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Based on observation, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure that expired equipment and supplies commonly used in life-saving procedures and for use in emergencies were removed to prevent potential use. The failure to remove expired equipment/supplies could result in ineffective treatment or complications and places all patients at risk for harm.

Findings Include:

Review of hospital policy titled, "POLICY NUMER:320 Monthly Outdate Checklist," dated 09/14/2017, showed, "PURPOSE: Prevent outdated supplies and medication used in patient care area...All medication and supplies in the designated areas should be checked prior to the last day of the month..."

An observation on 09/02/25 at 9:00 AM of the Pediatric Resuscitation System showed the following expired supplies:
1. Endotracheal Tubes (ET)
a. One 4.0 ET expired 11/28/2024
b. One 4.5 ET expired 07/28/2024
c. One 5.0 ET expired 07/28/2025
d. One 5.5 ET expired 12/19/2024

2. Nasogastric Tubes (NG):
a. Two 8 French NG expired 02/28/2025

3. IV Catheters:
a. Two 20-gauge expired 11/14/2024
b. One 22-gauge expired 12/08/2024

An observation of Room 2 in the Emergency Department (ED) on 09/02/25 at 10:54 AM showed one 18 French indwelling catheter that expired on 11/30/24.

During an interview on 09/02/25 at 9:19 AM, Staff C, Director of Nursing, confirmed that the Pediatric Resuscitation System contained expired supplies of endotracheal tubes, nasogastric tubes and IV catheters.

Based on observation, policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure medications commonly used in life-saving procedures and for use in emergencies were secured. Failure to secure medications used to treat potentially life-threatening emergencies places all patients at risk for harm.

Findings Include:

Review of hospital policy titled, "POLICY NUMBER: 213 [Crash Cart]," dated 06/14/18, showed, " ...Each Crash Cart will be inspected and tested at least daily to ensure the integrity of its contents and validate the defibrillator is in working order ...Once stocked again with supplies a red lock on the care and return to the Emergency Room ..."

Review of Kansas Administrative Regulations Agency 28 Department of Health and Environment Article 34, "Hospitals 28-34-10a. Pharmacy services. (c) Pharmacy facilities." current through Register 06/26/25, showed, "Each hospital that maintains a pharmacy on its premises shall provide adequate equipment, supplies and facilities for the storage, safeguarding, preparation and dispensing of drugs. Drugs and biologicals must be kept in locked storage areas ..."

An observation on 09/02/25 at 9:00 AM, showed the crash cart was not secured with a lock and was accessible from a public area. An open syringe with 5% Dextrose 100ml [milliliters] and an IV [Intravenous] 18-gauge needle was laying on top of the crash cart.

An observation of Room 1 in the Emergency Department (ED) on 09/02/25 at 9:19 AM, showed an unlocked and unsecured cabinet with two bags of Lactated ringers (an IV solution) 1000 ml [milliliters] and four bags of Normal Saline (an IV solution) 1000 ml.

An observation of Room 2 in the ED on 09/02/25 at 10:55 AM, showed an unlocked and unsecured cabinet with two bags Lactated ringers 1000 ml and four bags of Normal Saline 1000 ml.

During an interview on 09/02/25 at 9:19 AM, Staff C, Director of Nursing, confirmed that the crash cart in the ED was unlocked and stated that he/she was unaware that IV fluids required secure storage.

Based on policy review and interview, the Critical Access Hospital (CAH) failed to ensure that hospital policies and procedures were reviewed at least biennially and as necessary by a group of professional personnel. This deficient practice places any patient or employee at risk for non-compliance related to failure to comply with new laws and regulations. This can result in inconsistent and outdated practices, causing poor patient outcomes and further safety concerns.

Findings Include:

Review of hospital policy titled, "Subject: Policy & Procedure Approval Policy," last reviewed on 11/01/21, showed that policy reviews and revisions must be completed once every year. A collaboration between the department manager, a mid-level provider, medical director and chief executive office must occur to institute or revise any policy.

Review of hospital policy titled, "Subject: Policy and Procedure Manual Review," revised 06/19/23, showed, " ...Nursing Policy and Procedure Manual will be reviewed and updated/revised as necessary, but at least once yearly ..."

Review of the Hospital's policies and procedure that were provided by the CAH showed the following policies were not reviewed and/or revised or signed by a group of professional personnel at least biennially:

"ACLS Certification" last revised and signed on 06/29/22.

