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Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the Kansas State food code regulations were implemented for preventing the potential contamination of food when an airgap was not installed on the kitchen preparation sink to prevent the backflow of sewage, gas, or other contaminates. This failed practice potentially placed all patients and visitors at risk of food contamination.

Findings include:

- Observation of the CAH kitchen on 9/20/16 at 7:45 AM revealed the sink used to prepare fresh food did not have an air gap to prevent contamination of the sink and food in the event of a backflow of sewage, gas, or other contaminates.

Interview with Maintenance Staff L on 9/21/16 at 2:30 pm acknowledged the sink had a garbage disposal installed but did not have an air gap.

An air gap drain kit was ordered by Maintenance Staff L on 9/21/16 for installation at the food preparation sink.

According to the Kansas State Food Code 2012 regulation 5-203.14 Backflow Prevention Device states "A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to ...cafeterias, public or nonprofit organizations routinely serving food ... " )

Based on observations, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure all supplies are maintained to safely meet patients' needs for the day-to-day operations for one of two Surgical Operating Rooms, one of one Operating supply cabinet, one of one Surgery Recovery Room Emergency Crash carts, one of one surgical central supply rooms, two of two hospital main central supply rooms, one of one laboratory and one of one Inpatient nursing medication room. This deficient practice or the failure of the facility to dispose of expired supplies placed all patients at risk for receiving ineffective supplies.

Findings include:

- Operating Room Minor #1 anesthesia cart observed on 9/19/2016 at 12:40 PM revealed the following outdated supplies:

1) One Nasopharyngeal (to maintain airway) size #30 French with expiration date of 4/2016.

- Operating Room Minor #1 supply cabinet observed on 9/19/2016 at 12:45 PM revealed the following outdated supplies:

1) Nine Endo Smart Caps (a complete solution to be used with an air or CO2 (carbon dioxide) and/or pump along with a sterile water source to supply air or CO2 and sterile water to a GI (gastro-intestinal) endoscope during endoscopic procedures) with expiration date of 6/2016.

- Surgery Recovery Room Emergency Crash Cart observed on 9/19/2016 at 1:20 PM revealed the following outdated supplies:

1) One Endotracheal 19 mm with expiration date of 7/2016.

Surgical Nurse Manager Staff A interviewed on 9/19/2016 at 1:20 PM acknowledged the outdated supplies should have been disposed.

- Surgical Central Supply room observed on 9/19/2016 at 1:25 PM revealed the following outdated supplies:

1) One box 200 pouches of self-seal View Pack Sterilization Pouch (used for steam and gas used only for instruments) with expiration date of 9/2014.

Surgical Nurse Manager Staff A interviewed on 9/19/2016 at 12:45 PM acknowledged the outdated supplies should have been disposed.

- Main Hospital Central Supply room #1 observed on 9/21/2016 at 2:00 PM revealed the following outdated supplies:

1) 9 Empty Evacuation 1000 milliliter glass containers (a negative pressure container to collect large volumes of body fluid) with expiration dates of 2/2013.

- Main Hospital Central Supply room # 2 observed on 9/21/2016 at 2:15 PM revealed the following outdated supplies:

1) 12 unopen boxes Esteem Stretchy Synthetic Powder-Free Vinyl gloves extra-large, # 130 with expiration dates of 12/2014.

2) 13 Laparotomy (surgical incision into the abdominal cavity) Sterile Drape packages with expiration dates of 1/2016.

Central Supply Staff R interviewed on 9/21/2016 at 2:45 PM acknowledged the expired supplies should have been disposed. Staff R stated "I missed those supplies".

- Laboratory observed on 9/20/2015 at 8:30 AM revealed the following outdated supplies:

1) 4 vials of Level 1 CRP control (a solution used to test lab equipment for C reactive protein, a blood test that is an inflammatory marker) found in Laboratory refrigerator outdated on 9/16/2016.

2) 5 vials of Level 2 CRP control (a solution used to test lab equipment for C reactive protein, a blood test that is an inflammatory marker) found in laboratory refrigerator outdated on 9/16/2015.

Lab Manager Staff G interviewed on 9/20/2016 confirmed the CRP control was expired. S/he threw the controls into the trash.

- Policy title "Outdated Supply Management" reviewed on 9/19/2016 directed, "...Outdated items will be removed and inventoried monthly through the MHS systems as spoilage..."

Based on documentation review, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the Medical Staff credentials for re-appointments and clinical privileges were updated in the required time per their policy for 2 of 11 medical staff personnel (Staff U and Staff V). This deficient practice had the potential to provide an unsafe environment and to cause poor patient outcomes.

Findings Include:

- Medical Staff Credentialing reviewed on 9/21/2016 at 10:00 AM revealed Staff U credentials were not approved by the Governing body in May 2016.

Medical Records Staff T interviewed on 9/21/2016 at 1:30 PM acknowledged Staff U's reappointment was not signed and approved by the Governing Body. Staff T stated she forgot to pull the Recommendation and Approval form and present it to the Governing Body meeting.

- Medical Staff Credentialing reviewed on 9/21/2016 at 10:30 AM revealed Staff V's re-appointment with privileges were not renewed since 7/2014.

Medical Records Staff T interviewed on 9/21/2016 at 1:30 PM acknowledged Staff V's reappointment was overlooked. Staff T stated she forgot to complete the Staff's reappointment and present it to the medical staff and the Governing board meetings.

