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Observations and interviews with the Dietary Manager (DM), Registered Dietitian (RD), Quality Coordinator (QC), Maintenance Lead (ML), Facility Management Leader (FML), and the Emergency Department Supervisor (EDS) revealed the Critical Access Hospital (CAH) failed to ensure the premises were clean and in good repair pertaining to the kitchen and the emergency department (ED). The CAH is licensed for 25 beds and had a census of 7 acute inpatients upon entrance. Findings include:

A. Observation of the kitchen with the DM and RD on 11/15/11 at 2:00 PM revealed the following areas in the kitchen to be in poor repair or unsanitary conditions. Interview with the DM and RD and Administrator indicated the dietary services are a contracted service and the DM has been in this position for approximately 1 month. The RD and DM acknowledged the kitchen served food to the CAH patients 3 meals a day, plus snacks if necessary. Examples are:

Dishroom:
1. An extensive buildup of lime on the plumbing that supplies water to the dishwasher, the dishwasher has a lime buildup along the sides and seams, and lime buildup on the dishroom floor under the dishwasher.
2. Wall fan has dust buildup on the fan grids and rotators.
3. Lack of a lid to a 30-gallon garbage can that was 3/4 full of discarded trash and food items. The garbage can also had a buildup on the outer plastic of hardened dried-on food.
4. The plumbing connection to the top and bottom of the dishwasher is corroded and lacks the manufacturer's finish, exposing the underlying metal. The tile floor underneath the entire dishwashing area is coated with a white lime substance, with the back splash wall splattered with discarded dried-on food and chemical substances.
5. The dishwashing metal sink is worn and lacks the manufacturer's finish, exposing the underlying metal and has a lime buildup on the faucets.
6. A single white porcelain hand washing sink is worn and exposes the underlying metal, and the faucets have a greenish appearance with an excess buildup of lime. This makes it difficult to clean or sanitize.

Ceiling area::
1. A count of 14 white double plastic-covered florescent ceiling light fixtures have a buildup of a black hairy substance on the outside and black debris on the inside. The DM was unsure if the black substance on the inside of the florescent light fixtures was dirt or dead bugs.
2. 9 white metal ceiling air vents are discolored with a black substance exposing the underlying metal. This makes it difficult to clean and sanitize properly.
3. Numerous white acoustic ceiling tiles located in the kitchen are discolored with a black hairy substance that hangs from the ceiling tiles. Interview with the DM was unsure when the vents or the ceiling tiles had been cleaned.

Hot food prep and cooking area:
1. A char grill, identified by the DM to be used for the preparation of patient meals ( mainly chicken breasts) and consumed by the CAH patients has a buildup of a hard black crusty debris. This surveyor took a metal spatula and scraped a large portion of the black hardened food debris off. The underlying drawer where the gas burners are located for the char grill has a buildup of food debris on the floor of the char grill. Interview with the DM and RD were unsure when the underlying drawer for the char grill was emptied or cleaned, but did acknowledge the char grill is used to prepare food for CAH patients and is supposed to be cleaned every day.
2. The overhead exhaust filters located above the food cooking area in the kitchen are coated with a black hairy substance. Directly below the exhaust filters is a filter guard with a metal piping. The guard and metal piping have a greasy appearance with what appears to be grease dripping from the pipe. This has a high potential for cross food contamination or a food borne illness and a fire hazard. The DM identified the substance to be built up grease and was not sure when the overhead exhaust fan filters, filter guard or pipe were cleaned but did acknowledge "they are to be washed once a month."
3. Between the char grill and the convection oven is approximately 2 feet of gas piping that extends upward from the floor. These gas pipes are soiled and greasy allowing for a high possibility of a kitchen fire and rodent infestation. The gas lines extend approximately 5-6 feet in length.
4. 2-burner and 6-burner gas stoves lack the manufacturer's finish, exposing the underlying metal. Both gas stoves have burnt-on black food residue. Interview with the DM and RD acknowledged the gas stoves are used to prepare food for the CAH patients. This makes the stoves difficult to clean and sanitize.
5. A convection oven identified by the DM as being used to prepare food for the CAH patients is coated with a brownish/black substance on the inside glass, the inside walls and floor. The metal racks are coated with hardened black splattered food debris. At the time of the observation tour of the kitchen on 11/15/11, this surveyor instructed the DM and RD that the convection oven was to be shut off and not used to prepare any food for the CAH patients until cleaned. The DM and RD could not be sure when the convection oven was last cleaned.
6. A steel pipe that extends from the back of a Combi oven (a combi oven is one that will prepare food either with steam, dry cooking or both at the same time). The steel pipe extends to a floor drain approximately 6 X 6 inches. The floor drainage is missing a large portion of the grid and does not completely cover the drainage hole, allowing for rodent infestation.
7. The top of the Combi oven and the convection ovens have a buildup of a greasy black substance. Interview with the DM was unsure when the top of the Combi oven or the convection ovens were cleaned.
8. The toaster exterior and crumb tray is full of food debris.
9. The Combi oven steam/water wells appear to have a green tint to the water with a buildup of lime. This makes the Combi oven difficult to clean and sanitize properly.
10. Between the 2-burner and 6-burner gas stoves is an area of approximately 2 feet by 8 feet. On the tile between the stoves the floor is hardened splattered food. The floor is coated with a hard white lime substance. Interview with the DM is unsure when the area was last swept, mopped or cleaned. This makes for a high potential for rodent infestation.
11. The Char broiler with flat top and identified to be purchased in 2009, has an excessive buildup of grease and dried-on food splatter. The metal top of the char broiler with the flat top is worn and exposes the underlying metal. Along the side of the char broiler flat top is a grill guide. which is blackened with splattered food debris and lacks the manufacturer's finish, exposing the underlying metal. This has a high potential for food contamination and makes it difficult to clean and sanitize the guide.

