HospitalInspections.org

Based on observation, staff interview, and document review the critical access hospital (CAH) failed to ensure a backflow prevention system is in place at the point of water connection for one of one prep sinks located in the kitchen. This deficient practice has the potential to allow dirty water to reenter the sink contaminating items being prepared in the skin.


Findings include:


- Kitchen observed on 6/21/2017 at 3:45 PM revealed a prep sink without evidence of a backflow preventer or an air gap.


Maintenance Staff G interviewed on 6/21/2017 at 4:00 PM acknowledged the kitchens prep sink does not have an air gap or a backflow preventer.


Policy review on 6/21/2017 at 5:00 PM revealed the facility failed to develop a policy requiring a backflow prevention system on the kitchens prep sink.


The FDA Food Code 2009 read in part:
5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non-FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, document review, and staff interview, the critical access hospital (CAH) failed to ensure temperatures were documented for 1 of 1 staff refrigerators. The CAH also failed to ensure temperatures were logged and appropriate action taken if out of range for 1 of 1 patient food refrigerator. Failure to ensure temperatures are documented puts all patients and staff at risk for exposure to bacteria causing foodborne illnesses. The CAH failed to ensure temperature and humidity was recorded in the pharmacy and central supply rooms, and air exchanges were recorded in the pharmacy, central supply and procedure rooms. Failure to ensure temperatures, humidity and air exchanges are recorded and within normal ranges puts all medications, supplies and patients at risk for receiving care, treatments and medical procedures that will cause reactions, illness and diseases related to bacteria and other pathogens.

Findings include:

- Observation on 6/19/17 at 2:08 PM revealed the staff refrigerator failed to ensure a thermometer to monitor temperatures for safety.

Interview on 6/19/17 at 2:08 PM, Chief Executive Officer Staff A verified the staff refrigerator failed to have a thermometer to verify the temperature.

Interview on 6/19/17 at 4:30 PM, Dietary Manager Staff C verified the staff refrigerator failed to have a thermometer to verify temperatures.

- Policy and Procedure review on 6/20/17 revealed policy "Refrigerators and Freezers" stated ...this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation ...

- Policy and Procedure review on 6/19/17 revealed policy "Personal Food Storage" stated ...all refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Staff will monitor and document unit refrigerator temperatures.

- Record review on 6/19/17 at 4:15 PM revealed the hospital patient refrigerator logs failed to be documented for temperatures for 26 of the 31 days in May 2017 and for 17 of the 19 days so far for the month of June 2017. Temperatures for 6 of the 7 documented logs for May and June 2017 were recorded at 41 degrees Fahrenheit (F) (a temperature scale). The normal range per the facility policy and procedure is 35-40 degrees F.

Interview on 6/19/17 at 4:30 PM, Dietary Manger Staff C verified the total number of documented days for May through June 19, 2017 were 7 (5/18, 5/20, 5/22. 5/26, 5/30, 6/8 and 6/12/17). Staff C stated these were the only days documented for this time frame.

- Policy and Procedure review on 6/20/17 at 4:30 PM revealed policy "Refrigerators and Freezers" stated ...acceptable temperatures should be 35 - 40 degrees F for refrigerators ...daily tracking sheets for all refrigerators, cold table and freezers will be posted to record temperatures ...daily tracking sheets will include day and evening shift, temperature, initials, and "action taken." A notation will be completed only if temperatures are not acceptable ...the supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded and given to maintenance personnel, including after regular work hours.



- Observation on 6/19/17 at 2:51 PM revealed the pharmacy room failed to provide documentation of temperatures, humidity and air exchanges.

- Observation on 6/20/17 at 9:15 AM revealed the procedure room lacking documentation of air exchanges.

- Observation on 6/20/17 at 2:09 PM revealed the central supply room failed to provide documentation of temperatures, humidity and air exchanges.

Interview on 6/20/17 at 5:00 PM, Chief Executive Officer Staff A and Director of Nursing (DON) Staff B verified the pharmacy, central supply room lacked documentation of temperatures, humidity and air exchanges and the procedure room lacked documentation of air exchanges.


