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Based on observation, staff interview and document review during the life safety code portion of the recertification survey conducted on February 22, 2016, the surveyor finds that the facility is not constructed and maintained as a safe environment for patients. See Tag C0231

Based on observation during the survey walk-through, staff interview, and document review during the life safety code portion of a recertification survey conducted on February 22, 2016 the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with associated K-Tags.

Based on a review of Critical Access Hospital (CAH) policy, observation, and staff interview, it was determined that the CAH failed to ensure proper food storage as per policy. This has the potential to affect all patient/ staff utilizing dietary servicers at the CAH.

Findings include:

1. The Hospital policy titled "Open Food Storage and Expiration of Food" was reviewed on 2/25/16. It indicated under "Policy: 3. As items are opened, they will be labeled with the date opened, and the use-by date".

2. During a tour of the CAH, conducted on 2/25/16 at 10:00 AM, the following items were observed without dates in Walk-In Freezer #1: two large bags of french fries, one large block of cheese (no name).

3. During the tour with the Dietary Manager (E # 12 ), E #12 verbalized that the foods should be identified and dated per policy.

B. Based on a review of CAH policy, a review of Kitchen Refrigerator/Freezer Temperature Logs, and staff interview, it was determined that the CAH failed to ensure that deviations in Refrigerator/Freezer temperatures were followed up as per policy. This has the potential to affect all patient/ staff utilizing dietary servicers at the CAH.

1. The CAH policy titled "Nutritional Service Monitoring of Food-Containing Refrigerator and Freezer Temperatures" was reviewed on 2/25/16. It indicated under "Policy: "The Nutritional Service Department will monitor all assigned food containing refrigerator and freezer temperatures twice daily to maintain food safety guidelines".

2. The "Kitchen Refrigerator/Freezer Temperature Logs" that include "Upright freezer 1, Upright freezer 2, Chicken freezer, ice freezer, cook fridge, produce refrigerator, bread freezer and milk cooler" for February 2016 was reviewed on 2/25/16. There were no temperatures documented on 2/24/16 per policy.

3. During a staff interview conducted with the E #12 on 2/25/16 at 10:45 AM, E #12 stated, "The staff are expected to check refrigerators and document completion daily."

C. Based on a review of CAH policy, a review of Kitchen Upright cooler, and staff interview, the CAH failed to ensure that all expired food items were removed from the kitchen cooler as per policy. This has the potential to affect all patient/ staff utilizing dietary servicers at the CAH.

1. The Hospital policy titled: "Open Food Storage" was reviewed on 2/25/16. It indicated under " policy: 3. As items are opened, they will be labeled with date opened, and use by date.

2. A tour of the CAH was conducted on 2/25/16 at 10:00 AM. The following items were observed in the Upright freezer 1: 2 cups of chopped up bacon in a large plastic bag dated expired 2/22/16, and a small round container of salad dressing (unidentified) with the expiration date of 2/24/16.

3. During a staff interview conducted with the E #12 on 2/25/16 at 10:45 AM, E #12 stated, "The staff are expected to check refrigerators and discard expired food per policy."

A. Based on document review and interview, it was determined in 1 of 20 (Pt #19) medical record reviewed, the CAH failed to ensure the nursing staff provided care to meet the patient needs as per policy. This has the potential to affect all patients receiving care at the CAH.

Findings include:

1. The policy titled "Wound Care Protocol" (effective 06/2005) was reviewed on 2/25/2016 at approximately 2:00 PM. The policy indicated "To promote the continuity of quality of care, the Medical/Surgical floor will utilize the Wound Care Protocol of Quad County Home Health Procedure:

- obtain an order to follow wound care protocol
- Copy pertinent care plan provided by Derma Services
- Treat wound per protocol
- Chart as appropriate including the following information as needed: size of wound,
color of wound, odor (if present), and any discomfort felt by the patient.

2. The clinical record of Pt #19 was reviewed on 2/25/2016 at approximately 11:00 AM. Pt #19 was admitted with a diagnosis of pneumonia and pressure ulcers. The clinical record did not have an order for the treatment of Pt #19's wounds.

3. An interview was conducted on 2/25/2016 at approximately 2:00 PM with the Inpatient Manager (E #3). E #3 agreed the policy was not followed by nursing staff..

Based on document review and staff interview, it was determined in 1 of 20 (Pt #1) medical record reviewed, the CAH failed to ensure verbal consent was authenticated by two staff members and circumstances requiring verbal consent was indicated as per policy. This has the potential to affect all patients receiving care at the CAH.

Findings include.

1. The policy titled "Policies-General" (effective 4/15) was reviewed on 2/25/2016 at approximately 1:00 PM. The policy indicated under " E. Consent for Treatment and Procedure C. 2 .c. Telephonic: This is valid provided two persons listen in on the line. Each should record the time and circumstances on the ED cobra form."

2. The medical record of Pt #1 was reviewed on 2/22/2016 at approximately 10:00 AM. Pt #1 was seen in the emergency room on 2/21/2016 with a diagnosis of shortness of breath. The Emergency Treatment Consent indicated a telephone consent was obtained by one registered nurse and did not indicate the circumstances requiring a verbal consent.

3. An interview was conducted with Nurse Manager (E #3) on 2/22/2016 at approximately 1:00 PM. E #3 confirmed the verbal Emergency Treatment for Consent was not signed, dated or timed by two hospital staff members or indicate the circumstances, as hospital policy required.

Based on internal documentation and staff interview, it was determined that the CAH failed to ensure it's Quality Assurance program included a program review by an outside review organization to determine that the Medical Staff provided quality treatment and appropriate diagnoses to the patients served by the Critical Access Hospital. This has the potential to affect all patients receiving care at the CAH.

Findings include:

1. During an interview conducted with the Chief Nursing Officer (E #1) on 2/25/2016 at 2:45 PM, E #1 reported the medical staff conducts their own peer review unless indicated, the case will be sent out to External Peer Review Network for review. The medical staff only will send out a case if beyond their scope of practice or a conflict of interest. "I cannot recall the last time a case was sent out for review." E #1 reported that Telemedicine is peer reviewed on a quarterly basis by Clinical Radiology thru RADPEER, which is an external peer review organization.