Pot and Pans:
Observation of the cooking utensils used to prepare food for the CAH patients were identified by the DM and this surveyor to be worn, dented and lacking the manufacturer's finish and exposing the underlying metal. This makes it difficult to clean and sanitize properly. The following items were discarded:
1. two 7-quart double broilers
2. four 11-quart stock pots
3. six 2-tray muffin pans
4. three 11-quart stock pots
5. twelve 18x26 sheet pans
6. six 18x24 half sheet pans

B. Observation of the ED on 11/16/11 with the EDS noted the ED has 4 patient bays. Above the patient examine tables are overhead adjustable lights. All 4 overhead adjustable lights were dusty on the top. When the surveyor swept her hand over the top of the lights the dust fell onto the examine table white linens. Interview with the EDS acknowledged the ED is cleaned by the ED staff and housekeeping.

Based on staff interview, review of current pharmacy policies and direct observation, the Critical Access Hospital (CAH) failed to follow its policies for drug storage and labeling. The hospital reported 1204 acute patient admissions for the fiscal year 2010. Findings include:

A. On 11/17/11 from 11:00 AM to 11:45 AM a tour of the pharmacy, the night cart storage of medications and outpatient pharmacy storage area conducted with the Pharmacy Director revealed:
1. The night cart storage unit kept in the patient care area contained a drawer labeled "Lanoxin", which did not follow the pharmacy labeling policy.
2. A tour of the outpatient medication storage area revealed a brown liquid in an unlabeled bottle. This liquid was poured from a bulk container of betadine. This practice fails to maintain the identity, strength, lot number, and expiration date of the product.

B. A review of the policy for sound-alike, look-alike medications read as follows: "Lanoxin is digoxin on the shelf."

C. During tour Pharmacy Director stated that the drugs stored in the outpatient area were not part of the pharmacy inventory and they did not maintain a list of medications stored or used in this area.

Based on staff interview, a review of practitioners' clinic privileges as compared with quality assurance information and the Medical Staff Bylaws, the Critical Access Hospital (CAH) failed to include the quality and appropriateness of the diagnosis and treatment furnished by individual practitioners and of treatment outcomes, and failed to follow the Bylaws in the reappointment process. The CAH reported 1204 acute patient admission for fiscal year 2010. Findings include:

A. The Medical Staff Bylaws, page 43 Section 7 states, "Quality Improvement. The Active Staff shall conduct quality improvement (QI) activities in accordance with the Hospital's QI plans and policies. This plan shall be structured and implemented to include systematic monitoring and evaluating of quality and appropriateness of the care of patients served by the Hospital and the clinical performance of all individuals with clinical privileges...continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges; recommending to the Medical Staff the criteria for clinical privileges that are relevant to the care provided in the department..."