- Policy and Procedure review on 6/20/17, DON Staff B stated the facility fails to provide documentation of a policy concerning temperatures, humidity and air exchanges.

Based on observation, interview and policy and procedure review, the critical access hospital (CAH) failed to ensure expired medications and supplies were discarded appropriately and timely from: Labor and Delivery Room (LDRP) #1 and #2, the Physical Therapy Room, Emergency Department (ED) Room 1, ED Triage Room, the Pharmacy Room, the Nursing Medication Room, the Observation Room, and the Central Supply Room. The CAH also failed to discard open multi-dose vials that were dated past the 28 day expiration date for 5 of 5 opened multi-dose vials observed. Failure to discard expired medications and supplies puts all patients at risk for received care and treatments that are ineffective and unsafe for use.

Findings include:

- Observation on 6/19/17 at 2:15 PM revealed LDRP #1 with the following expired medications found in an unlocked cabinet and a sterile supply on the wall:
- One single use sterile suction tubing package opened on the wall by the patient bed
- One box of Dextrose 50% Injection (a medication of sugar and water) expired 5/1/17
- Two boxes of Infant Sodium Bicarbonate (a compound of salt and bicarbonate) expired 6/1/17
- Three boxes of Atropine Injection (a medication to treat heart rhythms, stomach or bowel problems and certain types of poisoning) expired 6/1/17
- One 1000 milliliter (ml) bag of 0.9% Sodium Chloride (a medication used to increase fluids in the body), Three 1ml vials of Pitocin (a medication used to induce labor), and Six 10ml syringes of 0.9% Sodium Chloride.

- Observation on 6/19/17 at 2:25 revealed LDRP #2 with an unlocked cabinet containing:
- Two 1000ml bags of 0.9% Sodium Chloride, Three 1ml vials of Pitocin and Twenty-eight 10ml syringes of 0.9% Sodium Chloride.

Interview on 6/19/17 at 2:19 PM, Director of Nursing Staff B verified the opened sterile supply and medications (expired and not expired) found in the unlocked cabinet in LDRP #1. The opened sterile supply and expired items were discarded.

Interview on 6/19/17 at 2:25 PM, Administrative Staff A verified the medications were stored in the unlocked cabinets and confirmed the cabinets should be locked when medications are stored in them.


- Observation on 6/19/17 at 2:51 PM revealed Pharmacy Room with the following expired medications:
- Twenty two vials of 8.4% Sodium Bicarbonate 50ml expired 6/1/17
- Eight boxes of Infant 4.2% Sodium Bicarbonate expired 6/1/17
- Twenty vials of Tobramycin 80 milligrams (mg) in 2ml (an antibiotic) expired 5/17
- One Hundred tablets of Theophylline Extended Release (ER) 100mg (a medication to treat asthma and other lung problems) expired 4/17
- Twenty Three vials of Bacteriostatic Water (water containing 0.9% benzyl alcohol (as a preservative)) expired 6/1/17
- Fourteen vials of Cefepime 1 gram (a medication to treat bacterial infections) expired 5/17
- Twenty Five vials of Hydroxyzine HCI (a medication used to treat itching caused by allergies, anxiety and to help you feel sleepy/relaxed before and after surgery) expired 2/17
- Twenty vials of Influenza Vaccine (flu vaccine) expired 4/17
- Six vials of High Dose Influenza Vaccine expired 3/4/17
- 1 box of Atropine 1mg expired 6/1/17
- 4 vials of Demerol 50mg/ml (a medication to treat moderate to severe pain) expired 6/1/17


- Observation on 6/20/19 at 8:32 AM revealed Observation Room with the following expired medications and supplies:
- Three vials of Heparin (a blood thinner) expired 4/17
- One bottle of Nitroglycerine (a medication to treat and prevent chest pain) expired 4/17
- Two Endotracheal Tubes (a tube inserted to establish and maintain an airway to ensure adequate oxygen) expired 2/16
- One Endotracheal Airway expired 2/17
- Four bags of 100ml Sodium Chloride 0.9% expired 4/1/17
- One 250ml bag of 5% Dextrose expired 1/1/17
- Two 30ml vials of Bacteriostatic Water expired 6/1/17
- Two Dextrose 50% 50 ml vials expired 5/1/17
- Two 1ml ampule (glass container) of Epinephrine (a medication to treat asthma and allergic reactions) expired 4/1/17
- Four bottles of Bacteriostatic Water 0.9% expired 5/1/17

Interview on 6/20/17 at 8:32 AM, DON Staff B verified the expired medications and supplies and discarded them immediately.


