing and controlling the transmission of infection by not implementing proper PPE (protective personal equipment) in an isolation room.

Findings include:

1. On 2/24/20, the Hospital's policy titled, "Droplet Precautions," (revised 12/30/2019), was reviewed and required, "...Just before entering the patient's room, put on a mask and secure the ties or elastic band... Remove and discard... your mask in the anteroom or, or if an anteroom isn't available, at the patient's doorway just before leaving the room..."

2. On 2/24/20 at 1:30 PM, and observational tour was conducted in the Emergency Room. Physician (MD #1) was observed coming out of a droplet isolation room (Pt #11) wearing a mask. MD #1 entered the ER (Emergency Room) hallway & then entered another patient's room to throw the mask away.

3. On 2/24/20 at 1:40 PM, an interview was conducted with the Emergency Room Charge Nurse (E #8). E #8 stated that MD #1 should not have worn the mask outside the isolation room.