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Based on observations, staff interview and record review CAH failed to install and monitor temperature and relative humidity levels in the Central Sterile Processing, Perioperative, and Endoscopy areas. Findings include:

During a tour on 3/19/18 at 11:47 AM of the perioperative area, central supply area (including decontamination, preparation and packing and sterile storage), and endoscopy procedure rooms, there were no gauges noted in these areas to monitor the temperature and relative humidity to prevent microbial and bacterial growth. Per interview with the Nurse Manager of Peri-operative services at that time s/he stated that the maintenance department was measuring the temperatures and relative humidity in those areas. Per interview on 3/19/18 at 2:38 PM with the Director of Maintenance, s/he stated that the maintenance department was not monitoring the temperature and humidity in those areas and had not been doing so for years.

Per national standards developed by AAMI (Association for the Advancement of Medical Instruments) hospitals are expected to monitor and maintain temperatures and relative humidity within recommended levels in all locations associated with Central Sterile Reprocessing (CSR) to include decontamination, preparation & packing and sterile storage. Monitoring and maintaining temperatures and relative humidity at specific parameters is recommended to prevent microbial and bacterial growth in packaged sterilized material and instruments.

Per AORN (Association of periOperative Registered Nurses) -Guidelines for a Safe Environment of Care, Part 2, effective May 15, 2014 pgs. 10-17) "Recommendation IV-The health care organization should create and implement a systemic process for monitoring HVAC (heating, ventilation, air conditioning) performance parameters and a mechanism for resolving variances .....
IVe.1.The relative humidity in a restricted area should be maintained within a range of 20-60%.
IVe.2.The humidity in a semi-restricted area:
-sterile storage-maximum 60%
IVe.3.The relative humidity in an unrestricted area:
-PACU (post-operative care unit)-20-60%;
-endoscopy procedure room-20-60%
-procedure room-20-60%
IV.f.1.The temperature range in a restricted area should be 68 degrees F to 75 degrees F (20 to 24 degrees C)
IV.f.2.The temperature in a semi-restricted area:
-sterile storage-75 degrees F (24 degrees C)
-decontamination room-60 degrees F to 73 degrees F (16 degrees C to 23 degrees C)
IV.f.3.The temperature of an unrestricted area should be between 70 degrees F and 75 degrees F (21 degrees C and 24 degrees C)
IV.f.4.The temperature of an endoscopy procedure room should be between 68 degrees F and 73 degrees F (20 degrees C and 23 degrees C)"

Based on staff interview and record reviews, the CAH (Critical Access Hospital) failed to assure that all policies were reviewed and/or revised at least annually by members of the group of professional personnel as required, and reviewed by the CAH as necessary. Findings include:

At the time of the recertification survey, department policies were reviewed to confirm CAH staff had conducted a annual review and/or revision of policies. The following departments failed to demonstrate compliance with the regulation to include:

1. Per record review and staff interview, the Laboratory (Lab) Supervisor confirmed on 3/20/18 at 9:41 AM that Lab policies are not consistently reviewed or revised annually. The following Lab policies were last reviewed in 2016: "SYSMEX XN-200 Automated hematology analyzer" - approved 2/23/16; "Sure-VUE Mono" - approved 10/31/16; "QA04 Guidelines for Record and specimen retention" - approved 12/14/16"; and "QA03 - CAP terms of accreditation" - approved 12/18/16 and reviewed 12/9/16.

2. Per record review and staff interview, the Health Information Management Director confirmed on 3/20/18 at 2:40 PM that Health Information policies are not consistently reviewed or revised annually. The following Health Information polices were last reviewed on the following dates: "Medical Completion" - approved 4/21/09 and reviewed 4/25/14; "Chart Analysis" - approved 4/24/14; and "De-identification of Protected Health Information" - reviewed 4/24/14.

3. Per record review Emergency Department policies were not consistently reviewed or revised annually. The following Emergency Department policies were last reviewed on the following dates: "Admission of Patients to the Emergency Department", last reviewed 8/25/2016, Discharge Criteria, Summary, and Instructions for the Emergency Department", last reviewed 8/18/2016 and "Clinical Conflict Resolution in the Emergency Department" last reviewed 5/19/2014.

4. Per review of the policy "Malignant Hyperthermia in the OR", start date of 2/13/14, there was no evidence that the policy was reviewed or revised annually. Per interview on 3/20/18 at 3:00 PM with the Nurse Manager of Peri-operative services s/he confirmed that the policy was not updated.

5. Per record review the following Anesthesia Department policies were not revised or reviewed annually: "Anesthesia Provider Duties and Responsibilities" reviewed 7/12/13, "Guidelines for the Ethical Practice of Anesthesiology" reviewed 7/12/13, "Standards for Patient Care" prepared 7/17/13, "Malignant Hyperthermia" no revised or reviewed date, "Safety Guidelines for Anesthesia" reviewed 7/17/13, and Documentation of Anesthesia Care Guidelines" reviewed 7/17/13. Per interview on 3/21/18 at 8:30 AM with the Nurse Manager of the Operating room, s/he confirmed that the anesthesia policies had not been updated.