- Observation on 6/20/17 at 2:09 PM revealed Central Supply Room with the following expired supply:
- One Urological Catheter (a tube inserted into the bladder to drain urine) expired 1/15

Interview on 6/20/17 at 2:09 PM, Central Supply Director Staff L verified the expired supply and discarded it.


Observation on 6/19/17 at 2:21 PM revealed an unlocked closet in the hallway between LDRP 1 and LDRP 2 with 2 unsecured drawers containing:
- Six Urojet vials (a numbing medication used to numb skin)
- Three Saline Flushes (saline solution used to flush intravenous lines)
- One ampule of Vitamin K (used to reverse excessive bleeding)
- Six bottles of Bupivacaine (injectable numbing medication)
- Keys to the remaining shelves of the cabinet

Interview on 6/19/17 at 2:21 PM, Medication Aid Staff D acknowledged the presence of the keys to medications and was directed by CEO, Staff A to remove the keys from the unlocked cabinet.


- Observation on 6/19/17 at 2:05 PM revealed ED room 1 with the following supplies unsecured in the top right hand drawer:
- Three culture swabs (used to test for infection)
Interview on 6/19/17 at 2:05 PM, Central Supply Staff D confirmed supplies were expired.

- Observation on 6/19/17 at 2:52 PM revealed Emergency Department Room 1 with the following expired supplies:
- One Endotracheal Tube (breathing tube used in emergencies) size 3.5 mm with an expiration date of 11/2016
- One Endotracheal Tube size 2.5 mm with an expiration date of 4/2017

- Observation on 6/19/17 at 3:30 PM revealed the following expired supplies:
- One catheter kit (used to insert catheters into the bladder) with an expiration date of 8/16
- One catheter kits with an expiration date of 1/17
- Six catheter kits with an expiration date of 5/17

Interview on 6/19/17 at 3:35 PM, Director of Nursing Staff B confirmed the supplies were expired.


- Observation on 6/20/17 at 1:00 PM revealed the Physical Therapy Room with the expired supplies:
- One bottle of Ultra Sound Gel (used in ultra sound testing) with an expiration date of 12/09
- Three Telfa (non-stick bandages) pads with an expiration date of 1/20014
- One package of Steri-strips (used to close wounds) with an expiration date of 5/2005, one with an expiration date of 5/2006, one with an expiration date of 10/2006, and six with an expiration date of 1/2007.

Interview on 6/20/17 at 1:20 PM, Physical Therapy Director Staff T communicated that most of the supplies in the cupboard were likely to be expired because they no longer provide wound treatments. Staff T stated all the items would be thrown away.

- Policy and Procedure review on 6/19/17 revealed policy "Outdated Medications and Supplies" stated ...weekly checks for outdated medications will be performed by the Pharmacy RN or Charge nurse as directed. Nursing staff on duty when checks are due will be responsible for checking specific, assigned areas for outdated medications and supplies. The personnel assigned to perform the outdated medication and supply checks will also be responsible for replacing those medications and removing the outdated medications or supplies from the use area to the pharmacy outdate area.

- Policy and Procedure review on 6/19/17 revealed policy "Storage of Drugs and Biologicals" stated ...emergency room medications and biological products are stored in locked cabinets in the ED with overflow and ED narcotics being stored in the hospital pharmacy ...patient medication currently in use is stored in the Medication Administration Room. Cabinets containing medications in this room are to be locked.