- Policy titled Credentialing of Phillips County Professional Staff reviewed on 9/21/2016 directed "Re-certification of credentialed professional will be handled by the agency's procedures on an every two year basis. The packets will be sent out 6 months prior to their birth month of the required 2 year interval..." "....Re-certification of credentialed professional will be handled by the agency's procedures on an every two year basis. The packets will be sent out 6 months prior to their birth month of the required 2 year interval..."

Based on observation, interview and policy review the Critical Access Hospital (CAH) failed to ensure that outdated, unusable medications were removed and made unavailable for patient use in the Emergency Room (ER) medication storage cabinet #4 and in the nurse's medication room and narcotic cabinet. Failure to ensure that outdated medications are removed placed all patients at risk for receiving ineffective medications.

Findings include:

- Observation on 9/19/2016 at 12:20 PM of the ER medication storage cabinet #4 revealed 1 vial of Xylocaine 2% (a medication injected to numb an area of the skin) marked, opened on 8/8/2016.

Staff Paramedic P interviewed on 9/19/2019 confirmed the Xylocaine was beyond 28 days and in the cabinet stating, "that should be gone". Staff RN B came to the ER and disposed of Xylocaine.

Review of policy titled Medication Labeling on 9/19/2016 at 2:15 PM directed "...9. All multi dose vials of injectable medications shall be dated and initialed by the nurse when first opened. Such opened vials shall be considered safe for administration for a period of 28 days or according to package instructions, whichever is shorter."

- Observation on 9/20/2016 at 9:30 AM of the nurse's medication room revealed 4 bags of D5 ¼ NS (an intravenous fluid with 5% dextrose and ¼ normal saline) with expiration date of 8/1/2016 and 14 tablets of Alprazolam (a medication given for anxiety) 1 mg (milligram) tablets expired on 7/31/2016 in the locked narcotic cabinet.

Pharmacy RN C interviewed on 9/20/2016 at 9:50 AM confirmed expired D5 ¼ NS IV fluids and Alprazolam tablets. She reported that expired medications are logged and reported at the monthly medical staff meetings. The decision to reorder or not is made by the medical staff board.

Review of policy titled Removal of Outdated/Expired Drugs on 9/21/2016 at 1:00 PM directed "... 2. Medications are routinely inspected and pharmacy personnel remove all outdated/expired medicines from supply ..."

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Based on observation, interview, and policy review the Critical Access Hospital (CAH) failed to maintain clean and sanitary conditions in the kitchen. Failure to ensure a clean environment in the food service area put all patients, staff, and facility at risk of exposure to bacteria and insect infestation.


Findings Include:


- Observation of the nutrition department on 9/20/16 at 7:45 am revealed food particles and debris under the dishwashing machine, under the floor mat at the dish sanitation sink, and at the drink preparation counter. Wood cabinets above the counter tops throughout the food preparation area had residue from splashed liquids on the cabinet doors. No check off lists were available for documentation of areas cleaned.


Interview with Nutrition Department Manager Staff D acknowledged s/he had been in her/his position "a few months and is working on changes within the department, including cleanliness of the area."


Policy review titled "Mopping Kitchen Floor", "Cleaning Pantry", and "Assigned Department Cleaning" directed "...floor in the kitchen and chiller will be free of debris and maintained as needed during each day with total floor being swept and mopped once daily...", and "...all areas of the Nutritional Services Department shall be clean and sanitary at all times...". The policies include specific areas and devices to be cleaned daily, weekly, and monthly.

The Critical Access Hospital (CAH) reported a census of two acute inpatients and seven skilled swing bed patients. Based on policy review, staff interview, and medical record review revealed the CAH failed to ensure all medical record documentation is legible for two of two surgical patients' records reviewed (Patient #6 and #11). This deficient practice put all surgical patients at risk as other healthcare workers may not be able to retrieve complete information about the patients.

Findings Include:

- Review of twenty medical records on 9/20/16 at 10:00 AM revealed illegible documentation by anesthesia Staff X for two of two surgical patients' records reviewed (patient #6 and #11).

Interview of Health Information Management (HIM) Staff E acknowledged documentation by Staff X is written and scanned into the electronic medical record (EMR) after surgical procedures are complete and is difficult to read. "We have asked him to start documenting in the EMR instead because his writing is not legible."

Based on policy review, staff interview, and employment record review, the Critical Access Hospital (CAH) failed to ensure background checks were performed for five of twelve clinical employees' records reviewed (Staff A, C, E, G, and I). This deficient practice of placed all patients at risk of receiving care from people who had been convicted of crimes such as abuse, neglect, and exploitation.

Findings Include:

- Personnel record review of twelve clinical staff on 9/21/16 at 1:00 PM revealed the records for Staff I, Staff E, RN Staff C, Lab Staff G, and RN Staff A lacked documentation of background checks.

Interview of Human Resources Staff S acknowledged background checks are performed on all new employees and have been performed for only 4 years. Background checks have not been performed for employees hired longer than 4 years.

Review of CAH policy titled "Swing-Bed Abuse, Neglect, And Exploitation" effective date 9/2015, directed "...Pre-hire procedure: In addition to inquiry of the State nurse aide registry or other licensing authorities, Phillips County Health systems will check all staff references and make reasonable efforts to uncover information about any past criminal prosecutions..."