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Based on observation and staff interview, it was determined the CAH failed to ensure expired medical supplies were not available for patient use. This has the potential to affect 100% of patients receiving care.
Findings include:

1. During a tour of the Respiratory department on 4/9/13 at 2:00 PM, it was observed in the cabinet 26 packages of "GC Series Foam ECG Wet Gel Electrodes" were expired as of August 2012.

2. During an interview with the Respiratory Department Manager on 4/9/13 at 2:15 PM, the Manager confirmed the electrodes had expired and should have been discarded. During an interview with the CNO on 4/11/13 at 12:00 PM, the CNO stated there is no policy for outdated supplies.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on April 8 - 9, 2013, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on April 8 - 9, 2013, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 9, 2013.

Based on a review of Critical Access Hospital (CAH) policy, observation and staff interview, it was determined the CAH failed to follow their policy of expired drugs and biologicals. This failure has the potential to affect 100% of patients receiving care.
Findings include:

1. The CAH undated policy titled, "Outdated Drug Control" was reviewed on 4/11/13. Under "POLICY: Outdated drugs will be removed from stock and will either be returned for credit or properly disposed of."

2. During a tour of the Radiology department on 4/10/13 at 2:00 PM, it was observed in Room 2 in a supply care, a container with 18 - 10ml Normal Saline syringes that had expired 4/11.

3. During an interview with the Radiology Manager on 4/10/13 at 2:15 PM, the Manager confirmed the syringes were expired and should have been discarded.

Based on observation and staff interview, it was determined the CAH failed to ensure Infection Control measures were maintained to prevent cross contamination for patients in the surgical department. This failure has the potential to affect 100% of all surgical patients.
Findings include:

1. During observation of a surgical procedure on 4/9/13 at 10:00 AM, patient (P) -21 was being prepared for a Left Inguinal Hernia with mesh, the Certified Registered Nurse Anesthetists (CRNA) administered IV medication which caused P-21 to become restless, moving head side to side and moving right arm. The CRNA was observed to place an anesthesia mask attached to hose tubing over P-21's mouth and nose and instructed P-21 to take some breaths. The CRNA then turned away from the patient toward the anesthesia cart. At the same time P-21 turned P-21's head causing the mask to fall off P-21's face to the floor. When the CRNA turned back toward the patient the CRNA noted the mask to be off and on the floor and reached for the mask, replacing it on the patient's nose and mouth.

2. During an interview with the Circulating Nurse/ Infection Control Manager (E#2) on 4/11/13 at 11:45 AM, when asked what guidelines are used to establish infection control guidelines E#2 reported the hospital uses Centers for Disease Control, Association for Professionals in Infection Control and Epidemiology Recommendations and other recommended guidelines specific to hospital departments. E # 2 was present as the Circulating Nurse in the surgical procedure for P-21. E#2 reported she observed the CRNA reach to the floor for the mask after it fell from P-21's face and replace it over P-21's nose and mouth. E#2 reported the incident was discussed with the Operating Room Manager and the CRNA and all agreed the mask should have been disposed and a new mask used in its place.

A. Based on observation and staff interview, it was determined the CAH failed to ensure all food was properly labeled with expiration or use by date and discarded when expired, to ensure the quality and safety of food storage. This has the potential to affect 100% of the patients who receive dietary services.
Findings include:

1. During a tour of the Dietary Department on 04/08/13 at 1:30 PM, it was observed the cooler contained 2 individual fruit juice containers with no expiration or use by date.

2. During a tour of the Emergency Department on 04/08/13 at 12:45 PM, it was observed the patient refrigerator contained 4 prune juice cans that expired 04/05/13.

3. During a tour of the Medical Surgical Floor on 04/09/13 at 10:00 AM, it was observed the patient refrigerator contained 12 orange juice cans with no expiration or use by date.

4. During an interview with the CNO on 04/09/13 at 2:00 PM, it was confirmed that all food provided by the Dietary Department should contain an expiration date or use by date.

B. Based on a review of CAH policy, observation and staff interview, it was determined the CAH failed to ensure expired chlorine test strips were not available for use in the dietary department. This has the potential to affect 100% of patients receiving dietary services.
Findings include:

1. During a tour of the Dietary department on 4/8/13 at 1:30 PM, it was observed above the 3 compartment sink a bottle of chlorine test strips expired 11/11.

2. During an interview with the Dietary Manager on 4/8/13 at 1:30 PM, the Manager confirmed the test strips had expired and should have been discarded. During an interview with the CNO on 4/11/13 at 12:00 PM, the CNO stated there is no policy for outdated supplies.