Based on observation, interview and policy and procedure review the critical access hospital (CAH) failed to ensure a system for identifying, reporting, investigating and controlling infections and communicable diseases as evidenced by un-dated and expired food in the patient refrigerator, failing to clean a glucometer (a medical device to test blood sugar) after use (Registered Nurse (RN) Staff J), failing to ensure proper hand hygiene (RN Staff U) and ensuring equipment (physical therapy mat and wheelchairs) are free from contamination, tears and holes. Failure to ensure a safe and sanitary environment puts all patients at risk for bacteria causing food poisoning, illness and diseases.

Finding include:

- Observation on 6/19/17 at 1:42 PM revealed the patient refrigerator in the nutrition area with the following findings:

- Food items lacking a patient name and date: small salad, small container of shredded cheese, two bowls of strawberries, ice cream, hamburger, 2 bags of veggies, slices of bread in a baggie, a baggie with green peas and a veggie burrito, syrup bottle, chocolate syrup bottle, salted caramel syrup and strawberry syrup.

- The following items found in the patient refrigerator were found to be expired:
- Vitamin D milk (1/2 gallon) 1 expired on 6/14/17
- Several slices of Swiss cheese dated 6/2/17 use by 6/5/17
- Grape Juice (1 container) expired 6/15/17
- Baggie of Roast Beef Slices dated 6/2/17 use by 6/5/17
- Baggie of Turkey Slices dated 6/2/17 use by 6/5/17
- Baggie of Ham Slices dated 6/2/17 use by 6/5/17

Interview on 6/19/17 at 1:58 PM, Chief Executive Officer Staff A verified the mislabeled and expired foods in the patient refrigerator and disposed of them immediately.

- Policy and Procedure review on 6/19/17 revealed policy "Food Storage" stated ...an area that is clean, dry and free from contaminates. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded ...All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe and use by dates, or frozen (if applicable), or discarded.

- Policy and Procedure review on 6/19/17 revealed policy "Food Safety and Sanitation" states ...food protection measures that are performed by the food service department include: all time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored. They are used within 72 hours (or discarded) ...foods with expiration dates are used prior to the use date on the package.



- Observation on 6/20/17 at 12:37 PM, Registered Nurse (RN) Staff J demonstrated use of the glucometer (as the facility failed to have a diabetic patient at the time of our survey). Upon completion Staff J failed to demonstrate knowledge of how to disinfect the glucometer.

Interview on 6/20/17 at 12:49 PM, RN Staff J stated and provided a copy of the manufacturer's guidelines for cleaning the glucometer and stocked the nurse's station with the appropriate wipes.

- Document review on 6/20/17 revealed "Manufactures Guidelines for Glucometer" stated ...Your Contour Link system should be cleaned and disinfected once a week ...Use only Clorox Germicidal Wipes containing 0.55% sodium hypochlorite (bleach), which has been proven to be sage to use with the Contour Link meter and Microlet 2 lancing device ...Note: if your meter is being operated by a second person who is providing testing assistance to you, the meter and lancing device should be disinfected prior to use by the second person.

- Policy and Procedure review on 6/20/17 revealed policy "Glucose Meter Policy - Bayer Contour" failed to address the cleaning of the glucometer.



- Observation on 6/20/17 at 10:33 AM revealed RN Staff U during a dressing change procedure failing to complete hand hygiene or change his/her gloves after cleansing the wound and prior to applying a clean dressing to the wound.

Interview on 6/20/17 at 10:42 AM, RN Staff U acknowledged they did not wash their hands before applying the clean dressing. Staff U indicated they thought that since they had cleaned the wound, applying a clean dressing would not be an issue.

- Policy and Procedure reviewed on 6/22/17 for policy "Infection Control: Handwashing" stated ...handwashing must be performed ... before handling clean or soiled dressings ....after handling items potentially contaminated with blood, body fluids ..." and " ... the use of gloves does not replace handwashing ..."



- Observation on 6/20/17 at 12:49 PM of the Therapy Treatment Room revealed a small hole in the therapy treatment mat, failing to provide a cleanable surface.

