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A. Based on the Hospital Licensing Act, observation, and staff interview it was determined that the Critical Access Hospital (CAH) failed to ensure that Complaint procedures were posted which has the potential to effect all patients, employees, and visitors.

Findings include:

1. The Hospital Licensing Act -(210 ILCS 85/6.14c) under "Sec.6.14c. Posting of information. Every hospital shall conspicuously post for display in an area of its offices accessbile to patients, employees, and visitors...(2) a description, provided by the Department, of complaint procedures established under this Act and the name, address, and telephone number of a person authorized by the Department to receive complaints;".

2. During a tour of the CAH on 1/10/12 at 9:00 AM, it was observed that there was no posting of Complaint procedures as required by the Hospital Licensing Act.

3. During an interview with the Director of Nursing on 1/10/12 at 3:00 PM, the above findings were confirmed.

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 February 22, 2012, 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.

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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 February 22, 2012, 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 February 22, 2012.

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A. Based on observation and staff interview it was determined that the CAH failed to ensure that biologicals and supplies were safe for patient usage which has the potential to effect all patients receiving services.

Findings include:

1. During a tour of the Emergency Department (ED) on 1/10/12 at 10:00 AM,the following items were observed to be expired:

2- containers of "SPROAM" (1) expired 3/2010 (1) container expired 10/2011
1-bottle of Hydrogen Peroxide expired 9/11
2-Nasopharyngeal Airways expired-3/2011 (Respiratory Cart)
2-Nasopharyngeal Airways expired-4/2011 (Respiratory Cart)
2-Nasopharyngeal Airways expired-5/2011 (Respiratory Cart)
1- 1000cc bag of Lactated Ringers-expired 12/2011
2- 1000 cc container Sodium Chloride 0.9%-expired 1/1/2012

2. During a tour of the Surgical Department (Anesthesia) on 1/11/12 at 10:30 AM, the following items were expired:
4 bottles of Cidex test strips (2) expired in 2007 and (2) expired in 2008
1- bottle of Metritest test strips expired in 6/2011

3. During an interview with the Surgery Manager on 1/11/12 at 10:45 AM, the above findings were confirmed.

B. Based on policy, observation, and staff interview it was determined that the CAH failed to ensure that biologicals are safe for patient usage which has the potential to effect all patients receiving services.

Findings include:

1. The CAH policy titled, "Administering Medications" was reviewed on 1/11/12. The policy indicated under "Medication Orders: 5. Multiple Dose Vials: A. When opening a multiple dose vial, it must be dated and initialed by the person opening the vial.

2. During a tour of the Physical Therapy (PT) department on 1/11/12 at 11:30 AM, an opened bottle of Normal Saline was observed without a date or initials.

3. During an interview with the PT Department Manager on 1/11/12 at 11:30 AM, the above finding was confirmed.

A. Based on CAH policy, observation and staff interview, it was determined the CAH failed to ensure confidentiality of patient information, which has the potential to effect all patients receiving services.

Findings include:

1. The CAH policy titled "Workstation Security Policy" under "Procedure(s): Workstations will be positioned such that the monitor screens and keyboards are not within view of unauthorized individuals."

2. During a tour of the medical-surgical unit on 1/09/12 at 1:00 PM, it was observed that a workstation being used by Respiratory Therapy for treatments was in the hall with patient information visible on the computer screen. The position of the workstation allowed for any person passing to view the confidential information.

3. During an interview with the Director of Respiratory Therapy on 1/10/12 at 9:30 AM, the above finding was confirmed.