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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 July 21-22, 2014, the surveyors find 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 July 21-22, 2014, the surveyors find 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 July 22, 2014.

A. Based on policy, observation and staff interview it was determined that the CAH failed to ensure all dietary practices are followed per their policy and food service standards to ensure safe food is prepared for all patients.
Findings include:

1. The policy titled Food Labeling, dated 3/29/11 was reviewed on 7/14/14. The policy indicates under "PROCEDURE 1. All refrigerated ready to eat potentially hazardous foods prepared and held for more than 24 hours shall be clearly marked. 2. Labeling shall include day opened, prepared and use by date."

2. During a tour of the dietary department with the Dietary Manager (E#12) on 7/14/14 at 2:00 PM, it was observed in the deep freeze 3 unidentified bags with frozen foods, 2 with frozen fries and 1 with a breaded item, all without a label or use by date. The bags had no closures. Observed on the shelf where dry goods are stored, a box of baking mix was noted to be opened with no date of opening.

2. During an interview with the Dietary Manager (E#12) on 7/14/14 at 2:30 PM, E#12 reported it is the expectation any open items have a label to include date of opening and use by or an expiration date.


B. Based on policy, observation and staff interview, it was determined the CAH failed to ensure all surgical staff followed policies for surgical attire to maintain a safe and sanitary environment, potentially affecting all patients receiving surgical services.
Findings include:

1. A review of the policy titled "Surgical Attire" was completed on 7/14/14 at 10:30 AM. The policy dated 5/23/11 (review date) indicates under Procedure 14. "Earrings, necklaces and bracelets should not be worn in the Operating room. Rings must be removed if one is scrubbing a case."

2. During a tour of the surgical area on 7/15/14 at 9:00 AM, a Certified Registered Nurse Anesthetist (CRNA) was observed exiting operating room #1 wearing two necklaces, one silver in color and the second a brown leather looking necklace with a pendant attached.

3. During an interview with the operating room manager (E#11) on 7/15/14 at 10:00 AM, E# 11 reported she had not observed the jewelry but the policy does indicate that no jewelry be worn in the surgical area.

A. Based on policy, observation, and staff interview, it was determined the CAH failed to ensure that outdated drugs and biologicals were removed from patient care areas, potentially affecting all patients receiving services.

1. CAH undated policy "Expired Medications" was reviewed 7/16/14 at 1:50 PM. Under "POLICY" indicated "Whenever the expiration date of any medication has been exceeded, or the integrity of a medication cannot be verified, it shall be removed from active stock."

2. During a tour of the Respiratory department on 7/15/14 at 1:30 PM, it was observed in the work room area less than one-half of a box of vials of normal saline were all expired 10/13.

3. During a tour of the Physical Therapy (PT) department with the PT Director (E#6) on 7/14/14 at 2:15 PM, it was observed in the medication cabinet a tube of Santyl ointment expiration date 10/13.

4. During an interview with E#6 on 7/14/14 at 2:15 PM, E#6 verbalized the Santyl ointment had expired and should have been discarded.

5. During an interview with Respiratory Therapist (E#9) on 7/15/14 at 1:15 PM, E #9 stated the expired saline was "a problem." E#9 verbalized that the saline was expired and should be discarded.


B. Based on observation and staff interview, it was determined the CAH failed to ensure surgical supplies were maintained in a sterile package. This has the potential to affect all patients receiving surgical services
Findings include:

1. During a tour of Operating Room #1 on 7/14/14 at 10:30 AM, it was observed in the second drawer of the anesthesia cart, one sterile package 6.0 mm Tracheal Tube (Cuffed) was open with a stylet attached and one sterile package 7.5 mm Tracheal Tube (Cuffed) with a stylet attached were ready for patient use.

2. During an interview conducted on 7/16/14 at 2:30 P.M. with the CRNA( E#10), E#10 verbalized that the 2 sterile tracheal tube packages should not have been opened with the stylet attached and should have been discarded.

Based on patient interview, record review and staff interview it was determined in 1 of 25 (Pt. # 14) medical records reviewed the CAH failed to ensure nursing services provided complete patient assessments.
Findings include:

1. An interview was conducted with Pt. #14 on 7/15/14 at 2:45 PM. Pt. #14 was asked about care provided by the CAH. Pt. #14 stated "I have not received anything for my bowels since I have been here. I usually take something everyday."

2. The medical record of Pt. #14 was reviewed on 7/15/14 at 3:00 PM. Pt. #14 was admitted on 7/12/14 with diagnoses of generalized weakness, dehydration and constipation. The initial nursing assessment was completed on 7/12/14 at 2201 with last bowel movement documented on 7/12/14 as "normal for patient". Subsequent nursing assessments completed on 7/13/14, 7/14/14 and 7/15/14 indicated no bowel movement assessments were completed.

3. An interview was conducted with the Chief Nursing Officer (E# 4) on 7/15/14 at 2:30 PM. E#4 stated" it is a verbal policy to complete a bowel movement assessment on each shift as part of the complete nursing assessment. Nursing assessments are done once every 12 hours. A nursing assessment includes all body systems including bowel patterns." E#4 verified that bowel movements had not been documented after the initial nursing assessment completed on 7/12/14.

Based on record review and and staff interview, it was determined in 2 of 8 patients who presented to the Emergency Department (Pt # 21, #22), the registered nurse failed to document ongoing assessments to determine patient status and meet their needs.

Findings include:

1. The medical record of Pt #21 was reviewed on 7/16/14 at 9:00 AM. Pt #21 presented to the ED on 7/14/14 at 0025 with chief complaint of "vomiting green emesis." and admission diagnoses of ileus and bowel obstruction. Documentation in the ED record indicated 3 sets of vital signs: at 0026 AM,
0030 AM and 0045 AM and nursing notes documenting orders carried out but failed to document Pt #21's condition, tolerance to procedures, and ongoing assessment of overall status. Pt #21 was discharged from the ED department and taken to the inpatient floor at 0350 AM.

2. The medical record of Pt #22 was reviewed on 7/16/14 at 09:40 AM. Pt #22 presented to the ED on 7/15/14 at 0118 AM with chief complaint and admission diagnosis of gi bleed. Documentation in the ED record indicated 1 set of vital signs taken at 0120 AM and nurse's notes documenting orders carried out but failed to document Pt #22's condition, response to procedures or ongoing assessment of overall status. Pt #22 was discharged from the ED department and taken to the inpatient floor at 0330 AM.

3. During an interview with the CNO (E#4) on 7/16/14 at 3:00 PM, E#4 stated nurses are educated in documentation of patient status and instructed to document and take vital signs on critical patients every 15 minutes and other patients every 30 minutes. E#4 indicated this is the expectation regarding patient documentation.

Based on record/document review and interview, it was determined the CAH failed to ensure in 1 of 25 medical records reviewed (Pt #25) emergency room physician orders were not authenticated, potentially affecting all patients receiving care in the emergency department.
Findings include:

1. The medical record of Pt #24 was reviewed with E #7 on 7/15/14 at 10:00 AM . Pt# 25 was seen in the E.D. with chief complaint of congestive heart failure.. There is no date on the "Emergency Room Physican Orders" sheet.

2. On 7/14/14 at 11:00 AM a review of the CAH bylaws (revised 5/19/14) were reviewed. Under "ENTRIES: a." it indicated "All clinical entries in the patient's record shall be accurately dated and authenticated."

3. On 7/15/14 at 10:30 AM an interview with Staff Development (E #7) was conducted. E #7 verbalized the physician order was not dated are required a date.