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Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure all supplies available for patient use were not expired. This has the potential to affect all patients served by the CAH, with a current census of 3 patients.

Findings include:

1. A tour of the Nuclear Medicine Department was conducted on 5/14/19 at approximately 1:00 PM with the Manager of Radiology (E #11). The Nuclear Medicine Department contained one (1) Stop Cock (valve that regulates the flow of fluids through IV tubing) (expiration date 3/2012).

2. During the tour of the Nuclear Medicine Department, E #11 verbally confirmed the stop cock was expired and should have been removed from the patient care area.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on May 22, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see C231.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure patient care equipment was maintained and safe for usage. This has the potential to affect all patients receiving services through the Emergency Department, with an average monthly census of 450 patients.

Findings include:

1. During an observational tour of the Emergency Department (ED) with the Emergency Department Manager (E#3) on 5/14/19 at 12:40 PM-1:40 PM, the following items were available for patient use: Stand up scale with preventative maintenance (PM) due 02/19; Pyxis Refrigerator with PM due 02/11/19; and Vein Finder with PM due 02/11/19

2. During the tour of the ED, E #3 verified the above item's PM dates and stated, "Biomed should check these items and they have not."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on May 22, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure proper medication storage. This has the potential to affect all patients receiving services through the Emergency Department, with an average monthly census of 450 patients.

Findings include:

1. On 5/14/2019 at 12:40 PM-1:40 PM, an observational tour was conducted in the Emergency Department with the Emergency Department Manager (E#3) and the Chief Nursing Officer (E#13). In the unlocked ante-room to room 6, that was accessible to patients and visitors, an unlocked neonatal emergency kit was sitting unsecured on the counter. The neonatal emergency kit contained the following: one (1), Brethine 1 mg/ml (milligram/milliliter) injectable; one (1), Calcium Gluconate 1000 mg/10 ml injectable; one (1) bag of Dextrose 10% water 250 ml; one (1), Epinephrine 0.1 mg/ml 10 ml injectable; one (1) Erythromycin ointment 0.5% 3.5 gram; one (1) Misoprostol 100 mcg; one (1) Neo/Poly B/ Bacitracin Ointment; one (1) Oxytocin 10 units/ml; one (1) Sodium Chloride 0.9% 20 ml; one (1) Sterile water 20 ml; and one (1) Vitamin K 1 mg/0.5 ml.

b. In the fluid warmer were four (4) bags of 0.9% Normal Saline 500 ml; three (3) bags of 0.9% Normal Saline 1000 ml; and one (1) bag of Sterile Water 1000 ml. The fluids lacked a beyond-use date. The fluid warmer also contained 4 adult gowns, 2 pediatric gowns, and one pair of non-skid slippers.

2. The Hospital policy titled, "Drug Storage Throughout the Hospital (last revised by the Hospital: 3/1/16)" was reviewed on 5/14/19 at 2:00 PM. It required "... All medications must be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation and security."

3. The Hospital policy titled, "Temp Log Policy (last reviewed by the Hospital: 6/26/17)" was reviewed on 5/14/19 at 2:30 PM. It required "... 2.7 Storage of Drugs or Sterile Solutions in Warmers 2.7.1 Drugs or sterile solutions should be segregated from other items when stored in warming devices. 2.7.2. Products stored in warmers should have labels affixed that indicate the beyond-use date (expiration date) appropriate for the product at the specified temperature."

4. During the tour of the ED, E#3 and E#13 stated that the Neonatal Emergency Kit should be stored in a secured area. E#3 and E#13 agreed the fluids should have a beyond-use label on them and no other supplies should be stored with the fluids.


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B. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure expired medications were not available for patient use. This has the potential to affect all patients served by the CAH, with a current census of 3 patients.

Findings include:

1. A tour of the Nuclear Medicine Department was conducted on 5/14/19 at approximately 1:00 PM with the Manager of Radiology (E#11). The Nuclear Medicine Department contained the following expired medications: one (1) sterile water 10 milliliter (ML) (expiration date 11/1/18) and one (1) Intravenous (IV) Fluids Sodium Chloride 100 ML (expiration date 3/2016).

