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Based on direct observation and staff interview, the hospital failed to ensure temperature control was maintained for all pharmaceuticals. This failed practice had the potential to affect all patients receiving medications at the hospital which required a controlled temperature environment. The facility reported 220 inpatients according to the most recent program evaluation.

Findings:

1. The pharmacy delivered medications to the patient care areas in the hospital by means of a pneumatic tube system which was located in the ceiling, along with the heating and cooling systems throughout the facility.

2. Interview with the Chief Pharmacist (on 12-13-18 at 11:00 A.M) revealed the environmental conditions that the medications were subjected to during transport had never been evaluated for extremes of temperature.

During this same interview, the pharmacist confirmed the environmental conditions of medications stored in the pharmacy, at room temperature had not been monitored. At 2:00 P.M. the head of maintenance confirmed that there was an electronic monitor of the pharmacy area, however, he had never reviewed the data to confirm that the storage conditions in the pharmacy were maintained at optimal temperatures and the electronic system had not been set up to notify them if temperatures were outside the acceptable limits.

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Based on record review and staff interview, the Critical Access Hospital failed to grant surgical privileges according the written procedures governing the medical staff. This failed practice had the potential to affect all patients receiving surgery at the hospital. The facility reported 220 inpatients were served, according to the most recent annual program evaluation.

Findings:

1. A review of the policy labeled 'Credentialing Process - Basis for Granting Privileges' revealed "...will take into account ongoing monitoring of information concerning the individuals professional performance, judgement and clinical and technical skills."

2. A review of the privileges granted to the general surgeon (Physician E) included Thyroidectomy (the removal of the thyroid gland, which is located in the neck. It is located adjacent to numerous other structures and blood vessels. The thyroid gland controls many vital metabolic functions such as heart rate; Parathyroidectomy (the removal of the parathyroid gland located in the neck surrounded by other structures and blood vessels. It also controls many metabolic functions such as calcium levels) and amputation (Amputation is the removal of an arm or a leg, which involves blocking the blood vessels and nerves to the limb and closing the remaining area with skin flaps).

The list of surgical procedures performed by physician E for the time period 2016, 2017 and 2018 failed to include the above specified procedures. Therefore, his clinical and technical skills could not be evaluated as per the policy.

3. An interview conducted with the Chief Executive Officer on 12-12-18 at 4:00 P.M. confirmed the above procedures had not been performed in the hospital within the past 3 years and the privileges granted did not match the actual physician practice.

This STANDARD is not met based on record review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practice increased the probablility that the generator would fail to run during an emergency loss of power, which would affect the emergency sytems in the facility. The facility has the capacity of 18 beds with a census of 3 on the day of survey.

Findings are:

Record review on 12-11-2018 at 2:50pm revealed that there was no documentation that the diesel fuel for the generator was tested for quality.

During an interview on 11-28-2018 at 2:50pm, Maintenance Staff A confirmed the lack of fuel testing.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.