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Based on observation, interview and document review, the critical access hospital (CAH) failed to complete manual weekly checks of the Zoll R series defibrillator monitors (used to create an electrical charge to stop an abnormal heart rhythm) for 2 of 2 defibrillator monitors reviewed equipment and supplies.

Findings include:

On 8/19/24 at 11:53 a.m., registered nurse (RN)-A stated there was a sign off sheet on the top of the crash cart, which staff had to sign off after they checked the lock was intact and the number on the lock matched the number recorded. In addition, the defibrillator (in the crash cart) would do a self-check, and as part of the crash cart check, staff would make sure the self-check light was green. If it wasn't green, staff would need to do a manual defibrillator check to make sure the defibrillator was working.

On 8/20/24 at 8:27 a.m., during the nursing tour, RN-B stated the nurses checked the defibrillator on each 12 hour shift to make sure the defibrillator passed the automatic defibrillator check that would run each night after midnight. They would look for a green check mark. Staff would record the lock number, date and time, and record an "A" for days and "P" for nights, record a check mark in the "Defib Check" column, and sign the "Crash Cart Lock Log." If there was a red "X," staff would then need to perform a manual defibrillator check.

On 8/22/24 at 10:43 a.m., the chief nursing officer (CNO) stated the facility had two Zoll R series defibrillators. The CNO stated on each shift, the nurses were expected to check for the green check mark. If they saw a red "X," they would be expected to perform a manual defibrillator check. They were not currently performing any manual defibrillator checks on any kind of schedule.

The Defibrillator/Pacer Check (Emergency Room and Hospital) policy dated 12/14/23, did not address regular manual testing.

The Zoll R Series Operator's Guide dated 1/18, Chapter 12 Maintenance Frequency identified the following:
Visual inspection - once per day, inspect Code Readiness indicator.
Code Readiness test (automatic) - once per day, unless configured Off, in which case, perform manual defibrillator testing daily.
Manual Defibrillator Testing - Once per week; daily if Code Readiness Test is configured Off.

Based on observation, interview and document review, the critical access hospital (CAH) failed to complete monthly maintenance checks for the negative air flow rooms for 6 of 8 negative pressure rooms (used in airborne isolation - a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room).

Findings include:

On 8/19/24 at 11:34 a.m., a bed count of the nursing unit was completed with registered nurse (RN)-A. RN-A stated room 8 was a negative air flow room, the door was closed, the display outside of the room read -0.0006 Inches of Water Guard (IWG). A tissue test (a test used to check if a room has negative air flow, or negative pressure. Hold a piece of tissue at the bottom of the door. If air pressure is appropriately negative the tissue will be sucked TOWARD the room.) was performed and failed. RN-A verified the tissue was not sucked into the room. RN-A stated they only recorded the pressure readings every hour if there was a patient in the room who needed airborne precautions.

On 8/20/24 at 8:45 a.m., the chief nursing officer (CNO) stated all of the rooms (1-8) in the nursing department were negative air flow rooms. Plant Services (PS)-A verified room 8 was not working and stated it was likely a belt on the roof. PS-A stated maintenance checked all of the rooms monthly for pressure to make sure they were working and ready for use.

On 8/21/24 at 10:50 a.m., CNO verified it was important to test negative air flow rooms on a regular basis to make sure they were ready for use. The CNO verified nursing only recorded readings when there were patient's using the rooms for airborne precautions.

On 8/22/24 at 11:30 a.m., PS-A reviewed the maintenance records and verified nursing rooms (1-6) were not being checked monthly for negative air pressure.

Documents titled Pressure and Particulate Testing provided by the facility identified the following:
2/8/24, had hospital rooms 1-6 crossed off with no pressure readings
3/5/24, had hospital rooms 1-6 crossed off with no pressure readings
4/9/24, had hospital rooms 1-6 crossed off with no pressure readings
5/2/24, had hospital rooms 1-6 crossed off with no pressure readings
6/6/24, had hospital rooms 1-6 crossed off with no pressure readings
7/25/24, had hospital rooms 1-6 crossed off with no pressure readings

The Precautions-Airborne Airborne + Contact dated 7/23 directed the IWG must remain greater than -0.001 Inches of Water Guard (IWG). If this reading is out of range, contact maintenance immediately!!

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags:

Building 1: K-0211, K-0226, K-0321, K-0345, K-0372, K-0511, K-0920, K-0923
Building 2: K-0353, K-0781, K-0920

Based on interview and document review, the critical access hospital (CAH) failed to ensure pharmacy and dietary department policies and procedures were reviewed biannually.