B. A review of page 25 of the Medical Staff Bylaws labeled, "Criterion/Data" specified:
"Results of Treatment and QA-I conclusions"
"Relevant practitioner-specific data, as compared to the aggregate data"

C. A review of the clinical privileges granted for 3 family practitioners (Physicians A-1, D-1, E-1), one surgeon (C-1) and 2 mid-level practitioners (B-1, F-1). failed to include evidence of clinical performance for the privileges granted, failed to include treatment and QA-I conclusions and relevant practitioner-specific data, as stated in the Medical Staff Bylaws.

D. On 11/17/11 at 2:00 PM, interviews with the Chief Quality Officer and Quality Assurance Coordinator confirmed the QA program failed to include practitioner specific data related to the privileges granted to each practitioner.

I. Based on staff interviews and lack of written documentation, the Critical Access Hospital (CAH) failed to include all services affecting patient health and safety in the Quality Assurance program. The hospital reported an annual acute care census of 1204 for fiscal year 2010. Findings include:

A. On 11/15/11 at 1:30 PM, interviews with Chief Quality Officer, Quality Assurance Coordinator and Chief Executive Officer stated that contracted services were not included in the quality assurance program.

B. On 11/17/11 at 2:00 PM, review of the current quality assurance program lacked evidence of monitoring of contracted services. Examples of contracted services not monitored are Anesthesiology, Physical Therapy and Speech Therapy.

II. Based on staff interview and lack of evidence, the CAH failed to monitor or compare radiologic findings interpreted by the local physicians or mid-level practitioners as compared with the radiologist interpretations.

A. On 11/16/11 at 11:30 AM, interview with the Lead Radiology Technician, revealed clinicians view radiology images and initiate treatment of patients seen in the emergency department, based on their initial impression. Radiologist provides the official interpretation of the images and sends a written report within 12 hours. Lead Radiology Technician stated these 2 interpretations were not evaluated for agreement to assure continuity of patient care.

Observations and interviews with the Dietary Manager (DM), Registered Dietitian (RD), Quality Coordinator (QC), Maintenance Lead (ML), Facility Management Leader (FML), and the Emergency Department Supervisor (EDS) revealed the Critical Access Hospital (CAH) failed to ensure the premises were clean and in good repair pertaining to the kitchen and the emergency department (ED). The CAH is licensed for 25 beds and had a census of 7 acute inpatients upon entrance. Findings include:

A. Observation of the kitchen with the DM and RD on 11/15/11 at 2:00 PM revealed the following areas in the kitchen to be in poor repair or unsanitary conditions. Interview with the DM and RD and Administrator indicated the dietary services are a contracted service and the DM has been in this position for approximately 1 month. The RD and DM acknowledged the kitchen served food to the CAH patients 3 meals a day, plus snacks if necessary. Examples are:

Dishroom:
1. An extensive buildup of lime on the plumbing that supplies water to the dishwasher, the dishwasher has a lime buildup along the sides and seams, and lime buildup on the dishroom floor under the dishwasher.
2. Wall fan has dust buildup on the fan grids and rotators.
3. Lack of a lid to a 30-gallon garbage can that was 3/4 full of discarded trash and food items. The garbage can also had a buildup on the outer plastic of hardened dried-on food.
4. The plumbing connection to the top and bottom of the dishwasher is corroded and lacks the manufacturer's finish, exposing the underlying metal. The tile floor underneath the entire dishwashing area is coated with a white lime substance, with the back splash wall splattered with discarded dried-on food and chemical substances.
5. The dishwashing metal sink is worn and lacks the manufacturer's finish, exposing the underlying metal and has a lime buildup on the faucets.
6. A single white porcelain hand washing sink is worn and exposes the underlying metal, and the faucets have a greenish appearance with an excess buildup of lime. This makes it difficult to clean or sanitize.

