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Based on observation, document review and staff interview the Critical Access Hospital, (CAH) failed to ensure that outdated and mislabeled drugs and biologicals stored in one of one emergency room, one of one nurses station supply cart and one of one crash cart were not available for patient use.

Findings include:

- CAH policy "Crash Cart Testing and Inventory Maintenance" reviewed on 1/12/11 directs the nursing staff that all medications and supplies will be checked for expiration dates and replaced when outdated.

- Observation of the crash cart on 1/11/11 at 9:25am revealed one vial of Procainamide (a drug used to help keep the heart beating normally) 1gram/10ml with an expiration date of December 2010.

Staff A interviewed on 1/11/11 at 9:45am acknowledged the CAH failed to replace the expired Procainamide.

- Observation of the nursing station supply cart on 1/11/11 at 12:05pm revealed the following:
1. One-500 milliliter bottle of Sterile Water with an expiration date of 8/10.
2. One-500 milliliter bottle of Normal Saline with an expiration date of 11/09.
3. One-500 milliliter bottle of Normal Saline with an expiration date of 9/10.
4. One-500 milliliter bottle of Normal Saline with an expiration date of 12/10.

Staff D interviewed on 1/11/11 at 12:05pm acknowledged the CAH failed to replace the expired Sterile Water and Normal Saline.

- CAH policy "Medication Administration" reviewed on 1/12/11 directs that multi-dose vials will be marked with a date, time and initials of nurse when opened.

- Observation of the medication cabinet in the emergency room on 1/11/11 at 9:25am revealed the following:
1. One-30 milliliter vial of 0.5% Marcaine (a numbing medicine) with no date and time when opened and no initials of the nurse.
2. One-20 milliliter vial of 2% Xylocaine (a numbing medicine) with no date and time when opened and no initials of the nurse.
3. One-20 milliliter vial of 1% Lidocaine (a numbing medicine) with no date and time when opened and no initials of the nurse.

Staff A interviewed on 1/11/11 at 9:25am acknowledged the CAH staff failed to date, time and/or intitial the vials of Marcaine, Xylocaine and Lidocaine.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and timed all medical record entries, including physician orders, for 8 of 10 sampled emergency room records (#'s 1, 2, 3, 5, 6, 7, 8 and 9).

Findings include:

- Medical Staff By-Laws reviewed on 1/10/11 revealed direction for the medical staff to date, time and authenticate(sign) entries in the medical record.

- Patient #1's medical record reviewed on 1/11/11 revealed the emergency room physician order sheet, initiated on 11/11/10, lacked the date or time when authenticated.

- Patient #2's medical record reviewed on 1/11/11 revealed the emergency room physician order sheet, initiated on 11/7/10, lacked the date or time when authenticated.

- Patient #3's medical record reviewed on 1/11/11 revealed the emergency room physician order sheet, initiated on 7/24/10, lacked the date when authenticated.

- The defecient practice also effected patient #'s 5, 6, 7, 8 and 9.

Staff A interviewed on 1/11/11 at 1:50pm acknowledged the CAH failed to assure all entries into the medical record were dated and timed.

Based on interview, document review and record review the facility failed to follow their policy and assure that sufficient and appropriate social services were provided to meet the skilled swingbed patients' needs for 5 of 5 (#'s 11, 12, 13, 14 and 15) sampled skilled swingbed patients.

Findings include:

- Record review on 01/11/11 for skilled swingbed patient #11 lacked a social history or intervention performed by a social worker or social worker designee.

- Record review on 1/11/11 for skilled swingbed patient #12 lacked a social history or intervention performed by a social worker or social worker designee.

- Record review on 1/11/11 for skilled swingbed patient #13 lacked a social history or intervention performed by a social worker or social worker designee.

- Record review on 1/11/11 for skilled swingbed patient #14 lacked a social history or intervention performed by a social worker or social worker designee.

- Record review on 1/11/11 for skilled swingbed patient #15 lacked a social history or intervention performed by a social worker or social worker designee.

Interview with staff A and staff B on 1/11/11 at 3:40pm indicated the facility lacked a social service professional and lacked a contract with a professional Social Service Worker for the skilled swingbed patients.

Interview with staff A on 1/12/11 at 3:30pm confirmed the care coordinator took care of the social services but quit several months ago and the nurses just took over and take care of arrangements for transfers, home health or nursing home placement.

Review on 1/12/11 of the swingbed policy "Social Services-Swingbed", on page 6, revealed under SOCIAL SERVICES: Care coordinator will be available to all swing bed patients. The Care Coordinator is responsible for assessment of the patient's and family's psychosocial status and coordination of services. The Care coordinator is responsible for social evaluation and documentation of same in the form of a social history. In paragraph Two,the policy reads 'The Care Coordinator is available for arranging counseling with resident and families. Resources available include: Consultant Living Center Social Worker, Harvey County Consolidated Social Services, Pastors, etc......