Findings include:

The following polices had not been reviewed biannually:
Pharmacy Department
-Patient's Own Meds last reviewed6/15
-Medication Errors last reviewed 2/20
-Controlled Substance Records last reviewed 1/19
-Pharmacy Access: After Hours last reviewed 4/21
-Procedure for Adverse Drug Reactions last reviewed 219
-Director of Pharmacy last reviewed 6/18
-Pharmacy Technician Duties and Responsibilities last reviewed 5/19
-Pharmacy Monthly Unit Inspection last reviewed 6/18
-Medication Administration last reviewed 1/20
-Pharmacy Scope of Service last reviewed 10/20

Dietary Department
-Patient/Residents at Nutritional Risk last reviewed 3/14
-Responsibility for Menus last reviewed 2/15
-Emergency Food Supply last reviewed 7/21

On 8/19/24 at 1:12 p.m., the pharmacist stated there had not been a comprehensive review of all the pharmacy polices since they had been employed (approximately 5 years).

On 8/21/24 at 1:41 p.m., the certified dietary manager (CDM) stated per the hospital, policies should be reviewed yearly. The CDM opened the policy manager program and indicated they had 62 tasks listed in the program for policy reivew. The CDM confirmed they had not completed a comprehensive policy review biannually or yearly, instead they reviewed policies as they became pertinent.

On 8/22/24 at 11:43 a.m., the administrator stated the facility required all policies be reviewed annually and indicated dietary and pharmacy policies were expected to be reviewed annually. For regulation compliance, the policies should at minimum be reviewed biannually.

A policy on policy review was requested but not provided.

Based on interview and document review, the critical access hospital (CAH) failed to assure dietician consults were obtained for three swing bed patients (P44, P40, P41).

Findings include:

The facility policy Patient/Residents at Nutritional Risk dated 3/14, directed the certified dietary manager (CDM) was to put in a dietician referral after the interdisciplinary team discussed and identified a patient with nutritional risk. The policy listed the following as criteria for nutritional risk:
-recent weight loss
-intake less than 75 percent of determined need, or intake inconsistent with historical
-increased nutrient need related to medical condition
-many food dislikes/food choices outside scope of therapeutic diet
-indicators of malnutrition
-diagnosis with major nutritional impact
-low body weight
-mediations with major nutritional impact
-alternations in swallowing or chewing process with nutritional impact
-potential for skin breakdown
-score of three or greater on the nurse assessment
-risk for dehydration

P44
P44 was admitted to the CAH on 6/5/24, for swing bed services with the diagnosis of chronic kidney disease, pneumonia, and generalized weakness. P44 had a consistent carbohydrate, low fat, low cholesterol, low sodium diet ordered. P44's record lacked evidence of a referral to the dietician for policy identified nutritional risk factors.

On 8/22/24 at 10:36 a.m., the CDM stated due to the complexity of P44's diet, they should have had a dietician referral.

P40
P40 was admitted to the CAH on 6/13/24, for swing bed services. P40's chart contained a provider order for a dietary consult for anemia and a history of multiple bowel obstructions. P40's record lacked evidence of a dietician consult being completed as ordered and as policy directed.

P41
P41 was admitted to the facility on 6/7/24, for swing bed services. P41's diagnoses included diabetes, acute kidney injury, chronic kidney disease with superimposed rhabdomyolysis [muscle tissue breakdown], likely dehydration, aspiration pneumonia, and traumatic contusion on the lower back and pelvis. P41's record lacked evidence of a dietician consult being completed as directed by policy for nutritional risk factors.

On 8/20/24 at 10:57 a.m., the CDM stated when there was a hospital dietary consult, they completed a review, and if they didn't have enough expertise to address the patient's needs, then they consulted the dietician.

During an interview on 8/22/24 at 11:01 a.m., MD-A stated the dietary consult order in the electronic medical record (EMR) required a reason for consult, but it did not require the provider to indicate if the consult should be done by the dietary department or the dietician. MD-A stated they would expect a dietary consult order for a patient with complex nutritional needs, diets, or risk factors to be completed by the dietician.

On 8/22/224 at 11:07 a.m., the director of nursing (DON) stated the care team held weekly meetings on all patients and nutrition was discussed. Registered nurse (RN)-C stated they were not clear what the CDM's process was for a dietician consult, but indicated things like complex diets, anemia, kidney problems, and skin break down were all reasons for the dietician to be consulted.

On 8/22/24 at 11:43 a.m., the administrator stated provider orders for dietary consult should clearly indicate if they wanted the patient seen by the dietician to avoid the possibility of the CDM only reviewing the patient when the provider intended for the dietician to see the patient. Polices should be followed.

A policy on dietician consults were requested but not provided.