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Based on document review and interview, it was determined that for 3 of 5 (E #5, #6, and #7) Emergency Department (ED) personnel files reviewed, the Critical Access Hospital (CAH) failed to ensure all Edmergency Department (ED) staff received annual competency training.

Findings include:

1. On 7/11/18 at approximately 2:00 PM, personnel files for 5 ED Registered Nurses (RN) were reviewed. Three (3) of 5 nurses (E #5, #6, and #7) lacked any or current ED specific competencies. The personnel files indicated the following:

-E #5 had a date of hire of 8/1/02, and the latest "Skills Validation Check off" was dated 6/18/12. The file lacked a current ED specific competency, including EMTALA (Emergency Medical Treatment and Labor Act) training. E #6 had a date of hire of 6/7/16 and lacked an ED specific competency, including EMTALA training. E #7 had a hire date of 8/5/16, and lacked an ED specific competency, including EMTALA training

2. The Registered Nurse (RN) Job Description for "Medical/Surgical, Swing-Bed, ER" (undated) required, "Maintain unit specific competencies and participates in review of the high risk/low frequency competencies."

3. On 7/12/18 at approximately 9:40 AM, the Interim Director of Nursing (E #1) was interviewed. E #1 stated that she could not find recent competencies for 3 of 5 ED registered Nurses (RN). E #1 stated that the EMTALA training used to be in the new employee orientation and annual training; however, the form no longer includes EMTALA training.

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 July 17 - 18, 2018, 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 July 17 - 18, 2018, 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 observation, document review and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure provision of services to include completion of transfer forms, staff adherence to operating room attire for 1 of 1 physicians, annual competency training for 6 of 11 staff, pain assessment, medication preparation, physician orders, and patient care plan. As a result, the Condition of Participation 42 CFR 485.635, Provision of services, was not met. This affects the approximately 3600 patients that come to Hospital foe services monthly.

Findings include:

1. The Critical Access Hospital (CAH) failed to ensure that the transfer form was completed. See deficiency cited at C-0271 A.

2. The Critical Access Hospital (CAH) failed to ensure the staff adhered to operating room attire as required. See deficiency cited at C-0271 B.

3. The Critical Access Hospital (CAH) failed to ensure all staff received annual competency training. See deficiency cited at C-0294.

4. The Critical Access Hospital (CAH) failed to ensure a pain assessment was completed before and after administration of pain medication. See deficiency cited at C-0296 A.

5. The Critical Access Hospital (CAH) failed to document the physician's wound dressing changes, as ordered. See deficiency cited at C-0296 B.

6. The Critical Access Hospital (CAH) failed to ensure administration of blood transfusion was appropriate, as required. See deficiency cited at C-0296 C.

7. The Critical Access Hospital (CAH) failed to ensure the staff cleaned the vial rubber stopper prior to drawing the medication, after the plastic cap is removed. See deficiency cited at C-0297.

8. The Critical Access Hospital (CAH) failed to ensure the patient's identified needs were included in the care plan. See deficiency cited at C-0298.

A. Based on document review and interview, it was determined that for 1 of 22 (Pt. #6) clinical records reviewed, the Critical Access Hospital (CAH) failed to ensure that the transfer form was completed.

Findings include:

1. On 7/12/18 at approximately 10:30 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a 60 year old female admitted on 6/5/18 with a diagnosis of diverticulitis (inflammation or infection in one or more small pouches along the walls of the intestine). The clinical record indicated that Pt. #6 was transferred to an outside hospital on 6/8/18. However, the clinical record did not include a "Patient Transfer Form."

2. On 7/12/18 at approximately 12:45 PM, the CAH's policy titled, "Transfer of a Patient" (revised 9/16) was reviewed and included, "Purpose: To ensure the safe transfer of patients... 2... The Patient Transfer Form is completed by the nurse and signed by the patient or patient representative indicating if the patient consents, refuses or if the transfer is per the patient's request..."

3. On 7/12/18 at approximately 1:45 PM, the findings were discussed with E #1 (Nurse Manager). E #1 stated that a transfer form is completed by the interdisciplinary team when a patient is transferred to another hospital. E #1 said, "It is a group effort... ultimately, the nurse is the one who is responsible." At approximately 3:30 PM, E #1 stated that Pt. #6's transfer form could not be found.


