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Based on observation, record review, and staff interview, the facility failed to meet the provisions applicable to Critical Access Hospitals (CAH) of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced.

Findings include:

In reference to Federal Life Safety Code citation K331 the facility failed ensure that smoke barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA (National Fire Protection Association) 101.

In reference to Federal Life Safety Code citation K353 the facility failed to ensure Sprinkler System in accordance with NFPA (National Fire Protection Association) 101 and 25.

In reference to Federal Life Safety Code citation K362 the facility failed to maintain the Corridor Walls in accordance with NFPA (National Fire Protection Association) 101.

In reference to Federal Life Safety Code citation K511 the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70.

In reference to Federal Life Safety Code citation K921 the facility failed to maintain Electrical Equipment-Testing and Maintenance in accordance with NFPA (National Fire Protection Association) 101 and 99. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

These findings were verified with the Facility Maintenance Supervisor at the time of discovery and again with the Administrator at the time of exit.

Based on observations, document review and staff interview, the hospital failed to ensure to maintain a clean and sanitary environment to avoid sources and transmission of infection in the laboratory department during the utilization of dip sticks while testing urine specimens, resulting in the potential of transmission of infection. This failure had the potential to adversely affect all patients receiving urine dipstick tests in the hospital or as outpatients.

Findings include:

An observation on 09/05/23 at 11:40 a.m. of the laboratory, revealed a laboratory technician at the urine dipstick testing area. The laboratory technician placed a urine dipstick in a specimen cup of urine, then dabbed it on a small stack of paper towels that were laying on the desk - noted to have multiple urine stains on it - and placed it in the urine testing machine. After a few seconds, the dipstick was removed from the machine, and the machine was wiped off with a lint free kintech wipe, that was wadded up and dropped on the desk. These paper towels and wipes were not discarded after the test was completed. They were left at the station stained with urine.

An observation on 09/06/23 at 8:38 a.m. revealed two (2) laboratory technicians at the urine dipstick testing area. One (1) laboratory technician placed a urine dipstick in a specimen cup of urine, then dabbed it on a small stack of paper towels that were laying on the desk and placed it in the urine testing machine. After a few seconds, the dipstick was removed from the machine, and the machine was wiped off with a lint free kintech wipe that was lying wadded on the desk. These paper towels and wipes were not discarded after the test was completed. They were left at the station stained with urine.

An undated policy, titled "Standard Precautions" provided by the hospital stated, in part: "It is the intent of this facility that all patient blood and body fluids will be considered potentially infectious, and standard precautions will be used for all patients ..."

An interview was conducted on 09/06/23 at 8:45 a.m. with the Laboratory Supervisor (LS) regarding the process for testing urine dip sticks. They stated they do not discard the paper towels on the desk used to blot excess urine from the dipstick between patients. The LS stated: "We just find an unused area of the paper towel to blot the dipstick and throw it away when it's fully covered in urine." The LS then confirmed the lint free kintech towels were reused for up to three (3) patients before discarding and stated, "This is how we have done this for thirty (30) years."

An interview was conducted on 09/06/23 at 9:00 a.m. with the Chief Nursing Officer/ Infection Prevention (CNO/IP) regarding the process for testing urine dip sticks. The CNO/IP stated, "This process has infection control and cross-contamination issues. The paper towels and kinetic wipes should be discarded after each patient specimen."