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Based on observations, interview, and review of the Critical Access Hospital's (CAH) policy and procedure, the CAH failed to ensure expired supplies were removed from patient care areas in 1 of 1 Emergency Departments (ED).

The findings are :

Observations on 10/21/2019 at 12:24 PM in the CAH's Emergency Department (ED) revealed an expired Pediatric/Infant Lumbar Puncture tray in Examination room one dated 2/28/2019. The ED Director verified the findings on 10/21/2019 at 12:28 PM stating, "Purchasing should pull them once they expire."

CAH's Policy and Procedures, titled, "Expiration Dates", reads, "All employees are responsible for checking expiration dates monthly." The policy further states, "In departments where equipment or supplies are used, check the expiration date. If expired, return to Surgery for sterilization, reorder, or take to Central Supply for exchange."

Based on observations, interviews, and review of the Critical Access Hospital's (CAH) policies and procedures, the CAH failed to ensure documentation for safety for patient care equipment (blanket warmer) used in the CAH's Emergency Department and Operating Room

The findings are:

On 10/21/19 at 12:38 PM, observations during a tour of the Emergency Department revealed a blanket warmer located in the clean utility room had no inspection maintenance sticker verifying the blanket warmer was inspected. The finding was verified by the Emergency Department Manager on 10/21/19 at 12:45 PM. The finding was verified by the Manager on 10/21/19 at 12:55 PM who stated, "The Biomedical company came in to check the one in surgery, but said he couldn't find this one."

CAH policy and procedure, titled, "Medical Equipment Management", reads, "Biomedical inspections will be performed on a 12 month cycle. The inspection sticker states the time the unit was inspected. On the next cycle the unit will be inspected within one year limit. If the unit is found without a sticker within one year, there will be a yellow sticker placed on it. It will then have three months to be inspected. If not will then be removed from service until inspected....".

Based on observations, interview, and review of the Critical Access Hospital's (CAH)policy and procedure, the (CAH) failed to separate storage of cleaning supplies and patient care supplies under six (6) of 6 sinks observed in the Emergency Department Laboratory.

The findings are:

Observations on 10/22/2019 at 11:07 AM revealed two sinks in the Laboratory area with multiple items stored underneath. Observations revealed Sink 1 had a lab tray filled with patient care items stored next to various cleaning supplies. Observations of Sink 2 revealed cleaning supplies, multiple patient basins, and one purple water bottle with a small amount of clear liquid that was not labeled. On 10/22/2019 at 11:10 AM, the Laboratory Director verified that no patient care items should be under sinks and stated, "The lab techs (technicians) like to use certain lab trays, but they don't always put them(lab trays) in the correct place."

CAH policy, titled, "Safety Management", reads, "Clean and dirty equipment / supplies are stored separately," and "Under sink storage for non-sterile, NON-patient care items only."

Based on closed patient record reviews, staff interviews, and review of the Critical Access Hospital's (CAH) policy, the CAH failed to provide restraint free environment for 1 of 20 patient charts reviewed. (Patient #4)

The findings are:

On 10/22/2019 at 1:30 PM, review of the closed record for Patient #4 for restraints revealed a nurse progress note dated 4/15/19 at 22:45 PM that reads, "..... told pt(patient) that I pulled up all 4 side rails and put an alarm on bed for safety reasons and that he was to call for assist to go to br(bath room) and pointed out 3 locations for call light." In an interview on 10/22/2019 at 8:35 AM, the Chief Nursing Officer stated, "We do not use restraints at this facility." On 10/22/2019 at 10:00 PM, a telephone interview with Registered Nurse(RN #9) who recorded the above nurse progress note revealed RN 9 verified that RN 9 recorded the progress note and implemented the use of the bed's 4 side rails on 4/15/19 for Patient 4. On 10/22/2019 at 8:35 AM, RN 9 reported that at the time of the incident, he/she did not know the CAH's policy for the use of 4 side rails, and stated, "I do now. May use 3 side rails but not 4."

CAH policy and procedure, titled, "Side Rail Use", reads, "All four (4) rails will be considered a restraint, even when the patient or family requests them, when not used according to above. They are to be used when: patient sedated, patient comatose, any patient with bed in high position, post-operative patient, patient being transported, critically ill patient, and patients under the age of eighteen months."