2. The Hospital policy titled "Expired, Damaged, Contaminated Medications" (revised by the Hospital: 2/4/15), was reviewed on 5/15/19 at approximately 9:45 AM. The policy required "1. It is the responsibility of the Pharmacy department to remove all expired medications from any and all storage areas in the hospital...2. Medications are monitored based on the following...expiration dates from the manufacturer..."

3. During the tour of the Nuclear Medicine Department, E #11 verbally confirmed the sterile water and sodium chloride IV fluids were expired and should have been removed from the patient care area.

Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure food/nutritional products were properly stored and maintained. This has the potential to affect all patients, employees and visitors receiving meals at the CAH.

Findings include:

1. On 5/13/19 at approximately 11:00 AM, a tour of the Dietary Department was conducted with the Dietary Manager (E#2). The walk in freezer contained two bags with approximately 6 chicken breast each, which lacked items name or open/expiration date. The dairy cooler contained one five pound bag of mozzarella shredded cheese and one five pound bag of cheddar cheese, which lacked items name or open/expiration date.

2. During the tour of the Dietary Department, E#2 stated, "They should be identified and dated. It looks like I need to do another in-service on dating and labeling products."

3. On 5/14/19 at approximately 1:00 PM, a tour of the Nuclear Medicine Department was conducted with the Manager of Radiology (E#11). The Nuclear Medicine Department contained six (6) Ensure (nutritional supplement) 8 fluid ounce bottles with expiration dates of 5/1/19.

4. During the tour of the Nuclear Medicine Department, E #11 verbally confirmed the 6 Ensure drinks were expired and should have been removed from the patient care areas.

Based on document review and interview, it was determined that in 2 of 11 (E #3, E#10) personnel files reviewed, the Critical Access Hospital (CAH) failed to ensure all staff received annual competency training. This has the potential to affect all patients served by the CAH, with a current census of 3 patients.

Findings include:

1. On 5/15/19 at approximately 3:00 PM personnel files were reviewed. The Emergency Department (ED) Supervisor's (E#3), and the Medical/Surgical Supervisor's (E#10) personnel files lacked documentation that annual competencies were completed.

2. The Policy titled "Competency Validation" (revised by the Hospital: 6/29/18) was reviewed on 5/16/19 at approximately 1:00 PM. The policy stated "Performance evaluations are conducted annually to ensure maintenance of competency..."

5. During an interview with the Director of Nursing (E#1) on 5/16/19 at approximately 1:30 PM, E#1 stated, "We don't have an Education Department, so I have just had my Department Managers do their own staff competencies...I don't have anyone to do competencies on my Department Managers." E#1 stated that E#3 and E#10 are "working" managers and do provide direct patient care.

Based on document review and staff interview, it was determined that the Critical Access Hospital (CAH) failed to maintain clinical records in accordance with written policies and procedures. This has the potential to affect all patients served by the CAH, with a current census of 3 patients.

Findings include:

1. The CAH policy titled, "Medical Records Section A." (Revised by the Hospital on 6/26/17) was reviewed on 5/16/19 at 10:30 AM. The policy indicated "17. The patients medical record shall be complete at time of discharge... When that is not possible ...the patient chart will be available until 15 days after discharge. If after 20 days the chart remains incomplete, it is considered a delinquent record... The Chief Executive Officer (CEO) is notified...CEO shall send a certified letter as well as a letter via mail...informing practitioner if delinquency is not corrected in 10 days, the practitioner's privileges to admit patients will be suspended until the record(s) have been completed... On the 30th day post discharge...the practitioner's privileges will be suspended".

2. The document titled, "Deficiency Report by Physician" was reviewed on 5/16/19. The report indicated a total of 9 delinquent patient records as of 5/15/19. The Hospital lacked documentation of CEO notification, certified letter, or regular letter sent to practitioner, or if indicated admitting privileges suspended.

3. During an interview with the Director of Nursing (E #1) on 5/16/19, E #1 stated that 8 of 9 delinquent records are waiting on one part time Physician's signature and policy was not followed.

