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Based on observation, staff interviews, and review of maintenance records between April 12 and April 13, 2022, the facility did not construct, install and maintain the building systems to ensure life safety for patients.

Findings include:

The facility was found to contain the following deficiencies:
K321 Hazardous Areas - Enclosure
K344 Fire Alarm - Control Functions
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barriers
K374 Subdivision of Building Spaces - Smoke Barrier Doors
K511 Utilities - Gas and Electric
K781 Portable Space Heaters
K909 Gas and Vacuum Piped Systems - Information and Warning Signs
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies are not compliant with 42 CFR 485.623(c)(e) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between April 12 and April 13, 2022, the facility did not construct, install and maintain the life safety systems for patients.

Findings include:

The facility was found to contain the following deficiencies.
K321 Hazardous Areas - Enclosure
K344 Fire Alarm - Control Functions
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barriers
K374 Subdivision of Building Spaces - Smoke Barrier Doors
K511 Utilities - Gas and Electric
K781 Portable Space Heaters
K909 Gas and Vacuum Piped Systems - Information and Warning Signs
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies with 42 CFR 485.623(d) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, the facility failed to ensure that staff were following facility policy in regards to completing patient assessments after the initiation of restraints in 1 of 2 patients with restraints reviewed, (Pt. (patient) #11), failed to monitor vital signs post operatively per policy in 1 of 6 (Pt. # 12) surgical patients reviewed and failed to follow facility policy for contact to the Organ Procurement Organization (OPO) at the time of a patient death in 1 of 3 (Pt. #12) expired patients reviewed in total sample of 20 records reviewed.

Example of lack of every 15 minute restraint assessments:

A review of the facility's policy titled, "Restraints/Seclusion", dated 04/2021 revealed, "...Nursing: directly observe and assess patient every FIFTEEN (15 MINUTES) while restrained. Observations include: 1. Hydration needs 2. Feeding 3. Toileting Needs 4. Range of motion 5. Skin condition..."

A review of Patient #11's closed medical revealed, "non-violent restraint soft limb restraints, 4 point" restraint initiation from 02/16/2022 at 8:27 PM to 02/16/2022 at 11:15 PM. Review of Nursing Assessment notes revealed missing "Restraint Assessments" every 15 minutes while restraints were applied to Patient #11.

During an interview on 04/13/2022 at 10:54 AM with Director of Nursing (DON) G, who confirmed lack of 15 minute "Restraint Assessment" documentation for Patient #11 stated, "It doesn't appear 15 minute checks were done."


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Example of no contact to the OPO:

Review of facility policy titled, "Death, Care of Deceased, DOA's (Deceased on Arrival)" dated 11/2020, unnumbered, under "Procedure ...2. Contact the University of Wisconsin Organ Procurement Organization at (phone #) to report death and possible organ tissue and eye donation."

Review of Pt. (patient) #12's medical record revealed he/she was admitted to the facility on 11/29/2022 and expired on 11/30/2021. Review of the "Nursing Assessment Death Record" revealed a time of death of 6:06 AM with "Disposition of the body: funeral home." There was no notation to indicate that the OPO was notified.
In an interview on 4/13/2022 at 11:20 AM with Staff S, Staff S confirmed that, "It appears we didn't notify the OPO like we should have."

Example of lack of vital signs post-operatively:

Review of facility policy titled, "Nursing Standards of Care" dated 1/2021, unnumbered, under "2. Vital Signs ...a. i. All vital signs will be documented on the Vitals Flowsheet ...iii. Post-op Checks - follow post operative procedure - Every 15 min. x 4, Every 30 min. x 2, Every 1 hour x 4, Then every 8 hours if stable ...

Review of Pt. #12's medical record revealed he/she returned from surgery to the nursing unit at 12:30 PM on 11/29/2022. Review of the "Vitals Flowsheet revealed vital signs on the nursing unit on 11/29/2022 at 12:55 PM, 1:31 PM, 1:46 PM, 2:01 PM, 2:15 PM, 2:30 PM, 7:31 PM, 8:25 PM, and on 11/30/2022 at 1:16 AM. The record revealed every 15 minute vital signs began an hour after arrival to the nursing unit, vital signs were not documented per policy every ½ hour after that period, or every 1 hour after that, with a gap of 5 hours between 2:30 PM and 7:31 PM without recorded vital signs post op. This gap was within the 30 minute and 1 hour timeframe for post-op vital signs.

In an interview on 4/13/2022 at 2:00 PM with Quality Director I, Quality Director I confirmed that the documented frequency of vital signs post op on Pt. #12 did not follow policy.

Based on observation, record review and interview the facility failed to follow their infection prevention program to ensure expired food, donated breast milk, was removed from the freezer in the Obstetric Department. This had the potential to impact all newborns who required donated breast milk.

Findings Include:

Review of Facility Policy titled, "Infection Prevention Program," not numbered, last reviewed 4/20/2021 under program goals revealed, "Develop communication systems with licensed independent practitioners, staff,.....about infection prevention and control issues, including their responsibilities in preventing the spread of infection within the hospital. Maintain awareness and working knowledge of guidelines and recommendations that are published by regulatory and accrediting agencies.....to provide current and evidence-based infection prevention and control services."

Review of Facility Policy titled, "Human Milk Bank," no review date, not numbered, revealed no guidelines addressing the timeframe and disposal for expired breast milk.

On 04/12/2022 at 10:00 AM during a tour of the Maternal/Newborn department with DON (Director of Nurses) G, 1 bottle of breast milk, batch 2993, labeled with an expiration date of 02/03/2022, was observed in the freezer designated for donor breast milk storage. During an interview on 4/12/2022 at 10:10 AM with DON G when asked about the expired donated breast milk in the freezer, DON G stated, "That shouldn't be there, the lactation consultant is responsible for monitoring the freezer."

On 04/12/2022 at 3:15 PM in an interview with DON G, when asked what the process was for checking for outdated donated breast milk, DON G stated, "It shouldn't have been there, the HUC (Health Unit Coordinator) or the Registered Nurse (RN) check for outdates monthly and that item needs to be added to the checklist. There is no current written policy on how that is monitored." DON G stated, "Nursing thought lactation was doing it (checking for outdated milk) and lactation thought nursing was doing it. It appears that no one was monitoring the expiration dates."

On 04/13/2022 at 12:45 PM in an interview with Quality Director I when reviewing the Donor Breast Milk Policy, Quality Director I confirmed that there is nothing specific for outdates of donor breast milk in the policy.