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Observations and interview with the Dietary Manager (DM) revealed the Critical Access Hospital (CAH) failed to ensure the premises were in good repair pertaining to the kitchen and failed to ensure patient safety in the Laboratory, Radiology and Operating Room departments of the CAH. The CAH is licensed for 12 beds and had a census of 3 upon survey entrance. Findings are:

A. Observation of the dietary area and interview with the DM on 3/15/10 at 1:00 PM revealed the following:

1. Seventeen ceiling lights measuring approximately 12 inches x 30 inches and covered with a plastic protector area identified by the DM to "have bugs in them and unsure when the plastic protectors were cleaned last."

2. Ceilings and walls located in the dry goods pantry, main kitchen and dishwashing areas appear discolored to a yellowish-grey tint, with areas on the walls and ceilings with cracks, gouges, and chipping paint exposing the underlying drywall. Interview with the DM revealed: "the ceiling and walls are the responsibility of the maintenance personnel, not sure when the walls and ceilings were last fixed or painted."

3. The 12 inch x 12 inch tile flooring located in the kitchen pertaining to the dry goods pantry, main kitchen and dishwashing areas has scattered areas of chipping and discoloration. The tile flooring is extensively worn and no longer has the manufacturer's sealant. Interview with the DM acknowledged: "the tile flooring was the original floor that was installed when the kitchen was built in 1971; estimating the tile floor to be approximately 40 years old."

4. Observation of the 4-burner gas stove with dual ovens revealed the insides of the dual ovens and baking racks to be rusted, with a black hardened substance on the inside oven doors, top, floor and bottom. On the outer areas of the 4-burner gas stove along the top, sides, front and backsplash the manufacturer's sealant is extensively worn, exposing the underlying metal. Interview with the DM revealed: "the 4-burner gas stove was purchased in 1986, making it to be approximately 25 years. The stove is used to prepare 3 meals a day for the CAH and LTC (Long Term Care) patients and is just worn out."

5. Located on the East wall in the kitchen is a single porcelain handwashing sink. The manufacturer's porcelain finish is extensively worn off and has exposed the underlying metal. Interview with the DM did not know how old the handwashing sink is, stating: "we have just about scrubbed all the porcelain all off."

6. Along the South wall of the kitchen and identified by the DM are an upper row of 17 count wooden door cabinets with inside wood shelving. Along the South wall of the kitchen and identified by the DM are a lower row of 4 count wooden cabinets with inside wood shelving. All of the wood cabinets and shelving lack the manufacturer's sealant, with chipping, scratches and bits of the wood missing. Interview with the DM revealed: "the wood cabinets are used to store food products and were installed when the kitchen was originally built in 1971, making them to be approximately 40 years old." The lack of the manufacturer's sealant on the wood does not allow for proper cleaning and sanitation, with a high probability of cross food contamination.

7. Observation of the kitchen along the South wall revealed a counter identified by the DM as a food prep area with a formica top. The formica countertop is extensively worn and exposes the underlying surface. The DM is unsure of the age of the formica countertop.

8. Observation of the dry food storage area revealed and identified by the DM to store food products that are served to the CAH and LTC patients to have approximately 129 steel shelves. The manufacturer's sealant is missing from a large majority of the shelves, which have a rusty appearance and the underlying metal surface is exposed.

B. Observation on 3/18/10 at 2:30 PM with the Radiology Supervisor (RS) revealed the Radiology Department has 3 entrances directly on a main egress corridor and directly connect the 3 areas by inside doors. The first entrance holds patients' x-ray films. Actual count of films are unknown but thought by the RS to "be in the hundreds." The second entrance holds the x-ray machine with an x-ray film processing area holding 2 1-gallon tanks of a caustic processing fluid and identified by the RS as "caustic and harmful if swallowed, or used improperly." The third entrance is the CT area. Located in an unlocked wood cabinet are:
-16 vials of Optiray 320 50 ML
- 9 prefilled syringes of Opiray 320 100 ML. This is identified by the RS as an IV contrast administered to the patients for CT scans and is harmful if used improperly.
- 9 prefilled syringes of Opimark 20 ML
- 4 prefilled syringes of Opimark 15 ML. This is identified by the RS as an IV contrast administered to patients for mobile MRI exams and is harmful if used improperly. Further interview with the RS revealed the CAH services pediatric, suicidal and dementia patients; the Radiology Department does not and is not locked when unattended or after normal business hours, does not limit unauthorized persons access, and is not directly visible from the nurses station.