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B. Based on observation, documentation review and staff interview, it was determined that for 1 of 1 anesthesiologist (MD #1), the Critical Access Hospital (CAH) failed to ensure adherence to operating room attire. This could potentially affect the 5 to 20 surgical cases performed weekly.

Findings include:

1. On 07/11/18 at approximately 8:30 AM, during observation of operating room (OR) #2, MD #1 (anesthesiologist)preparing for a surgical procedure, was wearing nail polish with white tips and glitter.

2. The CAH policy titled, "Attire in the Operating Room" (revised 3/22/17), was reviewed on 07/11/18 at approximately 9:45 AM. The policy required, "...Nail polish is not permitted."

3. On 07/11/18 at approximately 10:15 AM, the Operating Room Manager (E #3) was interviewed. E #3 stated, "Nail polish is not allowed in the OR."

Based on document review and interview, it was determined that for 6 of 11 (E #3, #5, #6, #7, #8, and #9) personnel files reviewed, the Critical Access Hospital (CAH) failed to ensure all staff received annual competency training.

Findings include:

1. On 7/11/18 at approximately 2:00 PM, personnel files for 11 Registered Nurses (RN) were reviewed. Six (6) of 11 staff (E #3, #5, #6, #7, #8, and #9) lacked any or current competencies. The personnel files indicated the following:

-E #3, an operating room (OR) Licensed Practical Nurse (LPN), with the last competency dated 2/24/15.
-E #5, an Emergency Department (ED) RN, with a date of hire of 8/2002 and the latest skill checklist of 12/2012, lacked a current ED specific competency.
-E #6, an ED RN with a date of hire of 6/2016, lacked an ED specific competency.
-E #7, an ED RN, with a date of hire of 8/2016, lacked an ED specific competency.
-E #8, a wound care RN, with a date of hire of 12/2004, lacked competency as a wound care nurse.
-E #9, an OR-RN, with a date of hire of 1/2016, lacked competency since orientation.

2. The Registered Nurse (RN) "Job Description" for "Medical/Surgical, Swing-Bed, and ER" (undated) required, "Maintain unit specific competencies and participates in review of the high risk/low frequency competencies."

3. The Registered Nurse (RN) "Job Description" for "OR" (undated) required, "Maintain unit specific competencies and participates in review of the high risk/low frequency competencies."

4. The Licensed Practical Nurse (LPN) "Job Description" (undated) required, "Demonstrates competency in skills verified by Skills Check List."

5. On 7/12/18 at approximately 9:40 AM, the Interim Director of Nursing (E #1) was interviewed. E #1 stated all staff should have an annual competency; however, E #1 could not find recent unit specific competencies for the 5 RNs and 1 LPN.

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #2) open clinical record reviewed for pain medication administration, the Critical Access Hospital (CAH) failed to ensure a pain assessment was completed before and after administration of the pain medication.

Findings include:

1. On 7/10 /18 at approximately 11:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 56 year old male, admitted on 7/9/18 with diagnoses of left foot cellulitis (foot infection) and insulin dependent diabetes mellitus. The clinical record indicated that Norco (pain medication) was administered on 7/10/18 at 2:15 AM. However, the clinical record did not include a pain assessment before and after administration of the pain medication.

2. On 7/10/18 at approximately 12:00 PM, the findings were discussed with E #1 (Nurse Manager). E #1 stated that there should have been a pain assessment before and after administration of pain medication, and that the CAH does not have a policy regarding pain assessments. E #1 added that she (E #1) could not find documentation of the pain assessment. E #1 further stated that it is the Hospital's practice that nurses conduct a pain assessment before and after a pain medication is administered.

B. Based on document review and interview, it was determined for 1 of 2 (Pt. #5) clinical records reviewed, the Critical Access Hospital (CAH) failed to document the physician's wound dressing changes, as ordered.

Findings include:

1. On 7/12/18 at approximately 10:00 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a 68 year old female, admitted to the CAH from 8/7/17 to 8/11/17 with a diagnosis of non-healing wound of left hip and right heel. The clinical record included a physician's wound dressing order for a Dakin's solution (a solution used to cleanse wounds to prevent infection) moistened gauze packing into left trochanter (near the thigh bone) two times a day. However, Pt. #5's clinical record lacked documentation that the wound dressing order was completed on 8/10/18.