Based on document review and staff interview, it was determined in 2 of 25 (Pt #17 and Pt #25) patients' records reviewed, the CAH failed to ensure that discharge summaries were completed per policy. This has the potential to affect all patients receiving care at the CAH, with a current census of 3.

Findings include:

1. On 5/14/19 at 2:15 PM, the medical record of Pt#17 was reviewed with the Registered Nurse (E#14). Pt#17 was admitted on 8/25/18 and expired on 8/26/18. Pt#17's record lacked documentation of a Discharge Summary.

2. On 5/15/19 at 12:30 PM, the medical record of Pt#25 was reviewed with E#14. Pt#25 was admitted on 4/19/19 and expired on 4/19/19. Pt#25's record lacked documentation of a Discharge Summary.

3. On 5/15/19 at 10:35 AM, the CAH policy "Characteristics Of An Inpatient Medical Record" (last reviewed by the Hospital: 7/7/18) was reviewed. Under "Discharge Summary" it stated "2. Discharge Summary to include the following: a. Final Diagnosis b. conclusion at termination of hospitalization c. Clinical resume..."

4. During an interview conducted with Nursing Director (E#1) on 5/15/19 at 10:40 AM, E#1 verbalized "The medical records do not contain Discharge Summaries (Pt #17, Pt #25)."

Based on document review and staff interview, it was determined in 2 of 3 (Pt #18, Pt #19) surgical patients' records reviewed, the Critical Access Hospital (CAH) failed to ensure anesthesia orders and evaluations were signed, dated, and timed per policy. This has the potential to affect all patients receiving surgical services with a average monthly census of 12 patients.

Findings include:

1. The Hospital policy titled, "Record Completion by Provider (last revised by the Hospital: 3/10/16)" was reviewed on 5/15/19 at 3:00 PM. The policy stated "... Paper forms such as pre/post op surgical forms and anesthesia forms are to be signed and dated at time of procedure."

2. The clinical record of Pt #18 was reviewed on 5/15/19 at 9:00 AM. Pt #18 was admitted on 5/13/19 with diagnosis of Screening Colonoscopy. "Pre-Anesthesia Orders Day of Surgery" lacked the time orders were signed; "Pre-Procedure Anesthesiology Consultation and Evaluation" lacked the date and time when it was completed; and "Anesthesia Record" lacked the time post anesthesia assessment was completed.

3. The clinical record of Pt #19 was reviewed on 5/15/19 at 9:30 AM. Pt #19 was admitted on 4/16/19 with diagnosis of Left eye cataract. "Pre-Anesthesia Orders Day of Surgery" lacked the time orders were signed; "Pre-Procedure Anesthesiology Consultation and Evaluation" lacked the date and time when it was completed; and "Anesthesia Record" lacked the time post anesthesia assessment was completed.

4. During an interview conducted with the Operating Room Director (E #6) on 5/15/2019 at 9:45 AM, E #6 reviewed Pt #18's and Pt #19's clinical records and stated, "Anesthesia forms were not signed and/or dated and should have been. I have addressed this previously with the providers."

Based on document review and interview, it was determined that in 1 of 4 (Pt. #16) clinical records reviewed of expired patients, the Critical Access Hospital (CAH) failed to ensure that the staff notified the Organ Procurement Organization of the patient's death. This has the potential to affect all patient's families/caregivers served by the CAH, with a current census of 3 patients.

Findings include:

1. On 5/15/19 at 11:00 AM, the policy titled, "Organ and Tissue Donation (last reviewed by the Hospital: 1/15) was reviewed. The policy indicated, ..."for this institution Mid-America Transplant Specialist (MTS) is the organization to be notified after death is declared...All deceased patients should be considered for tissue donations". "Routine referrals must be made on every death...."

2. On 5/15/19 at approximately 9:45 AM, the clinical record of Pt#16 was reviewed. Pt#16 expired at the Hospital on 1/24/18. Pt#16's clinical record lacked documentation of a referral made by Hospital staff to MTS for determination of tissue donation.

3. During an interview conducted with the Nursing Director (E#1) on 5/16/19 at approximately at 2:45 PM, E#1 stated, "The staff should have notified the Organ Procurement Organization when this patient died and documented the referral in the patient's chart."