Ceiling area::
1. A count of 14 white double plastic-covered florescent ceiling light fixtures have a buildup of a black hairy substance on the outside and black debris on the inside. The DM was unsure if the black substance on the inside of the florescent light fixtures was dirt or dead bugs.
2. 9 white metal ceiling air vents are discolored with a black substance exposing the underlying metal. This makes it difficult to clean and sanitize properly.
3. Numerous white acoustic ceiling tiles located in the kitchen are discolored with a black hairy substance that hangs from the ceiling tiles. Interview with the DM was unsure when the vents or the ceiling tiles had been cleaned.

Hot food prep and cooking area:
1. A char grill, identified by the DM to be used for the preparation of patient meals ( mainly chicken breasts) and consumed by the CAH patients has a buildup of a hard black crusty debris. This surveyor took a metal spatula and scraped a large portion of the black hardened food debris off. The underlying drawer where the gas burners are located for the char grill has a buildup of food debris on the floor of the char grill. Interview with the DM and RD were unsure when the underlying drawer for the char grill was emptied or cleaned, but did acknowledge the char grill is used to prepare food for CAH patients and is supposed to be cleaned every day.
2. The overhead exhaust filters located above the food cooking area in the kitchen are coated with a black hairy substance. Directly below the exhaust filters is a filter guard with a metal piping. The guard and metal piping have a greasy appearance with what appears to be grease dripping from the pipe. This has a high potential for cross food contamination or a food borne illness and a fire hazard. The DM identified the substance to be built up grease and was not sure when the overhead exhaust fan filters, filter guard or pipe were cleaned but did acknowledge "they are to be washed once a month."
3. Between the char grill and the convection oven is approximately 2 feet of gas piping that extends upward from the floor. These gas pipes are soiled and greasy allowing for a high possibility of a kitchen fire and rodent infestation. The gas lines extend approximately 5-6 feet in length.
4. 2-burner and 6-burner gas stoves lack the manufacturer's finish, exposing the underlying metal. Both gas stoves have burnt-on black food residue. Interview with the DM and RD acknowledged the gas stoves are used to prepare food for the CAH patients. This makes the stoves difficult to clean and sanitize.
5. A convection oven identified by the DM as being used to prepare food for the CAH patients is coated with a brownish/black substance on the inside glass, the inside walls and floor. The metal racks are coated with hardened black splattered food debris. At the time of the observation tour of the kitchen on 11/15/11, this surveyor instructed the DM and RD that the convection oven was to be shut off and not used to prepare any food for the CAH patients until cleaned. The DM and RD could not be sure when the convection oven was last cleaned.
6. A steel pipe that extends from the back of a Combi oven (a combi oven is one that will prepare food either with steam, dry cooking or both at the same time). The steel pipe extends to a floor drain approximately 6 X 6 inches. The floor drainage is missing a large portion of the grid and does not completely cover the drainage hole, allowing for rodent infestation.
7. The top of the Combi oven and the convection ovens have a buildup of a greasy black substance. Interview with the DM was unsure when the top of the Combi oven or the convection ovens were cleaned.
8. The toaster exterior and crumb tray is full of food debris.
9. The Combi oven steam/water wells appear to have a green tint to the water with a buildup of lime. This makes the Combi oven difficult to clean and sanitize properly.
10. Between the 2-burner and 6-burner gas stoves is an area of approximately 2 feet by 8 feet. On the tile between the stoves the floor is hardened splattered food. The floor is coated with a hard white lime substance. Interview with the DM is unsure when the area was last swept, mopped or cleaned. This makes for a high potential for rodent infestation.
11. The Char broiler with flat top and identified to be purchased in 2009, has an excessive buildup of grease and dried-on food splatter. The metal top of the char broiler with the flat top is worn and exposes the underlying metal. Along the side of the char broiler flat top is a grill guide. which is blackened with splattered food debris and lacks the manufacturer's finish, exposing the underlying metal. This has a high potential for food contamination and makes it difficult to clean and sanitize the guide.

Pot and Pans:
Observation of the cooking utensils used to prepare food for the CAH patients were identified by the DM and this surveyor to be worn, dented and lacking the manufacturer's finish and exposing the underlying metal. This makes it difficult to clean and sanitize properly. The following items were discarded:
1. two 7-quart double broilers
2. four 11-quart stock pots
3. six 2-tray muffin pans
4. three 11-quart stock pots
5. twelve 18x26 sheet pans
6. six 18x24 half sheet pans

B. Observation of the ED on 11/16/11 with the EDS noted the ED has 4 patient bays. Above the patient examine tables are overhead adjustable lights. All 4 overhead adjustable lights were dusty on the top. When the surveyor swept her hand over the top of the lights the dust fell onto the examine table white linens. Interview with the EDS acknowledged the ED is cleaned by the ED staff and housekeeping.