Interview on 6/20/17 at 12:49 PM, Physical Therapy Director Staff T acknowledged the presence of the hole.

- Observation on 6/19/17 at 1:05 PM the Patient entrance area revealed a wheelchair with tears in both armrests and the seat bottom edges.

- Observation on 6/19/17 at 1:45 PM the Ambulance entrance observed revealed a wheelchair with tears in both armrests and the seat bottom edges.

Interview on 6/19/17 at 1:45 PM, Administrative Staff A confirmed the wheelchair had tears in both armrests and the seat bottom edges.

- Policy and procedure review on 6/19/2017 revealed the facility failed to provide a policy directing staff members to ensure all items with tears in the material are removed from service until repaired or replaced.

Based on interview, record review and policy and procedure review the critical access hospital (CAH) failed to ensure nursing care plans were completed in 16 of 23 records reviewed (Patient #'s 11, 13-17, 21-26, 28-30, and 33). Failure to ensure care plans are completed puts all patients at risk for lack of direction, continuity of care and discharge individualized for each patient according to their health care needs.

Findings include:

- Medical Record reviews on 6/21/2017 revealed an individualized nursing care plan lacking in patient #'s 11, 13-17, 21-26, 28-30, and 33 medical records.

Medical Records Director Staff O interviewed on 6/21/2017 at 10:05 AM verified they were unable to locate the missing care plans from patient #'s 11, 13-17, 21-26, 28-30, and 33 electronic medical records.

Director of Nursing Staff B interviewed on 6/21/2017 at 11:00 AM confirmed they were unable to locate nursing care plans in the computer system. Staff B indicated they spoke with nursing staff who reported they completed them, but upon looking in the chart the nursing care plans could not be found.

- Policy titled "Care Plans" reviewed on 6/21/2017 directed "...Patients will have a nursing care plan added to the electronic medical record (EMR) within 24 hours of admission. All nursing diagnoses are to be a clinical judgement about the patient response to actual or potential health problems or life processes. All nursing diagnoses are to provide nursing staff with a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable..."

Based on interview, record review and policy and procedure review the critical access hospital (CAH) failed to ensure patient records are complete and accurate. The CAH failed to ensure a diet order for 1 of 23 records (patient # 27) and the CAH failed to ensure a History & Physical (H&P) for 1 of 23 records (patient # 30). Failure of the facility to ensure patient medical records are complete and accurate puts all patients at risk for receiving care, medications and treatments not relevant to their diagnosis, allergies and medical condition.

Findings include:

- Medical Record review on 6/21/17 revealed patient # 27 failed to have documentation of a diet order.

- Medical Record review on 6/21/17 revealed patient # 30 failed to have documentation of an H&P in the medical record.

Interview on 6/21/17 at 2:54 PM, Medical Record Director Staff O verified the medical record for patient #27 failed to contain a diet order and medical record for patient #30 failed to have an H&P.

- Policy and Procedure reviewed on 6/22/17 revealed policy "Dietary" stated ...when a new resident is admitted, or a diet has been changed, the nurse supervisor shall ensure that the food services department receives a written notice of the diet order ...

- Policy and Procedure reviewed on 6/21/17 revealed policy "Physicians Orders" stated ...all orders for medication and treatments are to be in writing. Verbal orders must be dictated to a licensed nurse and subsequently signed by the attending physician ...physician orders will be noted and carried out as soon as possible following receipt.

- Policy and Procedure reviewed on 6/21/17 revealed policy "Transcription" stated ...transcriptions of History and Physicals ...will be completed in a timely manner ...History and Physical: Shall be on the chart within 48 hours after admission unless a thorough admission progress note is written in the chart at the time of admission. If a thorough admission progress note is written, the history and physical examination can be dictated at a later date.