2. On 7/12/18 at approximately 12:30 PM, the CAH's policy titled, "Wound Care Program" (revised 4/2015) was reviewed and included, "... Purpose... to ensure that the appropriate treatment is utilized... Procedure... 4. Once the Physician order is received... 5. Documentation in the medical record is completed... by the nurse who changes the patient's dressing."

3. On 7/12/18 at approximately 1:35 PM, the findings were discussed with the Nurse Manager (E #1). E #1 stated that the nurse should document the dressing changes as ordered by the physician. E #1 added that the nursing documentation for the wound dressing changes, as ordered on 8/10/17, could not be found.

C. Based on document review and interview, it was determined for 2 of 3 (Pt. #7 and Pt. #8) clinical records reviewed for blood transfusions, the CAH failed to ensure administration of blood transfusions was appropriate, as required.

Findings include:

1. On 7/12/18 at approximately 11:00 AM, the clinical record of Pt. #7 was reviewed. Pt. #7 was a 62 year old female, admitted on 10/9/17 with a diagnosis of anemia. On 10/9/17, the clinical record indicated that Pt. #7 received blood transfusion. However, the physician's order lacked the blood type component to be given (packed red blood cell or fresh frozen plasma), number of units, as well as the indication for the blood transfusion.

2. On 7/12/18 at approximately 11:30 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 79 year old female admitted on 1/18/18 with a diagnosis of anemia. On 1/18/18, the clinical record indicated that Pt. #8 received a blood atransfusion.

- The physician's order lacked the blood type component to be given as well as indication for the blood transfusion.

- The clinical record lacked documentation of the the blood transfusion data (post vital signs, date and time the the transfusion was completed, amount given, observation regarding adverse reaction, and signature of the RN [registered nurse] completing the transfusion).

3. On 7/12/18 at approximately 1:00 PM, the CAH's policy titled, "Blood/Blood Product Administration" (revised 5/17) was reviewed and included, "... Purpose: To provide guidelines for administration of blood and blood products...I. General Information... 1. Registered Nurses employed by (the CAH)... may administer blood products. 2. The physician's order should include: a. The specific blood component... b. The specific reason for blood administration... c. Number of units or amount of blood/blood product to be administered... d. appropriate rate of transfusion... e. The order for blood product transfusion is to be ordered into the electronic medical record/documentation system... 14. Transfusion data must be recorded on the Record of Transfusion. This form will only be provided by the Blood Bank... III. Procedure Upon Notification That Crossmatch Is Complete: 1. Verify physician's order... 13. Finish documenting the transfusion by recording the following on the Record of Transfusion Form: a. Post vital signs, b. Date and Time the transfusion was completed, c. Amount given, d. Observations regarding Adverse Reactions, e. Signature of the RN completing transfusion."

4. On 7/12/18 at approximately 2:00 PM, the findings were discussed with E #1. E #1 stated that there should be a complete physician's order before the blood is administered. E #1 stated that the physician's order should include the number of units as well as the type of blood product. At approximately 3:30 PM, E #1 stated that the physician's order for Pt. #7 and Pt. #8 were incomplete. Further, E #1 said that the blood transfusion data should have been completed by the nurse who administered the blood.

Based on observation and staff interview it was determined that for 1 of 1 Anesthesiologist (MD #1), the Critical Access Hospital (CAH) failed to ensure the staff cleaned the rubber stopper prior to drawing the medication, after the plastic cap is removed.

Findings include:

1. On 07/11/18 at approximately 8:30 AM, during an observation of Operating Room (OR) #2, MD #1 (Anesthesiologist), while preparing for a surgical procedure, removed the plastic cap from a medication vial and failed to clean the top of the vial prior to withdrawing the medication.

2. On 07/11/18 at approximately 10:15 AM, E #3 (Operating Room Manager) was interviewed. E #3 stated, "The medication vial top must be cleaned when the cap is removed, prior to drawing the medication."

3. On 07/11/18 at approximately 2:05 PM, E #4 (Pharmacist) was interviewed. E #4 stated, "We do not have any specific policy for cleaning the rubber stopper, prior to drawing a medication however, it is the practice and the expectation. We train the staff by the use of a video."