C. Observations on 3/18/10 at 2:00 PM with the Laboratory Supervisor (LS) revealed the Laboratory is located on a main egress hallway and has 1 entrance. Inside the refrigerator stored in the lab are numerous agents used only by the lab employees to acquire physician ordered labs and blood products for patient usage. Further interview with the LS revealed the CAH services pediatric, suicidal and dementia patients, is not locked when unattended or after normal business hours, does not limit unauthorized persons access, and is not directly visible from the nurses station.

D. Observation of the Operating Room (OR) on 3/18/10 at 3:00 PM with the Operating Room Supervisor (ORS) revealed the OR has 6 separate entrances. 5 of the entrances are directly located on main egress hallway and 1 entrance is directly accessible from the Labor and Delivery Room. Interview with the ORS revealed the OR holds numerous narcotics and biologicals that are very harmful if used improperly, the OR does not and is not locked up when unattended or after normal business hours, and does not limit unauthorized persons access. The OR is not directly visible from the nurses station.

Based on a review of selected personnel files of individuals hired within the last year, and an interview with the Assistant Administrator/Director of Nursing on 3/22/10 at 10:00 AM revealed the Critical Access Hospital (CAH) failed to maintain documented evidence of orientation for 2 of 6 Registered Nurses (RN-A and RN-B) pertaining to specific job duties. The CAH is licensed for 12 beds and had a census of 3 upon survey entrance. Findings are:

A. 2 of 6 personnel files (RN-A and RN-B) reviewed lacked documented evidence of orientation to specific job duties and non-medical emergencies. RN-A was hired on 11/10/09 and RN-B was hired on 11/09/09. Interview with the Assistant Administrator acknowledged the lack of documentation in the personnel files and revealed there is not always the opportunity or patients available to ensure staff orientation, but the orientation checklist should have been readdressed.

Staff interview and review of the Policy and Procedure Review revealed the Critical Access Hospital (CAH) failed to have at least 1 member on the committee that is not a member of the CAH to assist with reviewing of the Policies and Procedures. CAH is licensed for 12 beds and had a census of 3 upon survey entrance. Findings are:

A. Review of the Policies and Procedures Review signatures, dated 11/30/09, and interview with the Risk Manager on 3/18/10 at 10:00 AM revealed the CAH did not have a non-hospital member on the committee.

Record review, and staff interviews revealed the Critical Access Hospital (CAH) failed to identify and maintain current care plans for 3 of 9 acute care patients (Patients 5, 9 and 10) pertaining to the usage of Foley catheters. The CAH is licensed for 12 beds and had a census of 3 upon survey entrance. Findings are:

A. Record review on 3/17/10 at 1:30 PM revealed Patient 5 was admitted to an acute care status on 3/11/10 and discharged on 3/16/10 with pertinent diagnosis of acute exacerbation of chronic obstructive pulmonary disease possibly brought on by bronchitis or pneumonia. Physician admit orders on 3/11/10 read: "Foley Catheter to dependent drainage." Interview with Registered Nurse (RN-A) regarding the care plans revealed the Foley catheter is not addressed on the care plans and probably should have been.

B. Record review on 3/17/10 at 2:00 PM revealed Patient 9 was admitted to an acute care status on 1/30/10 and discharged on 2/2/10 with pertinent diagnoses of hyponatremia, hypochloremia and degenerative arthritis with spondylolysis of the lumbar spine. Physician admit orders dated 1/29/10 read: "Foley Catheter to straight drainage with urethra care BID [twice a day] with Bactroban". Interview with RN-A regarding the care plans revealed the Foley catheter is not addressed in the care plans and probably should have been.

C. Record review on 3/17/10 at 2:15 PM revealed Patient 10 was admitted to an acute care status on 9/5/09 and discharged on 9/11/09. Pertinent Physician order dated 9/5/09 reads: "Foley catheter to dependent drainage". Interview with RN-A regarding the care plans revealed the Foley catheter is not addressed on the care plans and probably should have been.