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A. Based on observation, documentation, and interview, the CAH failed to ensure emergency carts and medication boxes were checked daily to ensure safe functioning per policy. This has the potential to affect all patients who receive care by the CAH emergency department.

Findings Include:

1. During the observational tour of the Emergency Department on 01/30/24 at 10:30 AM, the following was identified:

- 2 of 2 adult crash cart checks were not completed on 01/22/24.
- 1 of 1 pediatric crash cart check was not completed on 01/22/24.
- 1 of 1 neonatal airway box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24.
- 1 of 1 stat heart box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24.
- 1 of 1 Narcan box check was not was completed on 01/11, 01/12, 01/17, 01/18, and 01/19/24.

2. The policy "Crash Cart (& Emergency Stock Maintenance, Cleaning, etc.) SY-NG-037" (revised 10/18/22) notes, " ... III. Responsibilities. 1. Designated Staff: 1. Checks the crash cart daily as indicated ... V. Procedure. 1. Crash cart shift checks are done per crash cart check sheet. The designated department staff conducting the crash cart check completes the checklist posted in the department ... 2. Other outer contents and locks as per Checksheet such as oxygen, suction, where applicable, backboard, needle boxes, etc."

3. An interview with the ED director (E#5) during the tour was conducted. E#5 reviewed the checklists and verbally verified checks had not been completed as required per policy on the dates noted above. E#5 also stated, "a nurse on shift is responsible for performing and documenting crash cart checks were completed."


B. Based on observation and staff interview, it was determined the Facility failed to ensure open sterile supplies were not available for patient use. This failure has the potential to affect all patients who receive care by the CAH procedures area.

Findings include:

1. During the observational tour of the OR on 01/31/24 at approximately 11:00 AM, it was identified that open sterile supplies on the anesthesia cart were available for immediate patient use to include the following:
- One (1) Endotracheal Tube, open with contents still inside and available for use.
- One (1) Suction Catheter, open with contents still inside and available for use.
- Two (2) Oral Airways, open with contents still inside and available for use.

2. An interview with Quality Improvement Registry Coordinator (E#8) and OR Supervisor (E#9) was conducted during the observational tour. E#8 vebally agreed the items should have been disposed of. E#8 stated, "expired supplies and open sterile supplies should not be available for patient use. We have spoken to anesthesia about this before."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on February 6, 2024 the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on February 6, 2024, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

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

Based on document review and interview, it was determined for 2 of 2 (Endo Room #1 and Endo Room #2) procedure rooms (rooms that pain procedures utilize radiation) that required a dosimetry monitoring, the Hospital failed to ensure the dosimeter badges were monitored per policy. This has the potential to affect all patients and staff who are exposed to radiation.

Findings include:

1. An observational tour was conducted on 1/31/24 at approximately 11:30 AM with Quality Improvoment Registry Coordinator (E #8) and OR Supervisor (E #9). E #9 stated, "We monitor the dosimetry by the badges on the wall in procedure room #1 and room #2. Those rooms do not get much exposure so the staff do not get individual badges, unless they request it. The radiation exposure is monitored through the badges that are mounted on the wall. They are monitored monthly. The staff in the rooms have no other radiation exposure so they would not require the individual badges."

2. The policy titled, "Radiation Safety in the OR, SY-OR-023 (revised 6/6/23)" was reviewed on 1/31/24. The policy stated, "... III Responsibilities... 2. RSO (Radiation Safety Officer) 1. Determines the appropriate type of monitoring for radiation exposure based on the employee job duties. 2. Provides the appropriate monitor. 3. Collects and replaces monitoring devices on a regular basis (monthly, quarterly).... V. Procedures:... 2. Radiation monitoring devices (film badges)... 1. Surgical Services personnel who are (hospital) employees, are considered non-radiation workers and have the potential of receiving an exposure of 500m/Yr or higher are provided with radiation monitoring devices (film badges) by the RSO. Some areas will be monitored by using Area Monitors..."

3. The Dosimeter Reports from October 23 to present was requested. The reports were reviewed on 2/1/24 at approximately 9:00 AM. The Radiation Dosimetry Reports were provided were dated as follows:
Endo Room #1 dated - 10/24/23, 11/29/24, and 1/5/24
Endo Room #2 dated - 10/24/23

The reports lacked monitoring for Room #1 in December and Endo #2 November, December and January.

4. An interview was conducted with the System Director of Regulatory and Accreditation Compliance (E #1) on 2/1/24 at 9:30 AM. E #1 reviewed the reports and verbally agreed the dosimeter reports are not conducted monthly as required for the procedure rooms.

Based on document review and interview, it was determined that the Critical Access Hospital failed to comply with the Condition of Participation 42 CFR 485.614, Patient Rights.

Findings include:

1. The Hospital failed to ensure that least restrictive restraints were used in accordance with an order from a physician/licensed practitioner as required. See deficiency at C-2551.

