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Based on observation and interview it was determined that the facility was not able to access appropriate supplies needed for emergency care. Specifically, facility staff were unable to locate an infant blood pressure cuff in a reasonable amount of time.

Findings Include:

While reviewing charts on 1/22/15, at the nurses station, the nurse surveyor observed a 19 month old pediatric patient presenting to the nurses station and needing admission to the Emergency Department (ED). The patient had presented with fever, cold and positive for Respiratory Syncytial Virus and Influenza.

The patients mother is employed at the hospital as their Family Nurse Practitioner. The child was admitted to the hospital and an intravenous line (IV) was started. Prior to starting the IV the registered nurse caring for the patient was trying to find a pediatric blood pressure cuff. She had been unable to and was asking for help from other staff members. They were still unable to find an age appropriate blood pressure (BP) cuff for the patient. They were able to find a child size BP cuff that they contemplated using on the toddler. After approximately 45 minutes the nurse surveyor mentioned to the Director of Nursing (DON) that there was some confusion as to the location of the toddler BP cuff. The DON was able to obtain the BP cuff and provide it for the patient.

An interview with the DON was held on 1/22/14 when she stated that a scavenger hunt, including the infant BP cuff, had just been held with all of the staff (including those involved in the incident) so that they would be aware of where supplies were being stored. The DON indicated that there would be further education.

Based on record review, and interview, it was determined that the governing body did not ensure that the agency physicians and allied personnel had current licenses or were credentialed and appointed to the medical staff as required per regulation and hospital bylaws for 5 of 8 records reviewed. (Physician identifiers: 1, 2, 3, 5, and 8)

Findings include:

The surveyor requested a list of medical staff members and selected a sample of 8 practitioners credentialing files to review.

1. For 4 of 8 credentialing files, there was no evidence of current licensure. Review evidenced that the most current license on file for physicians 1, 2 and 8 expired 1/31/14; Pharmacist 5's most current license on file expired 9/30/13.

2. In an interview with the administrative secretary on 1/21/15, she stated that she could access the physicians' licenses online but agreed that the facility did not have evidence of current licensure when requested.

3. Physician 3's credentialing file contained a delineation of privileges dated 9/5/12 that was signed by physician 3, but had not been signed by the credentialing chairman or the governing board.

4. Physician 8's credentialing file contained a letter dated 12/19/12 indicating that his application for consulting medical staff had been approved, with a note on it that a new credential packet had been sent out but had not been received.

5. Under section 3 "Terms of Appointment" of the hospital's bylaws, rules and regulations, it stated that medical staff appointments would be for a period of two years.

Based on observation and interview it was determined that the facility was unable to show restricted access to concentrated or high risk medications. The hospital was also unable to provide a working call system for the Pharmacist.

Findings Include:

1. On 1/21/15, an interview was held with the Pharmacy Director of the Hospital. During the interview he indicated that there was a call system in place for the pharmacy. If he were to go out of town there is another pharmacist in the area that will cover for him. If he is at home then he is on call or the local pharmacy is able to be contacted if there is a medication not available and he is not reachable. During the interview the pharmacist indicated that if he is at a movie and is paged he will not answer the page until the movie is completed.

If there was a true emergency this would not be adequate coverage as the local pharmacy is at least a 30 minute drive from the hospital and therefore medications would not be available for that length of time.

2. During the same interview on 1/21/15, with the pharmacist, he was questioned about the separation of high risk medications from other medications in the pharmacy. He stated that he had not provided for any separation or restriction of high risk medications.

The nursing staff have access to the pharmacy during off hours so the possibility of an error is higher when the high risk medications are not secured or identified as high risk medications.