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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on June 14-15, 2017, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see C231.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on June 14-15, 2017, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on policy and procedure, observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired medications and unlabeled multi-dose vials were maintained and stored appropriately per policy. This has the potential to affect all patients receiving medications.

Findings include:

1. The CAH undated policy, titled, "Expired Medications" was reviewed on 6/6/17 at 1:30 PM. Under heading, "POLICY Whenever the expiration date of any medication has been exceeded, or the integrity of a medication cannot be verified, it shall be removed from active stock." Under "PROCEDURE" para 2 "Multi-dose vials will be dated at the time they are opened. Vials must be discarded after 30 days."

2. On 6/5/17 at 9:30 AM, a tour of the operating room (OR) was conducted with the Certified Registered Nurse Anesthetist (CRNA)/Director of Surgery (E#2). It was observed in the anesthesia cart (1) opened and unlabeled 10 milligram (mg) per milliliter (ml) multi-dose vial of Vercuronium and (1) opened and unlabeled 10 mg/ml vial of Nesostigmine.

3. On 6/5/17 at 9:45 AM, an interview was conducted with the CRNA/Director of Surgery (E#2). E#2 observed the unlabeled vials of medication in the anesthesia cart. E#2 confirmed the vials should have been labeled when opened per policy.

4. On 6/7/17 at 1:30 PM, a tour of the cardiac rehab was conducted with the Director of Cardiopulmonary (E#3). It was observed in the crash cart 2 syringes of 10% Calcium Chloride 1 gram/10 ml with expiration dates of 4/17. Also observed were 2 syringes of 10% Calcium Gluconate1gram/10 ml with expiration dates of 5/17.

5. An interview during the tour was conducted with E#3 at 1:50 PM. E#3 observed the expired medications and and confirmed the medications should not be in the cart. E#3 removed the medications and replaced them immediately.

Based on document review and staff interview, it was determined for 1 of 4 patients receiving blood transfusions (Pt #16), the nurse failed to ensure the transfusion documentation was completed per the hospital policy. This failure has the potential to affect all patient receiving blood transfusions.

Findings include:

1. A review of Pt #16's medical record was completed on 6/7/17 at 3:30 PM. Pt #16 was admitted to the CAH on 4/4/17 with a diagnosis of anemia. A physician order dated 4/4/17 was for type, crossmatch and transfuse 2 units packed red blood cells. Documentation in the patient progress notes indicate the first unit was started on 4/5/17 at 1535 and completed at 1805. Documentation indicated the second unit was signed out from the blood bank on 4/5/17 at 2300. Documentation verifies a consent signed and 2nd nurse verification of the unit of blood. There is no documentation of the patient type and crossmatch results, blood compatibility, vital signs or start and completion of the transfusion. There was no documentation to indicate if any adverse reactions occurred.

2. The CAH policy titled "Blood Transfusion", revision date 7/20/2016, was reviewed on 6/7/17 at 4:00 PM. The policy indicates under "Procedure, 7. Obtain and assess the patient's baseline blood pressure, pulse... prior to obtaining the blood from the blood Bank. Document the vital signs on the Blood Transfusion Flowchart in the EMR." The policy indicates under "14. Both RN's will document successful completion of the bedside verification... on the Blood Transfusion Flowchart. The policy indicates under "15. Both RN's will complete the Blood Transfusion Flowsheet in the EMR on all patients receiving a blood transfusion." In the policy under Documentation 2. Note any adverse reactions in the EMR..."

3. An interview was conducted with the Chief Nursing Officer (E#1) on 6/8/17 at 9:30 AM. E#1 reported she reviewed the record of Pt #16 and confirmed the documentation of the transfusion of the second unit of blood was not completed per the CAH policy.