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Based on Critical Access Hospital policy/ procedure review, (CAH) medication error reports review, and staff interview, CAH nursing staff failed to follow CAH policies for reporting medication errors to a physician in 7 of 7 medication error reports reviewed (Patients #1, #2, #3, #4, #5, #6 and #7). The CAH administrative staff reported a current inpatient census of one (1) patient.

Failure to report medication errors to a patients' physician may potentially cause harm if the patient received the wrong medication, medication at the wrong time, or by the wrong route. Failure to report medication errors may also deprive the physician of information that may impact the patient's health, medical care, or length of stay.

Findings include:

1. Review of the CAH policy titled 'Medication Error Reporting", approved 9/2010, revealed "all medication errors shall be reported to the prescriber. All medication errors shall be reported using form N-064/1 (Medication Variance Report) and given to pharmacy."

2. Review of medication error reports, completed by CAH nursing staff, revealed a lack documentation that CAH nursing staff notified a physician when medication errors were identified in 7 of 7 medication error reports reviewed (Patients #1, #2, #3, #4, #5, #6 and #7) .

3. During an interview, on 12/7/10 at 7:45 AM, the CAH Pharmacist confirmed that CAH nursing staff failed to notify a physician when a medication error occurred or a medication error was identified, as required by CAH policy and procedures.

4. During an interview, on 12/7/10 at 2:02 PM, the CAH Pharmacist stated that his/her concern with CAH nursing staff not reporting medication errors to the physician was addressed in Quality Improvement in May 2010. The CAH administrative staff failed to implement a plan to correct this concern and the CAH nursing staff continued to follow CAH policy to report all medication errors to a physician.

Based on observation, procedure/ document review, and staff interview, the Critical Access Hospital (CAH) dietary staff failed to ensure that staff cleaned all food preparation equipment baking pans prior to storage. The CAH Dietary Manager reported a monthly production of 199 meals.

Failure to maintain clean all food preparation equipment and baking pans could potentially result in less appealing appearance and/or less palatable food.

Findings include:

1. An observation, on 12/06/10 at 11:30 AM, during the initial tour of the dietary department and accompanied by Staff A, revealed 1 of 1 Kitchen Aid counter top mixers with flour and dry food debris on the head of the mixer.

Review of CAH dietary department cleaning document, on 12/06/10, titled "Daily Tasks-Dietary Cook" and dated December 2010; revealed CAH dietary staff charted cleaning the mixer daily.

Review of CAH dietary department procedure titled " Equipment Assembly, Operation Cleaning and Sanitizing Procedures", dated 10/10, stated in part ...."Wash base, head of machine, beater shaft and bowl saddle with sanitized cloth. Rinse and let air dry".

During an interview, on 12/06/10 at 11:30 AM, Staff verified that flour and dried food debris were on the head of the mixer, and stated he /she had not used the mixer on 12/06/10. Staff A acknowledged that the mixer was stored with flour and dried food debris and that dietary staff failed to clean the mixer before storage.

2. An observation, on 12/06/10 at 11:30 AM, during the initial tour of the dietary department and accompanied by Staff A, revealed 6 of 6 sheet pans and 8 of 8 cake pans stored and ready for use with a black-brown dried food debris present on the inside surface of the pans.

Review of CAH dietary department policy manual revealed that CAH administrative staff failed to ensure the dietary department developed a policy for the removal of the black-brown build-up on the inside surface of pans used for patient meals.

During an interview, on 12/06/10 at 11:30 AM, Staff A acknowledged the build-up on the inside of the pans. Staff A acknowledged he/she lacked knowledge of the need to remove build up on pans used for patient meals.