Based on staff interview, review of current pharmacy policies and direct observation, the Critical Access Hospital (CAH) failed to follow its policies for drug storage and labeling. The hospital reported 1204 acute patient admissions for the fiscal year 2010. Findings include:

A. On 11/17/11 from 11:00 AM to 11:45 AM a tour of the pharmacy, the night cart storage of medications and outpatient pharmacy storage area conducted with the Pharmacy Director revealed:
1. The night cart storage unit kept in the patient care area contained a drawer labeled "Lanoxin", which did not follow the pharmacy labeling policy.
2. A tour of the outpatient medication storage area revealed a brown liquid in an unlabeled bottle. This liquid was poured from a bulk container of betadine. This practice fails to maintain the identity, strength, lot number, and expiration date of the product.

B. A review of the policy for sound-alike, look-alike medications read as follows: "Lanoxin is digoxin on the shelf."

C. During tour Pharmacy Director stated that the drugs stored in the outpatient area were not part of the pharmacy inventory and they did not maintain a list of medications stored or used in this area.

Based on staff interview, a review of practitioners' clinic privileges as compared with quality assurance information and the Medical Staff Bylaws, the Critical Access Hospital (CAH) failed to include the quality and appropriateness of the diagnosis and treatment furnished by individual practitioners and of treatment outcomes, and failed to follow the Bylaws in the reappointment process. The CAH reported 1204 acute patient admission for fiscal year 2010. Findings include:

A. The Medical Staff Bylaws, page 43 Section 7 states, "Quality Improvement. The Active Staff shall conduct quality improvement (QI) activities in accordance with the Hospital's QI plans and policies. This plan shall be structured and implemented to include systematic monitoring and evaluating of quality and appropriateness of the care of patients served by the Hospital and the clinical performance of all individuals with clinical privileges...continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges; recommending to the Medical Staff the criteria for clinical privileges that are relevant to the care provided in the department..."

B. A review of page 25 of the Medical Staff Bylaws labeled, "Criterion/Data" specified:
"Results of Treatment and QA-I conclusions"
"Relevant practitioner-specific data, as compared to the aggregate data"

C. A review of the clinical privileges granted for 3 family practitioners (Physicians A-1, D-1, E-1), one surgeon (C-1) and 2 mid-level practitioners (B-1, F-1). failed to include evidence of clinical performance for the privileges granted, failed to include treatment and QA-I conclusions and relevant practitioner-specific data, as stated in the Medical Staff Bylaws.

D. On 11/17/11 at 2:00 PM, interviews with the Chief Quality Officer and Quality Assurance Coordinator confirmed the QA program failed to include practitioner specific data related to the privileges granted to each practitioner.

I. Based on staff interviews and lack of written documentation, the Critical Access Hospital (CAH) failed to include all services affecting patient health and safety in the Quality Assurance program. The hospital reported an annual acute care census of 1204 for fiscal year 2010. Findings include:

A. On 11/15/11 at 1:30 PM, interviews with Chief Quality Officer, Quality Assurance Coordinator and Chief Executive Officer stated that contracted services were not included in the quality assurance program.

B. On 11/17/11 at 2:00 PM, review of the current quality assurance program lacked evidence of monitoring of contracted services. Examples of contracted services not monitored are Anesthesiology, Physical Therapy and Speech Therapy.

II. Based on staff interview and lack of evidence, the CAH failed to monitor or compare radiologic findings interpreted by the local physicians or mid-level practitioners as compared with the radiologist interpretations.

A. On 11/16/11 at 11:30 AM, interview with the Lead Radiology Technician, revealed clinicians view radiology images and initiate treatment of patients seen in the emergency department, based on their initial impression. Radiologist provides the official interpretation of the images and sends a written report within 12 hours. Lead Radiology Technician stated these 2 interpretations were not evaluated for agreement to assure continuity of patient care.