Based on interview, record review and policy and procedure review the critical access hospital (CAH) failed to ensure the medical record contained an informed consent for 1 of 33 records reviewed (patient #24), History and Physicals (H&P) authenticated by a physician for 3 of 23 records reviewed (patients #21, 25, and 29), Discharge Summaries authenticated by a physician for 4 of 23 records reviewed (patients #21, 22, 25 and 29) and a physician signature for 3 of 23 records reviewed (patients # 23, 28 and 30). The facility failed to ensure the H&P exams were within the 30-day window of the procedure for 2 of 2 surgical patients (patient #31 and 32). This deficient practice has the potential to place all surgical patients at risk for incomplete patient information, which could decrease the quality, and safety of surgical procedures. Failure of the facility to ensure the patient signs an informed consent puts all patients at risk for receiving care against their patient rights and for the wrong diagnosis, treatment or surgery. Failure of the facility to ensure H&P and Discharge Summaries are authenticated and signed by a physician puts all patients at risk for receiving care that is unsafe and inaccurate resulting in harm and poor outcomes.

Findings Include:

- Record review on 6/21/17 revealed medical record for patient # 24 lacked an informed consent.

- Record review on 6/21/17 revealed medical records for patients #21, 25, and 29 failed to reveal documentation of a physician authenticating the H&Ps. The H&P was signed 54 days after discharge for patient #21, 90 days after discharge for patient #25, and 47 days after discharge for patient #29.

- Record review on 6/21/17 revealed medical records for patients #21, 22, 25 and 29 failed to reveal documentation of a physician authenticating the Discharge Summaries. The discharge summary was signed 54 days after discharge for patient #21, 42 days after discharge for patient # 22, 90 days after discharge for patient # 25, and 47 days after discharge for patient #29.

- Record review on 6/21/17 revealed medical records for patients # 23, 28 and 30 failed to reveal documentation of a physician signature for the Discharge Summaries.

Interview on 6/21/17 at 8:35 AM, Medical Record Director Staff O verified the missing informed consent, and signature for the H&Ps and Discharge Summaries. Staff O stated they need to have a better system in place.

- Policy and Procedure review on 6/21/17 revealed policy "Specific Items To Check" stated ...the appropriate consent form should be present, signed, and witnessed ...all entries made by the provider in the record shall be signed, dated and timed. Entries written by a Mid-level provider shall be counter-signed, dated and timed by the attending physician.

- Medical record review on 6/21/17 revealed patient #31 was admitted on 11/7/2016 for a colonoscopy procedure (using a camera to visualize the digestive tract) and was discharged following the procedure on 11/7/2016. Medical Record review revealed the H&P was completed on 7/29/2016, 101 days prior to the procedure, exceeding the 30-day window.

- Medical record review on 6/21/17 revealed patient # 32 patient was admitted on 3/14/2016 for an epidural procedure (a spinal injection) and was discharged after the procedure on 3/14/2016. Medical Record review revealed the H&P was completed on 1/18/2016, 56 days prior to the procedure, exceeding the 30-day window.

Interview on 6/21/17 at 3:00 PM, Medical Record Director Staff O confirmed the dates of the H&P being out of the 30-day range.

- Policy and Procedure review on 6/21/17 revealed policy "Transcription" stated ...History and Physical: Shall be on the chart within 48 hours after admission unless a thorough admission progress note is written in the chart at the time of admission. If a thorough admission progress note is written, the history and physical examination can be dictated at a later date.

Based on interview, record review and policy and procedure review the critical access hospital (CAH) failed to ensure the History and Physicals (H&P) for 3 of 23 patients contained a physician signature (patients # 13, 23 and 28). Failure of the facility to ensure a physician signature on the patients H&P puts all patients at risk for receiving care, treatments and medications causing allergies, adverse reactions, illness, harm and poor outcomes.

Findings include:

- Record review on 6/21/17 revealed physician signatures lacking on patient H&Ps (patients # 13, 23 and 28).

Interview on 6/21/17 at 8:35 AM, Medical Records Director Staff O verified the lacking physician signature on the H&P for patients # 13, 23 and 28.

- Policy and Procedure review on 6/21/17 revealed policy "Specific Items to Check" stated ...all entries made by the provider in the record shall be signed, dated and timed.

