HospitalInspections.org

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 November 2, 2021, 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 Recertification Survey conducted on November 2, 2021, 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 November 2, 2021.

Based on observation, document review, and staff interview it was determined the critical access hospital (CAH) failed to ensure expired biological's were disposed of per policy. This has the potential to effect all patients receiving services at a hospital with a current census of 12 patients.

Findings include:

1. On 10/25/21 at 10:45 AM, a tour of the medical surgical floor was conducted. In the crash cart it was observed that the "Adult Intubation Box" contained (1) endotracheal tube (ET) sizes 9.0, which expired on 9/20/21.

2. The CAH policy dated 5/11/11, titled, "Supply/Equipment Disposal" was reviewed on 10/26/21 at 9:30 AM. The policy under "PROCEDURE: 1. Expired supplies should be taken from inventory immediately to prevent possible use."

3. On 10/25/21 at 10:50 PM, E #2 confirmed the ET had expired and stated "that should have been checked by respiratory therapy and the expired items should have been replaced.

B. Based on observation and staff interview it was determined the CAH failed to ensure biological's are safe for patient use. This has the potential to effect all patients receiving services. Current census-1

1. On 10/27/2021 at 10:00 AM-10:30 AM, a tour of the emergency department (ED) was conducted with ED Registered Nurse (E #4). ED exam rooms #1, #2 and #3 each contained an open bottle of skin cleanser and medicated skin lotion without a date of opening.

2. On 10/27/2021 at 10:30 AM, an interview was conducted with the ED registered nurse (RN) ( E #4). E#4 stated that all opened skin cleansing and lotion products should have a label with a date of opening.

Based on observation, document and staff interview it was determined the critical access hospital (CAH) failed to ensure safe dietary practices were followed per policy. This has the potential to effect all patients and employees receiving dietary services at a hospital with a current census of 12 patients.

Findings include:

1. On 10/25/21 at 11:30 AM, a tour of the dietary department was conducted with the dietary manager (E# 2). During the tour, it was observed in the dry storage area, a box with approximately 27 individual boxes of cereal, with no expiration dates on them, thereby preventing expired food from being consumed by the patients, and employees. E #2 found a similar box that the cereal is shipped in and found that there was no expiration date printed on the box.

2. On 10/26/21 at 9:30 AM, the policy dated, 6/2009, titled, "DATING AND LABELING REFRIGERATED READY TO was reviewed. Under "POLICY: To ensure refrigerated, ready-to-eat, potentially hazardous food is dated and disposed of within food code requirements."

3. On 10/25/21 at 11:30 AM, an interview with E #2 was conducted. E #2 confirmed there were no expirations dates on the cereal boxes. E #2 indicated the cereal usually comes in a box that has the expiration date printed on the outside of the box.

Based on observation and staff interview it was determined the CAH failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. This failure has the potential to effect all patients receiving laboratory services.

Findings include:

1. On 10/26/21 at 9:45 AM, a tour of the laboratory was conducted with the laboratory manager (E#3). During the tour, in the laboratory blood draw area, it was observed that the blood draw chair had a tear in the vinyl on the arm rest, also observed a tear in the vinyl on the gurney mattress, and observed the office chair was worn and starting to tear open.

2. On 10/26/21, at 10:00 AM, an interview was conducted with the laboratory manager (E#3). E#3 observed the tears in the laboratory equipment and confirmed the need for repair.

Based on document review and interview it was determined for 1 of 3 (Pt #11) death records reviewed, the CAH failed to ensure that staff completed the "transplant services" form per policy. This failure has the potential to effect organ procurement services.

Findings include:

1. On 10/27/21 at approximately 2:00 PM, the medical record of Pt #11 was reviewed. Pt #11 expired on 1/12/21. The "Mid-America Transplant Services" form was not completed. The form lacked documentation in section #2, indicating if Pt #11 was a candidate for organ procurement or services were declined.

2. On 10/27/21 at 3:30 PM, the policy revision date 2/2/07, titled, "REPORTING OF ALL DEATHS IN A HOSPITAL" was reviewed. Under "PURPOSE: 2. Ensure that families of potential organ donors are made aware of the option of organ or tissue donation and their option to decline;".

3. On 10/27/21 at interview was conducted with the health information manager (E#5). E#5 reviewed the medical record of Pt #11 and confirmed the transplant services form was not completed regarding documentation of not a candidate or declined organ procurement services.