"Blood Product Administration" not dated or signed by group of professional personnel and no reviews/revisions.

"POLICY NUMBER:223 [Code Blue]" date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions.

"Patient Complaint and Grievance Policy" effective date 05/01/23, no reviews/revisions.

"Medication Administration" last revised date 04/12/22.

"POLICY NUMBER: 810 [Medication Variances]" date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions.

"Patient Leaving Against Medical Advice (AMA) / Elopement" not signed by group of professional personnel.

"POLICY NUMBER: 213 [Crash Cart]" date issued 06/14/18 not signed by group of professional personnel and no reviews/revisions.

"CONTROLLED DRUG MANAGEMENT" approved date 12/31/18, no reviews/revisions.

"POLICY NUMBER: 806 [Inventory Control]" date issued 09/14/17 no reviews/revisions.

"POLICY NUMBER: 320 [Monthly Outdate Checklist]" date issued 09/14/17 no reviews/revisions.

"POLICY NUMBER: 1023 [Discharge Planning]" date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions.

"POLICY NUMBER: 1027 [Discharge Planning Process]" date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions.

"POLICY NUMBER: 1028 [Elements of Discharge Planning]" date initiated 04/10/21 with no signature by group of professional personnel and no reviews/revisions.

"POLICY NUMBER: 216 [ER Discharge Instructions]" date initiated 09/14/17 with no signature by group of professional personnel and no reviews/revisions.

"Policy and Procedure Manual Review" last revised 06/19/23.

"Policy & Procedure Approval Policy" last revised 11/22/21.

During an interview on 09/03/25 at 1:37 PM, Staff C, Director of Nursing, stated that the policies are a "mess".

During an interview on 09/04/25 at 9:40 AM, Staff A, Chief Executive Officer, stated that the policy titled, "Policy & Procedure Approval Policy," is not current and that policies have not been up to date "like they should be."

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure a registered nurse maintained current Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications. This deficient practice has the potential to affect all patients by placing them at risk for delayed or inappropriate emergency care provided by non-qualified personnel.

Findings Include:

Review of hospital policy titled, "ACLS Certification," dated 03/10/22, showed, " ...All licensed nurses employed by [The Hospital] should have current ACLS certification ...Employees allowing their ACLS certification to lapse will have 30 days to get certification current. Failure to update certification within 30 days, without prior arrangements with the Director of Nursing, will result in suspension without pay until the employee becomes current with ACLS certification ...A copy of the card should be placed in employee's personnel file ..."

Review of hospital policy titled, "Code Blue, (an alert indicating a cardiac/respiratory arrest)" dated 09/14/17, showed, " ...All nursing staff will be certified in CPR [Cardiopulmonary Resuscitation] ..."

Review of Staff F, Registered Nurse (RN) personnel record on 09/04/25 failed to show documented evidence of BLS and ACLS certification on file.

Review of Staff K, RN, personnel record on 09/04/25 showed that BLS and ACLS certification expired on 12/2024.

During an interview on 09/04/25 at 11:10 AM, Staff C, Director of Nursing confirmed that Staff K, RN, BLS and ACLS expired in December 2024. Staff C stated that she did not track BLS and ACLS certifications for expiration dates.

During an interview on 09/04/25 at 12:41 PM, Staff J, Doctor of Medicine (MD), Medical Director, stated that registered nurses working in the emergency department are expected to hold current BLS and ACLS certifications and maintain those certifications.

Based on document review, policy review, and interview, the Critical Access Hospital (CAH) failed to have policies and procedures for patient visitation. This deficient practice has the potential to affect all patients and their visitors by not ensuring consistent visitation practices and protection of visitation rights.

Findings Include:

Review of a hospital document titled, "CONSTITUTIONS AND BYLAWS RULES AND REGULATIONS," last updated 08/01/25, showed that members of the Medical Staff, and the Governing Body must agree at the time of appointment to be governed by Statutes of Kansas and Federal Law, where applicable.

During an interview on 09/03/25 at 10:01 AM, Staff C, Director of Nursing, stated that there is no specific policy on patient visitation rights.

During an interview on 09/03/25 at 10:01 AM, Staff G, Registered Nurse, stated that visitation is allowed until 8:00 PM. Visitors need provider approval to stay later than 8:00 PM since staying later can disturb patients.

The CAH failed to provide a written visitation policy and procedure upon request.