6. Per record review and staff interview, the Infection Control RN confirmed employee health policies were in need of updating, to include: "Employee Influenza Immunization", last reviewed 2/8/2016.

Based on observation and staff interview, the CAH failed to ensure that patient care devices were stored in a manner that reduced the possibility of cross-contamination. Findings include:

During a tour on 3/20/18 at 10:30 AM of the stress test lab, radiology exam room 2, and the magnetic resonance imaging (MRI) suite, each of these areas had a wall connector that was used for oxygen with extension tubing coiled around it; and a wall connector used for suction with tubing that was uncovered and coiled around it. This observation was confirmed at the time of the tour by the Director of Radiology. Per interview on 3/20/18 at 4:23 PM with the Nurse Manager of the Medical/Surgical Unit, s/he stated that the facility practice was to leave the oxygen tubing and/or extensions unopened and unattached to the wall connection until the patient arrived to a procedure room and/or hospital room. When the patient was discharged and/or left the procedure area, the oxygen and/or extension tubing would be thrown away. S/he stated that the practice for suction set-up was to cover the suction container and tubing with a plastic bag. S/he stated that if the suction container was used, the system was thrown away and a new system with a bag covering the tubing and suction container was set up.

Based on staff interview and record review the CAH failed to assure patient care records are legible,complete and accurate and the provision of care conducted by providers was consistently documented and completed within the required time frame to facilitate continuity of patient care. Findings include:

1) Per record review of the Health Information Management (HIM) "Chart Deficiency Report" and staff interview, the HIM Director confirmed on 3/20/18 at 2:40 PM that one provider has an outstanding pattern of clinical record deficiencies which is known to the Medical Staff, Administration, Physician Leadership, and Chief of Physician Practices. Per record review of the "Medical Records Completion Policy" dated 4/14/16 and confirmed with the HIM Director on 3/20/18 at 2:40 PM, "The record must be completed promptly after discharge in accordance with State Law and Hospital policy but no later than 30 days after discharge and discharge summaries will be dictated within 7 days of discharge".

2. Per review of the medical records for 2 patients who had surgery at the CAH (Patients # 10 and #19), neither medical record had evidence of Post Anesthesia Evaluations conducted within 48 hours post anesthesia administration. During interview on 3/21/18 at 11:25 AM, the IT ( Information Technology) staff person assisting the surveyor with locating the documentation confirmed that the anesthesiologist for these patients confirmed that s/he does hand written evaluations in the medical record progress notes. The notes should have been scanned into the record by HIM staff post patient discharge from the hospital however, they could not be located and were missing from the records.

3. Per record review a patient (Patient #17) had a foreign body removed from his/her left forearm using local anesthetic, the Consent for Operation or Invasive Procedure was not signed and dated by the provider. Per interview on 3/21/18 at 11:43 AM with a Clinical Applications Specialist, s/he confirmed that the consent was not signed or dated by the provider.

Based on observation and staff interview the CAH failed to store medical records in a manner to ensure that they are safeguarded against loss and destruction and failed to ensure confidentiality of all medical records was maintained. Findings include:

1) Per observation of the "Multi Disciplinary Room" on 3/19/18 at 12:12 PM, clinical records with deficiencies waiting for provider review are stacked on shelves in this area and are unsecured from unauthorized access. Per staff interview, the Health Information Management (HIM) Director confirmed the "Multi Disciplinary Room" where clinical records with deficiencies are located is unsecured from unauthorized access twenty four hours a day seven days a week (24/7) and there are times when no providers or staff are present in this room and the door is left unlocked.

2) Per observation of the Child Birth Center on 3/19/18 at 12:20 PM, clinical records with deficiencies waiting for provider review are located at the nurses station and are visible to staff, patients, and visitors. Per staff interview, the Health Information Management (HIM) Director confirmed on 3/19/18 at 12:20 PM that clinical records with chart deficiencies waiting for provider review are located in an area that is unsecured from unauthorized access 24/7 and there are times when no providers or staff are present at the nurses station.

3) Per observation of the clinical record storage room called "The Cage", there is no barrier present to protect clinical records from water damage if the the sprinkler system is activated or from ceiling water leaks. In case of fire, this room has sprinklers which are located above the clinical records. In addition, brown staining was noted on the ceiling above the storage stacks. Per staff interview and confirmed with the Plant Manager on 3/19/18 at 2:00 PM, the clinical records stored in this area do not have a barrier in place to protect them from water damage if the sprinkler system is activated and that a ceiling water leak occurred in the past causing the brown staining on the ceiling.