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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 March 6, 2024, 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.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on March 6, 2024 , 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 March 6, 2024.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #20) reviewed for wound/pressure ulcer assessments, the Hospital failed to ensure that Pt. #20's pressure ulcer was assessed on admission, in accordance with policy.

Findings include:

1. On 2/28/2024, the Hospital's policy titled, "Elesivir - Ministry Nursing Guidelines" (dated 2024) was reviewed and required, "Wound assessment provides the baseline for planning and evaluating the wound care plan... Information provided in a detailed pressure injury or wound assessment includes: location, type of pressure injury or wound, extent of tissue involvement, type and percentage of tissue in the wound base, size and exudate (description of drainage)..."

2. On 2/29/2024, the Hospital's policy titled, "Patient Assessment: Initial and Ongoing (1/2023)" was reviewed and required, "Patient assessment ... is performed by the interdisciplinary team and documented in the patient's electronic health record. Guideline: Within 6 hours of admission, initiate patient assessment including the following: ... Skin risk assessment."

3. On 2/28/2024, Pt. #20's clinical record dated 12/26/2023 to 12/27/2023 was reviewed and indicated:
-Pt. #20 was admitted to the Hospital on 12/26/2023 with the diagnosis of COVID pneumonia.
-Pt. #20's admission skin assessment noted, "Pt. #20 had sacral pressure injury." There was no wound assessment documented in Pt. #20's clinical record regarding extent of tissue involvement, size or drainage of pressure injury.

4. On 2/28/2024 at 11:25 AM, an interview was conducted with the Quality and Safety Coordinator (E #1). E #1 stated that there was no wound assessment documentation for Pt. #20. E #1 stated that there should be an admission wound assessment documented for Pt. #20.

Based on document review and interview, it was determined that for 2 of 4 (Pt. #14 and Pt. #15) clinical records reviewed for expired patients, the Hospital failed to ensure the organ procurement organization was notified and documentation was included in the clinical record.

Findings include:

1. The hospital's policy titled, "Tissue Organ Donor (4/12/2023)" was reviewed on 2/28/2024 and required, "Tissue donation: ... Patients who have been pronounced dead ... Referral: Before talking to the family, call donor hotline ... Gift of hope will determine the tissues which may be donated. ... Contacting donor hotline and any other actions taken regarding organ/tissue referral will be documented in the patient's chart in the Post-Mortem Flowsheet"

2. The clinical record of Pt. #14 was reviewed on 2/28/2024. Pt. #14 was admitted on 6/17/2023 with the diagnosis of abdominal pain, shortness of breath and sepsis (severe infection). The discharge summary, dated 6/22/2023 at 7:47 AM included that Pt. #14 expired on the evening of 6/20/2023 (no time). The post-mortem flowsheet indicated that Pt. #14's time of death was 6/20/2023 at 7:07 PM. The flowsheet indicated that the organ donor network was not notified.

3. The clinical record of Pt. #15 was reviewed on 2/28/2024. Pt. #15 was admitted on 12/20/2023 with the diagnosis of altered mental status. The discharge summary, dated 12/21/2023 at 7:37 AM included that Pt. #15 expired on 12/21/2023 at 6:05 AM. The Post Mortem flowsheet indicated that Pt. #15's time of death was 12/21/2023 at 6:40 AM per coroner. The post-mortem flowsheet indicated that the organ donor network was notified with a 'Yes' answer to the question. The clinical record lacked documentation of the contact person or referral number for the organ donor network.

4. During an interview on 2/29/2024 at 9:00 AM, the Regulatory Coordinator (E#2) stated the organ procurement organization must be notified of all deaths. The person spoken to and the referral number should be documented in the clinical record.

Based on document review and interview it was determined that for 1 of 2 (Pt. #11) clinical records reviewed for patients in violent restraints, the hospital failed to obtain an order for initiation of restraints immediately, per policy.

Findings include:

1. The Hospital's policy titled, "Restraint and seclusion Management (5/2/2023)" was reviewed on 2/28/2024 and required, "Restraints and seclusion are ordered by licensed physicians. ... In an emergency situation, a registered nurse may apply a restraint or initiate seclusion prior to receiving an order. An order is obtained immediately (within a few minutes) following restraint application."

2. The clinical record of Pt. #11 was reviewed on 2/28/2024. Pt. #11 was admitted on 10/4/2023 with the diagnosis of alcohol abuse. A physician's order, dated 10/4/2023 at 3:26 PM included hard limb bilateral wrist and ankle for imminent risk of harm to self and others, patient exhibiting violent or aggressive threats/behaviors (violent restraints). The restraint flowsheet indicates that Pt. #11 was placed in violent restraints on 10/4/2023 at 1:15 PM (2 hours and 11 minutes before the order).

3. During an interview on 2/29/2024 at 9:00 AM, the Regulatory Coordinator stated that there should have been an initial order written immediately after restraint initiation.