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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on October 12, 2021, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

A. Based on observation, document review and staff interview it was determined the critical access hospital (CAH) failed to ensure equipment is maintained in safe operating condition. This has the potential to effect all patients receiving services.

Findings include:

1. On 10/4/21 at 2:30 PM, a tour of the physical therapy (PT) department was conducted with the PT supervisor (E#5). The temperature logs for hydrocollator was requested. There was no logs presented of temperatures. Also, observed during the tour was a pile of therabands on the countertop.

2. The policy effective date 2/1/11 (revised 10/4/21), titled, "Hydrocollator/Hot Pack Treatment" was reviewed on 10/4/21 at 3:30 PM. The policy under "Care of hydrocollator/hot packs: The tank should be cleaned monthly...The water temperature should be checked after each cleaning and daily records kept on attached form."

3. The policy effective 4/6/11 (revised 10/4/21), titled, "Cleaning and sanitization of equipment" was reviewed at 3:30 PM. The policy under "Procedure: All equipment and surfaces will be cleaned and disinfected between each patient following the CDC guidelines."

4. On 10/4/21 at 2:40 PM, an interview was conducted with E#5. E#5 stated, "temperatures are checked weekly." E#5 also stated, "I haven't kept a log of temperature checks." E#5 was asked about cleaning of therabands. E#5 stated, "we don't clean them and patients reuse them when they come in for treatment."

B. Based on observation, document review and staff interview it was determined the critical access hospital (CAH) failed to ensure preventative maintenance was completed on equipment. This has the potential to effect all patients receiving services.

Findings include:

1. A tour of the Emergency Department was conducted on 10/4/21 at 11:00 AM and on 10/6/21 at 10:15 AM. During the tour the following items for patient care were observed with preventative maintenance (PM) stickers indicating no evaluation of the equipment had been done since 2020: (2) PLUM A 360 intravenous pumps, (2) Dynascopes, (1) O 2 saturation monitor, (1) LifePac 20 Defibrillator, and (1) Mediquip Nebulizer.

2. The hospital policy titled "Equipment Management Plan (effective date 3/6/2003)" was reviewed on 10/7/21 at 10:00 AM. The policy indicates, in paragraph one, "All electrically operated equipment which is used for diagnosis, treatment, monitoring and care of patients..." In the policy under "Maintenance Requirements: Annual preventative maintenance and safety inspections will be completed on all equipment in the program."

3. An interview was conducted with the Quality Improvement Director (E#2) on 10/6/21 at 11:30 AM. E#2 reported he is responsible for the maintenance department and is aware the staff are behind with the checks of equipments. E#2 reported they do have logs for the PM checks and agreed the equipment in the emergency department had not been checked yet this year. E#2 reported "They are working on getting things caught up now."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on October 12, 2021, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated October 12, 2021.

A. Based on observation, document review, and staff interview it was determined the critical access hospital (CAH) failed to ensure expired drugs were disposed of per policy. This has the potential to effect all patients receiving services-current census 1.

Findings include:

1. On 10/4/21 at 2:00 PM, a tour of the respiratory department was conducted with the respiratory supervisor (E#4). During the tour, it was observed in the medication cabinet budesonide 0.5 milligrams (mg) 30 ampules were expired 5/21.

2. The CAH policy dated 11/1/05, titled, "Expired Drugs" was reviewed on 10/7/21. The policy under "I. POLICY All medications regularly for expiration dates and properly disposed of".

3. On 10/4/21 at 2:10 PM, E# 4 reviewed the budesonide and confirmed the medication was expired.

B. Based on observation, document review, and staff interview it was determined the physical therapy (PT) department failed to ensure multi-dose vials are labeled with date of initial opening. This has the potential to effect all patients receiving services-average daily census-15.

Findings include:

1. On 10/4/21 at 2:30 PM, a tour of the PT department with the PT supervisor (E#5). During the tour, it was observed a multi-dose vial of medication (dexamethasone) 30 milliters (ml) was unlabeled with date of initial entry. The medication had expired 8/21.

2. The CAH policy revision date 3/09, titled, "Multidose Vials" was reviewed on 10/4/21. The policy under "VI. DOCUMENTATION: Multi-dose vials will be documented will the date opened upon initial entry by the nurse".

3. On 10/4/21 at 2:40 PM, E#5 reviewed the multi-dose vial and confirmed there was no date of initial opening and medication was expired.

Based on observation, document and staff interview it was determined the CAH failed to ensure safe dietary practices were followed per policy. This has the potential to effect all patients and employees receiving dietary services.

Findings include:

1. On 10/5/21 at 9:50 AM, a tour of the dietary department was conducted with the dietary manager (E# 6). During the tour, it was observed several food items that were unlabeled. Observed pancakes, garlic bread, egg biscuits and California blend vegetables in the freezer with no date of opening or expiration.

2. On 10/5/21 at 11:00 AM, the policy dated, 10/1/09, titled, "READY-TO-EAT FOODS, DATE MARKING" was reviewed. The policy under "V. PROCEDURES INFECTION CONTROL: N/A The day the original container is opened in the food establishment shall be counted as Day 1." Bullet 3 "A date-marking system may include: Marking the date or day or preparation, with a procedure to discard the food on or before the last date.."

3. On 10/5/21 at 10:00 AM, E#6 reviewed the unlabeled food items and confirmed there was no date.