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Based on observation, staff interview, and policy and procedure review, the facility failed to ensure that the patient care environment was maintained in a safe manner during three (3) of three (3) days of survey.


Findings Include:


Observation of the Emergency Room (ER) Department made with the Infection Control Nurse on 08/20/18 at 2:56 p.m. revealed the ER interior door threshold had four (4) missing floor tiles; the trauma two (2) entrance door threshold had uneven flooring measuring two (2) to three (3) inches in width by 10 to 12 inches in length; the ER entrance door threshold to rooms A, B and C and the entrance door threshold to the ER supply room had uneven flooring.


Observation of the Computed Tomography (CT) Room made with the Infection Control Nurse and X-ray Technician #1 on 08/20/18 from 2:58 p.m. to 3:05 p.m. revealed the corner wall by the CT machine had a broken surface measuring two (2) to three (3) inches in width by seven (7) to eight (8) inches in length and a two (2) foot baseboard was loose; there was no emergency lighting inside the room; and a weak spot in the flooring at the same area measuring three (3) foot width by five (5) foot length sags when walked on. During an interview at the time of the observation, X-ray Technician #1 stated the floor had been repaired.


Observation of the ER exterior entrance door made with the Infection Control Nurse on 08/20/18 at 3:16 p.m. revealed a broken threshold the width of the door.


Observation of the Laboratory Department made with the Infection Control Nurse and Laboratory Director on 08/20/18 from 3:28 p.m. to 3:40 p.m. revealed the front room had peeling paint around the ceiling air vent, broken counter tops around the blood bank area, and multiple broken floor tiles.


During an interview on 08/20/18 at 4:30 p.m. all the environment findings were discussed with the Director of Nursing (DON) and Interim Chief Executive Officer.


Review of the "Work Orders" document for "Open Work Orders" revealed no documented evidence that a work order request had been placed for maintenance in the ER, CT Room or Laboratory Department.


During an interview on 08/22/18 from 9:20 a.m. to 9:40 a.m., all the environment findings were discussed with the DON and Maintenance Director. They both confirmed all observations and stated no current work orders had been submitted for ER, CT Room or the Laboratory Department.


Review of the facility's "Environmental Services (External and Internal) policy, reviewed August 2018 revealed: " ...Policy: Internal Environmental Services ...Procedure: The residence (facility) will be kept clean and well-maintained. This will be accomplished through ...a preventive maintenance program, and repair or enhancement of existing structures ...and fixtures. Policy: Maintenance; Purpose ...Provide a safe environment for ...visitors, and staff ...Procedure: 1. It is the job of all staff to identify areas of concern regarding the maintenance of the building. 2. Preventive maintenance will occur throughout the year ...Policy: Maintenance Work Request; Procedure: 1. When a ...staff member ...recognizes the need for maintenance service, a Maintenance Work Request will be placed in the TELS system ...2. Maintenance personnel will review all Maintenance Work Requests daily and prioritize work to be done ...3. All Maintenance Work Requests will be completed within five (5) days of receipt, unless the work needed is of an urgent nature, in which case it will be done immediately ...".


During the Exit Conference on 08/22/18 from 9:50 a.m. to 10:00 a.m. all environment findings were discussed. No further documentation was submitted for review.

Based on record review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the Critical Access Hospital (CAH), for six (6) out of 27 patient deaths in the last 12 months. One (1) patient in September of 2017, one (1) patient in October of 2017, two (2) patients in January of 2018, and one (1) patient in May of 2018 were called in greater than one (1) hour after Cardiac Time of Death and one (1) patient death in March of 2018 was not called to MORA at all.

Findings Include:

Review of the facility's "Tissue Donation Report" report for 2017 and 2018 revealed there
was one 1 patient in September of 2017, 1 patient in October of 2017, 2 patients in January of 2018, and 1 patient in May of 2018 who were called in greater than one hour after Cardiac Time of Death (CTOD) and 1 patient death in March of 2018 was not called to MORA at all.

During an interview on August 21, 2018 at 10:15 a.m. the Emergency Room Director confirmed the facility had been late in calling in five (5) deaths and did not call in one death to the OPO in the last 12 months.

Review of the facility's "Cardiopulmonary Resuscitation" policy number, effective 12/01/2010 and last revised 06/03/2018 revealed: "Policy: It is the policy of (......Hospital) to promote healing and provide optimum patient care. The patient's right to make decisions regarding his/her healthcare will be encouraged and accepted at all times. In those instances where a patient is found to have no palpable pulse and/or no discernible respirations, the individual noting the patient's condition will activate the "Code Blue" process and Cardiopulmonary Resuscitation (CPR) will be initiated ...Post Resuscitation: ...If Cardiac Death is ruled, by the provider, the primary nurse will notify MORA..... within 1 hour of cardiac time of death ..."