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Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on October 23, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.623, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

Based on observation, document review, and staff interview it was determined the Critical Access Hospital (CAH) failed to ensure patient care equipment was maintained in safe operating condition. This has the potential to affect all patients receiving services at the Facility.

Findings include:

1. On 10/16/19 at approximately 9:45 AM, a tour of the Emergency Department was conducted with the Nurse Manager of Outpatient Services (E #2). In room 101 there was a Glidescope (light source that assists with intubation), which was available for patient use, with the last preventative maintenance completed on 08/19 and a portable ventilator, which was available for patient use, without any documented preventative maintenance.

2. On 10/16/19 at approximately 11:30 AM, a tour was conducted in the Surgical Department. In the storage room there were two Flowtron compression devices which lacked inspection stickers and documentation to indicate the equipment had been inspected and/or calibrate for patient use.

3. The policy titled "New Equipment Inventory/Inspections (effective by the Facility, 2/18) was reviewed on 10/17/19 at approximately 2:30 PM. The policy required "each piece of equipment is tested prior to initial use and at least annually thereafter. Place a safety inspection sticker on equipment".

4. During an interview with the Nurse Manager of Outpatient Services (E#2) on 10/17/19 at approximately 3:00 PM, E#2 confirmed the above mentioned items lacked a inspection sticker and was unable to provide documentation as to when the last preventative maintenance had been performed.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on October 23, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated medications were not available for patient care and/or use. This has the potential to affect all inpatients and outpatients serviced by the CAH.

Findings include:

1. On 10/16/19 at approximately 9:45 AM, a tour of the Emergency Department was conducted with the Nurse Manager of Outpatient Services (E #2). The adult crash cart contained Magnesium Sulfate 2 grams/50 milliliters, which expired on 07/19.

2. On 10/17/19 at 11:00 AM, the Critical Access Hospital policy "Inventory Control - Expired and Other Unusable Medications" (effective by the Facility, 2/18) was reviewed. The policy stated, "... 1. The medication storage areas in the Pharmacy Department and in each patient care unit are monitored on a monthly basis by personnel familiar with the storage requirements. Medications are removed from the mediation storage areas if they are: a. Expired (outdated) ...."

3. An interview was conducted with E#2 during the tour. E#2 verbally confirmed the outdated medication was available for patient use and stated "should have been taken out and not available."

A. Based on observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure infection control supplies were labeled properly to ensure proper disinfection of patient care areas and equipment. This has the potential to affect all patients serviced by outpatient physical therapy with a monthly census of 780 patients.

Findings include:

1. On 10/16/19 at approximately 11:30 AM, a tour was conducted in the Physical Therapy Department treatment areas. A Physical Therapist Assistant (PTA) was cleaning a treatment table. The spray container used for cleaning, contained approximately 20 fluid ounces of clear liquid and lacked an open/or expiration date or a label identifying the content.

2. During an interview with the Chief Clinical Officer (E#1) conducted during the tour, E#1 verbally confirmed the spray bottles lacked the name of the liquid and any date of expiration. E#1 stated, "The spray bottles contain HB Quant a disinfection cleaner to be used for cleaning,"

B. Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired supplies were not available for patient care and/or use in order to control/prevent infections and communicable diseases of patients and personnel.. This has the potential to affect all inpatients and outpatients serviced by the CAH.

Findings include:

1. On 10/16/19 at approximately 9:45 AM, a tour of the Emergency Department was conducted with the Nurse Manager of Outpatient Services (E #2). The following expired supplies were in the pediatric crash cart:
a) two Purple Intubation Modules expired 06/19
b) two Yellow Intubation Modules expired 04/19
c) two Blue Intubation Modules expired 04/19

2. A request was made for a policy related to expired supplies, and the Facility was unable to provide the policy.

3. An interview was conducted with E#2 during the tour. E#2 verbally confirmed the outdated items were available for patient use and stated "these should have been taken out and not available."

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure foods were stored and maintained appropriately, in accordance with recognized dietary practices. This has the potential to affect all patients, staff and visitors at the CAH.

Findings include:

1. On 10/16/19 at 11:30 AM, a tour of the Dietary Department was conducted with Dietary Manager (E#5). Approximately 2 cups of shredded coconut were noted in a dry storage area with no name, date opened or expiration date. Approximately 10 pounds of ground beef patties were observed in the walk-in freezer in a box with the lid off, open to air. Also, approximately 20 frozen corn cobs were in an unmarked, unsecured bag with no expiration date.

2. A review of Facility policy "Open Food Storage and Expiration of Foods" (revised by the Facility, 6/2017) on 10/17/19 at 11:30 AM. The policy indicated "1. As items are opened, they will be labeled with the date opened and the use by date. 2. If a food is removed from the original container... a label will be placed on the new container and will be marked with the item name, date opened and the use by date".

3. On 10/16/19 at 11:30 AM, an interview was conducted with E#5. E #5 confirmed the above findings and stated that, "staff are well aware of the expectations for opened food items; they require name, date and use by or expiration date."

Based on document review and interview, it was determined for 2 of 20 (Pt #9, Pt #15) patients, the Critical Access Hospital (CAH) failed to ensure medical records were accurate and complete. This has the potential to affect all patients serviced by the Facility.

Findings include:

1. The clinical record for Pt#15 was reviewed on 10/17/19 at approximately 10:00 AM. Pt #15 was admitted with a diagnosis of confusion on 10/16/19. The "Emergency Room Consent" lacked a signature for the patient or guardian, date, time, and the RN (Registered Nurse) signature with the date and time.

2. The policy titled "Policies-General" (revised by the Facility, 10/17) was reviewed on 10/17/19 at approximately 1:30 PM. The policy on page 6 required the "Emergency Treatment Permit/consent to be completed with: a. Written: (the cobra form is satisfactory). The permit should be witnessed by hospital personnel. d. Verbal: This is valid provided two persons are present to witness the consent. Each should record the date, time, and circumstances."

3. During an interview on 10/17/19 at approximately 1:30 PM, Nurse Manager of Outpatient Services (E#2 ) verbally agreed the consent did not have all the required documentation per their Hospital policy.