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Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure crash carts were checked on a daily basis to assure safe functioning, per policy. This has the potential to affect all inpatients and outpatients who receive care by the CAH.

Findings include:

1. The Policy titled, "Emergency Medications" (reviewed 7/2023) was reviewed on 12/13/22 at approximately 10:15 AM. The policy noted, "Patient Care Area Inspections: Either Pharmacy or Nursing staff inspect crash/cart carts and all emergency containers, including malignant hyperthermia carts daily to verify that the seal is intact and all medications are present and usable."

2. A tour of the Med/Surg unit was conducted on 12/13/22 at approximately 11:30 AM. The following November 2022 logs were observed and lacked documentation of the required daily checks on the following dates:

10/30/22, 11/5/22, 11/6/22, 11/12/22, 11/13/22, 11/19/22, 11/20/22, 11/25/22, 11/26/22, 11/27/22, 12/3/22, 12/4/22

3. An interview was conducted with the Med/Surg Director (E #7) on 12/13/22 at approximately 12:00 PM. E #7 stated, "If I am not here then they are not getting done like they should be."

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 December 20, 2022, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH) failed to ensure all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients serviced by the CAH.

Findings include:

1. An observational tour of the Med/Surg unit was conducted on 12/13/22 at approximately 11:30 AM. Located in the storage closet was a "Maxi Move" patient lift device. The device lacked a preventative maintenance sticker. In the closet was also a vital signs machine with a preventative maintenance sticker stating "Next Due 10/22/22".

2. On 12/13/22 at approximately 11:45 AM, an interview with the Med/Surg Manager (E #7) was conducted. E #7 stated "We don't we even use that vitals machine, but it still should have been checked by the biomedical guy...and the Maxi Move doesn't look like it gets checked either."

3. On 12/14/22 at approximately 3:00 PM, the "Maxi Move Preventative Maintenance" manufacturer's recommendations was reviewed. The recommendations noted, "Every 12 months: Make sure battery is in good state of charge...test automatic cut off function...examine two lifting straps...test the immediate stop function...".

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 December 20, 2022, 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.

Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to provide safe care and services. Therefore the Condition of Participation 42 CFR 485.635, Provision of Services, was not met. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. The Critical Access Hospital (CAH) failed to protect patients from radiation hazards by ensuring that shielding aprons were routinely inspected. (See C - 1030).

Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH) failed to protect patients from radiation hazards by ensuring that shielding aprons were routinely inspected. This has the potential to affect all patients receiving x-ray imaging in the radiology department.

Findings include:

1. On 12/13/22 at approximately 11:00 AM, a tour of the Radiology Department was conducted with the Radiology Manager (E #5) and a Radiology Technician (E #6). In the x-ray room, there were 4 full lead aprons hanging and 1 half apron folded and stored in a closet.

2. On 12/13/22 during the tour an interview was conducted with E #5 and E #6. A request was made for lead apron checks. E #6 stated "We do not have a policy related to checking the lead aprons. There is no log. We do not have fluoro so I scan the lead aprons with a basic x-ray about every 6 months. I only do it because I have done it at a different facility." E #5 verbally agreed that there is no policy to check the lead aprons for cracks, holes, or damage to the lead. E #5 stated, "We will get the policy created today and get a log created to check the lead aprons."

A. Based on document review and interview, it was determined for 1 of 3 (Pt #9) patient records reviewed, who required the use of violent restraints, the Critical Access Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. This has the potential to affect all inpatients and outpatients who require the use of restraints by the Hospital.

Findings include:

1. The Policy titled "Restraints (revised 09/2020)" was reviewed on 12/14/22 at approximately 1:00 PM. On page 3, the policy stated, "Procedure..... 3. Must obtain Physician Order to include type (behavioral or medical)."

2. The clinical record of Pt #9 was reviewed on 12/14/22 at approximately 11:00 AM. Pt #9 presented to the Emergency Department (ED) on 12/12/22 with a chief complaint of "Seizures". A nursing note at 1:05 PM stated, "Pt is postictal. Pt is combative, fighting staff members, EMS and fire dept (department). Pt is attempting to bite and spit on staff.... Pt is too combative and aggressive to assess where blood originated from. 6 men holding patient down. Attempting to apply restraints safely." A nursing note at 1:10 PM stated, "Restraints applied per ER (Emergency Room) MD order." The record lacked an order for violent restraints.

3. An interview was conducted on 12/15/22 at approximately 10:00 AM with the ED Manager (E #4). E #4 reviewed Pt #9's record and verbally agreed the record lacked an order for restraints and stated "There should have been an order for restraints."


B. Based on document review and interview, it was determined for 2 of 3 (Pt #4 and Pt #5) patient records reviewed, who required the use of violent restraints, the Critical Access Hospital failed to ensure violent restraint documentation was complete and accurate. This has the potential to affect all inpatients and outpatients who require the use of restraints by the Hospital.

1. The Policy titled "Restraints (revised 09/2020)" was reviewed on 12/14/22 at approximately 1:00 PM. On page 8, the policy stated, "Documentation... 4. Documentation on removal; completed by any caregiver. a. Date and time discontinued. b. Total time in restraints."

2. The clinical record Pt #4 was reviewed on 12/14/22 at approximately 9:00 AM. Pt #4 presented to the ED on 6/11/22 with a chief complaint of "Psychiatric Issue." A nursing note at 10:10 PM stated, "... Patient grabbed at my hand with the exposed needle, I moved my hand back out of the way, then used my left hand to take positive control of patient right arm and secure it to the opposite side of the bed, while (ED Technician) secured the patient's left arm to the mattress.... (local police department) requested to scene, Sergeant present for placement of restraints. Patient was secured to bed using four point wrist and ankle restraints. Pt #4 was discharged at 9:01 AM. The record lacked documentation of the release of restraints.

3. The clinical record Pt #5 was reviewed on 12/14/22 at approximately 9:30 AM. Pt #5 presented to the ED on 1/15/22 with a chief complaint of "Psychiatric Issue." A nursing note at 4:10 AM stated, "Pt restrained at 4:10 AM by ems, police and nursing staff, pt flailing (Pt #5's) legs in the air showing every one (Pt #5's) testicles, as (Pt #5) tore (Pt #5's) paints off, prior to that pt was wandering the hall naked as police attempted to get (Pt #5) back in (Pt #5's) room, pt yelling, laughing posing a danger to (Pt #5's) self, staff, ems and police." Pt #5 was discharged at 9:15 AM. The record lacked documentation of the release of restraints.

4. An interview was conducted on 12/15/22 at approximately 10:00 AM with the ED Manager (E #4). E #4 reviewed Pt #4 and Pt #5's record and verbally agreed the records lacked documentation of the release of restraints and stated, "The nurses should have documented when the restraints were removed."