Based on observations, interviews, and review of the Critical Access Hospital's (CAH) policies and procedures, the facility failed ensure endoscopes were stored in a sanitary environment in 1 of 1 decontanination room and failed to perform hand hygiene in the provision of patient care for 2 of 2 Radiology Technicians (RT #1 and RT #2), and failed to ensure all suction devices in the emergency department are kept in unopened packing until patient use

The findings are:

On 10/23/19 at 9:50 AM, direct observation in the CAH's decontamination room revealed an intravenous pole with an endoscope hanging over the top of the pole, partly covered with a towel, and a towel was on the floor wrapped around the bottom of the pole. On 10/23/19 at 9:55 AM, Operating Technician 1 verified the finding and stated, "We've told them we need a cabinet."

CAH's policy and procedure, titled, "Endoscopes", reads, "....20. Hang endoscopes in a vertical position to facilitate drying. 21. Store endoscopes in a manner that will protect them from damage or contamination....".







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On 10/21/2019 at 12:34 PM, observations in the Emergency Department (ED) Examination Room 2 revealed a Yankeur suction device connected to tubing with the packaging open. At 12:34 PM on 10/21/2019, the ED Director stated, "No, that is not suppose to be opened. They had an emergency case coming. They probably opened it for that."

Observations on 10/22/2019 at 10:00 AM in the Emergency Department Triage Room revealed Radiology Technician (RT) 1 and RT 2 entered the Triage Room to transport the patient to Radiology. Neither technician was observed performing hand hygiene prior to entering and after exiting the Triage Room with the patient. Observations showed RT 2 transported the patient back to the Triage Room from Radiology wearing gloves. After assisting the patient to the bed from a wheelchair, observations showed RT 2 removed the soiled gloves, and exited the Triage Room without performing hand hygiene. Then observations revealed RT 2 went to a portable computer located at the nurse station and entered information. On 10/22/2019 at 10:24 AM, RT 2 stated, "I should have used hand hygiene after I removed my gloves."

CAH policy and procedure, titled, "Hand Hygiene", reads, "All healthcare workers are responsible for adherence to hand hygiene practices recommended by CDC, as stated in this policy." The policy also reads, "The wearing of gloves is not a substitute for hand washing; hands should be washed before donning gloves and always after their removal."

CAH policy, titled,"Safety Management", reads, "Clean and sterile supplies have seals intact."

Based on observations, interview, and review of the facility's policies and procedures, the hospital failed to ensure that foods were stored in a safe and secure manner and that cold temperatures were maintained at 41 degrees Fahrenheit (F) or below.

The findings are:

Observations in the walk - in freezer and refrigerators on 10/21/19 from 1:20 PM until 2:05 PM revealed multiple items without labels and multiple items without dates or secure wrapping. Items from the freezer which were opened but not dated included 2 bags of frozen corn on the cob, 1 bag of frozen okra, 1 box of frozen beef patties, 1 box of frozen pork chops, 1 bag or frozen rutabagas, 1 pitcher of pre mixed smoothies, and 1 package of ground beef. Items in the refrigerators which were not dated included 5 bags of minced pork, 1 pitcher of lemonade, 1 5 pound tub of barbeque sauce, 1 container of Italian dressing, 1 package of diced ham, and 1 package of Canadian bacon. Items from the freezer and refrigerator which were open, not securely wrapped, and undated, included a box of vegetable egg rolls, a box of frozen chicken, a box of frozen sausage, a package of cheese, a package of lettuce, a container of pasta salad, 7 pieces of layer cake, macaroni salad, cut tomatoes, mushrooms, chopped bell peppers, chopped onions, minced ham, orange slices, sliced pickles, sliced cucumbers, slice pears, sliced jalapeno, sliced banana peppers, sliced beets, broccoli, and 4 assorted salad dressings. The hospital policy for food storage was reviewed on 10/21/19 at 2:18 PM, and revealed all opened foods should be tightly covered and all foods should be labeled and dated. On 10/21/19 at 2:21 PM, the Registered Dietician confirmed the findings.

The hospital's salad bar temperatures were checked on 10/22/19 at 11:00 AM. Items observed on the salad bar revealed lettuce hard boiled eggs (61 degrees F), shredded cheese (61 degrees F), French dressing (48 degrees), Italian dressing (60 degrees), thousand island dressing (50 degrees), honey mustard dressing (50 degrees), and a second bottle of French dressing (60 degrees). Review of the hospital's food policy revealed all cold foods should be held at a temperature of 41 degrees F or below. On 10/22/19 at 11:32 AM, the Registered Dietician confirmed the foods on the salad bar all had temperatures over 41 degrees F and cold foods should be held at temperatures of 41 degrees F or below.