2. The Hospital failed to ensure documentation of a one-hour face to face evaluation was completed as required by policy. See deficiency at C-2553 A.

2. The hospital failed to ensure that a chemical restraint order was obtained as required by policy. See deficiency cited at See deficiency at C-2553 B.

Based on document review and interview, it was determined that for 2 of 3 violent restraint records (Pt #4 and Pt #13) reviewed, the Hospital failed to ensure that least restrictive restraints were used in accordance with an order from a physician/licensed practitioner as required. This has the potential to affect all patients that require violent restraints.

Findings include:

1. The Hospital's policy titled, "Restraints, Use of, SY-DR-010 (3/28/2023)," was reviewed. The policy stated, "... III. Responsibilities 1. Physician: 1. Provides the restraint orders... 3. RN: ... Attempts to alternatives to restraints or less restrictive restraint methods..."

2. The clinical record of Pt #4 was reviewed on 1/31/24. Pt. #4 arrived to the ED on 1/14/24 as 12:25 AM with a chief complaint of "suicidal." The ED nursing note at 12:50 AM stated, "... Pt became agitated and angry that (Pt #4's) phone was taken and tried to leave the room.... (ED MD) agreed to use soft restraints to obtain labs, place pt in paper scrubs and keep (Pt #4) in the hospital safe for evaluation)." The nursing flowsheet noted Pt #4 was placed in 4-point "locking" restraints. A physician order was noted at 1:31 AM for "Soft limb" 4-point (left lower, left upper, right lower, and right upper) restraints due to "Danger to others."

3. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of "Altered mental status and smoke inhalation." Pt #13 was placed in 4 point locked restraints due to being a danger to self on 12/3/23 from 11:17 PM. The right wrist and left ankle locking restraint was discontinued on 12/3/23 at 2:00 AM. The left wrist was discontinued at 3:30 AM with the Right ankle restraint being discontinued at 4:00 AM. Pt #13 was put back into 4 point locking restrains at 8:44 AM. The locking restraints were discontinued at 11:12 AM. Physician orders for violent-restraints, dated 12/2/23 at 11:17 PM and 12/3/23 at 8:44 AM, were reviewed. The orders were for 4- point (extremity) "Soft Limb" restraints due to "Danger to self."

4. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24, at approximately 3:30 PM. E #4 reviewed the records and stated that "the restraints ordered were soft restraints and the flowheets indicated the nurse utilized locking restraints. The staff should have followed the order and used the correct type of least restrictive restraints."

A. Based on document review and interview, it was determined for 1 of 3 patient's (Pt #13) clinical records reviewed for violent restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints.

Findings include:

1. The Hospital's policy titled, "Restraints, Use of, SY-DR-010 (3/28/2023)," was reviewed. The policy stated, "... III Responsibilities 1. Physician: ... 2. Does a face-to-face assessment within one (1) hour for violent or self-destructive restraint application per episode...."

2. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of "Altered mental status and smoke inhalation." Pt #13 was placed in 4 point locked restraints due to being a danger to self on 12/3/23 from 11:17 PM. The right wrist and left ankle locking restraint was discontinued on 12/3/23 at 2:00 AM. The left wrist was discontinued at 3:30 AM with the Right ankle restraint being discontinued at 4:00 AM. Pt #13 was put back into 4 point locking restrains at 8:44 AM. The record lacked documentation of a 1 hour face-to-face after Pt #13 was placed back in restraints at 8:44 AM.

3. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24 during the record review. E #4 verbally agreed the 1-hour face-to-face documentation was not documented on the second restraint event and stated "I thought the face-to-face only had to be done once in 24 hours. I train staff and have been training them wrong."



B. Based on document review and interview, it was determined for 1 of 2 patient's (Pt #13) clinical records reviewed for chemical restraints, the Hospital failed to ensure a chemical restraint order was placed as required by policy. This has the potential to affect all patients placed in chemical restraints.

Findings include:

1. The Hospital's policy titled, "Restraints, Use of, SY-DR-010 (3/28/2023)," was reviewed. The policy stated, "... V Procedure... 7. Physicians or Advanced Practice Professionals in the Emergency Department. 1. The order for the use of restraints are based on the identification of clinically justified behaviors. Orders include: A. Indication for use. B. Type of restraint...."

2. The clinical record of Pt. #13 was reviewed on 1/31/24. Pt. #13 was admitted on 12/2/23 at 7:31 AM with a chief complaint of "Altered mental status and smoke inhalation." Pt #13 was given Ativan (anti-anxiety) 0.5mg at 9:37 PM and Geodon (anti-psychotic) 10mg at 10:35 PM as Pt #13 was "agitated/restless." The record lacked a chemical restraint order.

3. An interview was conducted with the Quality Improvement Reviewer (E #4) on 1/31/24 during the record review. E #4 reviewed the record and stated, "the provider should have ordered a chemical restraint and did not."