Based on document review and interview, it was determined for 1 of 1 (Pt. #2) open clinical record reviewed for nursing care plan, the Critical Access Hospital failed to ensure the patient's identified needs were included in the care plan.

Findings include:

1. On 7/10/18 at approximately 11:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 56 year old male admitted on 7/9/18 with diagnoses of left foot cellulitis and insulin dependent diabetes mellitus. Pt. #2's nursing care plan included, "Risk for Falls and Acute Pain." However, the care plan did not include Pt. #2's foot infection and diabetes.

2. On 7/10/18 at approximately 3:30 PM, the Critical Access Hospital's policy titled, "Nursing Care Plan" (reviewed 2/16) was reviewed and required, "... On admission, the patient... will be interviewed by the nurse to determine... needs... The Nursing Care Plan for each patient is based on the nature of the illness... and other pertinent information by the interdisciplinary team."

3. On 7/10/18 at approximately 12:00 PM, the findings were discussed with E #1. E #1 stated that Pt. #2's foot infection and diabetes could affect Pt. #2's wound healing and added that the problems should be part of the nursing care plan.

Based on document review and staff interview, it was determined that for 1 of 3 (Pt #18) clinical records reviewed, the Critical Access Hospital (CAH) failed to ensure the medical records were complete, to include surgical consents.

Findings include:

1. On 07/12/18 at approximately 1:45 PM, the closed clinical record of Pt #18 was reviewed. Pt #18 was a 64 year old male, admitted on 02/26/18, with a diagnosis of cholecystitis (inflammation of gall bladder). Pt #18 arrived to the CAH on 02/26/18 at 11:50 AM, and underwent a surgical procedure to remove his gallblader on 02/26/18 at 12:20 PM. Pt #18's clinical record lacked the signed consent for the procedure.

2. The CAH Bylaws (08/10/17) included, "E. General Rules Regarding Surgical Care: 11. Surgery shall only be performed when all informed written consent signed by the patient or his/her legal representatives, except in emergencies."

3. The CAH policy titled, "Consent Requirements" (revised 12/10), was reviewed on 07/12/18 at approximately 3:55 PM. The policy required, "Policy ...an informed consent for the planned operative/invasive procedure will be obtained from the patient. Procedure: The medical record will be assessed for presence of a signed operative/invasive procedure informed consent."

4. On 07/12/18 at approximately 2:52 PM, E #10 (Director, Health Information) was interviewed. E #10 stated, "It (the consent) should be there."

5. On 07/13/18 at approximately 8:45 AM, E#1 (Nurse Manager) presented the document titled, "Surgical Safety Checklist" (02/25/18), which included the "Informed Consent" checked off on the checklist. E #1 stated, "We cannot find the consent, but, it is checked off on the Surgical Safety Cchecklist."

Based on document review and interview, it was determined that for 1 (Pt. #3) of 4 clinical records reviewed of patients that have expired, the Critical Access Hospital (CAH) failed to ensure that the staff notified the Organ Procurement Organization of the patient's death.

Findings include:

1. On 7/11/18, the policy titled, "Referral of Potential Tissue Donation" (effective 2/2016) was reviewed and indicated "...must refer all deaths...to the Organ Procurement Organization, which, for this institution is the Gift of Hope Organ and Tissue Donor Network...Procedure: 1. The nurse will notify Gift of Hope of all cardio-pulmonary death...within 1 hour of patient's death, as declared by an appropriate practitioner...Documentation: 1. Contacting Gift of Hope or any other actions taken regarding tissue referral and donation is to be documented on the patient's chart and/or on the Organ/Tissue Donation section of the Death, Donor and Release of body form..."

2. On 7/11/18 at approximately 10:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was an 85 year old female admitted on 10/12/17 with a diagnosis of intracranial hemorrhage. The "Hospice Referral/Admission sheet" dated 10/12/17 indicated, "10/14/17 TOD (Time of Death) 2050 (8:50 PM)."

3. On 7/11/18 at approximately at 2:45 PM, the Chief Nursing Officer (CNO-E #1) was interviewed. (E #1) stated, "It is our staff (CAH's staff) responsibility to notify the Organ Procurement Organization when a patient has died and document in the patient's chart."