Based on record reviews, interviews, and the policy provided by the facility entitled "Surgical Practice", the facility failed to ensure one (1) of one (1) open surgical patient's record, and two (2) of five (5) closed surgical patient's records reviewed for appropriate documentation had a comprehensive history and physical documented in their chart thirty days prior to their procedure for open patient 1 and closed patients 2 and 5.

The findings are:

On 10/23/19 at 10:30 AM, the review of open surgical patient 1 chart revealed the patient underwent surgery on 10/23/19. The updated History and Physical (H/P) is dated 10/23/19. The comprehensive H/P is dated 8/21/19.

The findings were verified by the Director of Nursing (DON) on 10/23/19 at 10:35 AM. He/she stated "The patient's procedure might have been canceled and rescheduled.".

On 10/23/19 at 1:00 PM, the review of closed surgical patient 2 revealed the patient underwent surgery on 7/31/19. The updated History and Physical (H/P) is dated 7/31/19. The comprehensive H/P is dated 6/23/19.

On 10/23/19 at 3:00 PM, the review of closed surgical patient 5 revealed the patient underwent surgery on 8/30/19. The updated History and Physical (H/P) is dated 8/30/19. The comprehensive H/P is dated 8/30/19. The comprehensive H/P is incomplete as all systems are not addressed on the form. The following systems missing are: Social History; Family History; Past Medical History.

The findings were verified by the DON on 10/23/19 at 4:00 PM.

The facility's policy and procedure titled "Surgical Practice" reads "....A history and physical should be completed and placed on the patient's chart prior to surgery by the surgeon. If the patient has had a history and physical in less than 30 days prior to the surgery, this history and physical can be used with an updated note placed on the chart in the progress note....".

Based on review of the hospital's Emergency Preparedness Program (EPP) and interview, the Critical Access Hospital(CAH) failed to have documentation that the CAH developed and implemented policies and procedures for the use of volunteers in an emergency situation or other emergency staffing strategies to address surge needs during an emergency.

The findings are:

On 10/23/19 at 3:00 PM, review of the CAH's Emergency Preparedness Program revealed there was no documentation of policies and procedures to address the use of volunteers and/or other staffing strategies in the CAH's EPP. On 10/23/19 at 4:00 PM, the Facility Manager stated, "No, we don't have that."

Based on review of the Critical Access Hospital's (CAH) Emergency Preparedness Program and interview, the CAH failed to show documentation that the CAH developed and implemented policies and procedures for the role of the CAH under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

The findings are:

On On 10/23/19 at 3:00 PM, review of the CAH's Emergency Preparedness Program revealed there was no documentation of policies and procedures for the role of the CAH under a waiver declared by the Secretary, in accordance with section 1135 of the Act. On 10/23/19 at 4:00 PM, the Manager stated, "No, we don't have that. I'm not sure what that is."

Based on review of the Critical Access Hospital's (CAH) Emergency Preparedness Program(EPP) and interview, the CAH failed to include documentation for contact information for the staff, entities providing services under arrangement, physicians, and volunteers in its EPP.

The findings are:

On 10/23/19 at 3:00 PM, review of the CAH's EPP revealed there was no documentation of contact information for the staff, entities providing services under arrangement, physicians, and volunteers in the emergency plan. On 10/23/19 at 4:00 PM, the Manager stated, "No, I don't have that in here."

Based on review of the Critical Access Hospital's (CAH) Emergency Preparedness Program (EPP), the CAH failed to show documentation of contact information for Federal, State, tribal, regional, or local emergency preparedness staff; State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman in its EPP.

The findings are:

On On 10/23/19 at 3:00 PM, review of the CAH's EPP revealed there was no documentation of contact information for the Federal, State, tribal, regional, or local emergency preparedness staff; State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman in the CAH's EPP. On 10/23/19 t 4:00 PM, the Manager stated, "I can get that."

Based on review of the Critical Access Hospital's (CAH) Emergency Preparedness Program (EPP), the CAH failed to provide documentation of the CAH's training for individuals providing services under arrangement.

The findings are:

On 10/23/19 at 3:00 PM, review of the CAH's EPP revealed there was documentation of training documented for the guards who provided services for the hospitalized inmates. On 10/24/19 at 10:00 AM, the Director of Nursing stated, "There are usually at least six or so guards here. They sign in at their facility and then come here."