Based on interview, record review and policy and procedure review the critical access hospital (CAH) failed to ensure physicians' orders in the medical record are timed, dated, and authenticated for 3 of 30 medical records reviewed (patients #23, 28 and 30). Failure to authenticate medical records puts all patients at risk for receiving care based on inaccurate medical information and causing unsafe and harmful outcomes.

Findings include:

- Medical record review on 6/21/17 revealed physicians' orders throughout the patients stay failed to be authenticated for patients #23, 28, and 30.

Interview on 6/21/17 at 8:35 AM, Medical Record Director Staff O verified physicians' orders failed to be authenticated in the medical record of patients #23, 28 and 30.

- Policy and Procedure review on 6/21/17 revealed policy "Specific Items to Check" stated ...all entries made by the provider in the record shall be signed, dated and timed. Entries written by a Mid-level provider shall be counter-signed, dated and timed by the attending physician.

Based on interview and policy and procedure review the critical access hospital (CAH) failed to ensure nosocomial infections (infections originating during hospitalization) and medication therapy are evaluated. Failure of the facility to ensure nosocomial infections and medication therapy is evaluated puts all staff and patients at risk for acquiring infections because of their hospital stay from all sources of bacteria to include those that are resistant to certain antibiotics resulting in communicable illness and disease.

Findings include:

Interview on 6/20/17 at 10:00 AM, Infection Officer Staff H stated the facility is not currently tracking or evaluating the outcomes for nosocomial infections and medication therapy. The facility failed to have any Quality committee meeting minutes discussing current issues, concerns and projects like these.

Interview on 6/20/17 at 1:07 PM, Quality Coordinator Staff K verified the Infection Control Officer failed to report nosocomial infections and medication therapy to the Quality Committee.

- Policy and Procedure review on 6/20/17 revealed policy "Infection Control" stated ...the objectives of our infection control policies and procedures are to: prevent and control the spread of communicable/contagious diseases; maintain a sanitary environment for personnel, residents, visitors, and the general public ...infections acquired in the CAH/LTCU (Long Term Care Unit) or brought into the CAH/LTCU from the community are potential hazards for all persons having contact with the CAH/LTCU, therefore, effective measures have been developed in preventing, identifying and controlling such infections in this facility.

- Policy and Procedure review on 6/21/17 revealed policy "Multi-Disciplinary: Quality Assurance Plan" stated ...all departments/services will submit monthly electronic/written reports to the Quality Assurance Coordinator ...Medical Staff and Medical Executive Committee ongoing Quality Assurance and Quality Improvement activities will include but not limited to: ...Infection Control.

Based on document review and interview the Critical Access Hospital (CAH) failed to provide for the social services needs for three of six swing bed sampled records (Patient #'s 14, 15, and 16). This deficient practice has the potential to cause patients to be unprepared discharge from the hospital.

Findings include:

- Patient # 14's medical record reviewed on 6/21/2017 revealed the patient was admitted to Swing Bed on 6/17/2016 and discharged on 6/27/2016. The medical record lacked evidence social services were provided during the admission.

- Patient # 15's medical record reviewed on 6/21/2017 revealed the patient was admitted to Swing Bed on 8/2/2016 and discharged on 8/5/2016. The medical record lacked evidence social services were provided during the admission.

- Patient # 16's medical record reviewed on 6/21/2017 revealed the patient was admitted to Swing Bed on 6/17/2016 and discharged on 6/27/2016. The medical record lacked evidence social services were provided during the admission.

Medical Records Staff O interviewed on 6/21/2017 at 10:30 AM confirmed they were unable to find Social Service documentation in Patient # 14, 15, and 16's medical record.

Social Service Designee Staff R interviewed on 6/21/2017 at 4:19 PM revealed they provide services including discharge planning to all Swing Bed patients, but since the computer system has changed they do not know where to document their provided services.

-Policy titled "Social Services and Skilled Swing Bed" reviewed on 6/21/2017 at 8:00 PM directed " ...It is important that Social Service functions to meet the medically-related and discharge planning needs for Swing Bed patients existing to allow them to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. These services will be provided by the Social Service Designee ..."