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Based on observation, record review, and staff interview, the facility failed to ensure the physical plant and environment are incorporated into the Critical Access Hospital's (CAH) Quality Assurance (QA) program and are in compliance with the QA requirements. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

1. In reference to Federal Life Safety Code citation K291 the facility failed to provide emergency lighting in accordance with National Fire Protection Association (NFPA) 101.

2. In reference to Federal Life Safety Code citation K321 the facility failed to protect hazardous areas in accordance with NFPA 101.

3. In reference to Federal Life Safety Code citation K324 the facility failed to provide kitchen range-hood inspections in accordance with NFPA 101 and 96.

4. In reference to Federal Life Safety Code citation K345 the facility failed to provide evidence of maintaining the Fire Alarm System in accordance with NFPA 101 and 72.

5. In reference to Federal Life Safety Code citation K346 the facility failed to provide a "Fire Alarm - Out of Service" policy and procedure in accordance with NFPA 99.

6. In reference to Federal Life Safety Code citation K347 the facility failed to provide smoke detection systems in spaces open to the corridors in accordance with NFPA 101.

7. In reference to Federal Life Safety Code citation K351 the facility failed to provide a sprinkler system installed in accordance with NFPA 13.

8. In reference to Federal Life Safety Code citation K353 the facility failed to maintain the sprinkler system in accordance with NFPA 25.

10. In reference to Federal Life Safety Code citation K363 the facility failed to provide corridor doors capable of resisting the passage of smoke in accordance with NFPA 101.

11. In reference to Federal Life Safety Code citation K511 the facility failed to provide electrical wiring in accordance with NFPA 70.

12. In reference to Federal Life Safety Code citation K712 the facility failed to conduct fire drills in accordance with NFPA 101.

13. In reference to Federal Life Safety Code citation K914 the facility failed to maintain the electrical system maintenance and testing requirements in accordance with NFPA 99.

14. In reference to Federal Life Safety Code citation K918 the facility failed to maintain the emergency generators in accordance with NFPA 110.

15. In reference to Federal Life Safety Code citation K921 the facility failed to maintain testing and maintenance requirements for Patient Care Related equipment in accordance with NFPA 99.

16. In reference to Federal Life Safety Code citation K926 the facility failed to provide personnel concerned with the application, maintenance, and handling of oxygen cylinders training on the risks in accordance NFPA 99.

17. The aforementioned deficiencies were discussed with the Administrator and the Maintenance Technician at the time of exit, whom agreed these deficiencies needed corrected.

Based on document review and staff interviews, it was determined the facility failed to follow their own policy to ensure crash cart checks were performed every shift. This deficient practice was noted in two (2) of two crash carts, at the Emergency Department (ED)and the Acute/Extended Care Unit, in order to ensure properly functioning emergency equipment. This failure has the potential to adversely affect all patients.

Findings include:

1) Review of the policy titled " Crash Cart Integrity", revised 3/06, revealed in part: The Emergency Room (ER) and Acute/Extended Care Unit crash carts are checked for integrity every shift by the ER Registered Nurse (RN) and the Acute/Extended Care Unit Charge RN.

2) Review of the crash cart checklist at the ED on 12/18/17 at approximately 1:00 p.m. revealed there was no documentation of crash cart equipment checks every shift on a daily basis.

3) Review of the crash cart checklist at the Acute/Extended Care Unit on 12/18/17 at 12:45 p.m. revealed there was no documentation of crash cart equipment checks every shift on a daily basis.

4) An interview was conducted with the Quality Assurance Director on 12/18/17 at 2:30 p.m., she agreed with the above findings.

Based on document review and staff interview it was determined the facility failed to maintain a clinical record in one (1) of twenty (20) clinical records reviewed (patient #7). This failure has the potential to negatively impact all patients who are provided services in the facility.

Findings include:

1. A list of open and closed clinical records were requested for review. Upon request for the clinical record of patient #7 the facility was unable to produce either a paper or electronic record.

2. In an interview with the Quality Assurance Director at 12:30 p.m. on 12/28/17, she concurred with the above finding.

Based on document review and staff interview it was determined the facility failed to maintain a clinical record in one (1) of twenty (20) clinical records reviewed (patient #7). This failure has the potential to negatively impact all patients who are provided services in the facility.

Findings include:

1. A list of open and closed clinical records was requested for review. Upon request for the clinical record of patient #7 the facility was unable to produce either a paper or electronic record.

2. In an interview with the Quality Assurance Director at 12:30 p.m. on 12/28/17, she concurred with the above finding.

Based on record review and staff interview it was determined the facility failed to maintain medical records that include discharge summaries, timed documentation and dated signatures of physicians providing care for twelve (12) of twenty (20) medical records reviewed (patients #1, 2, 3, 5, 12, 13, 14, 15, 16, 17, 18 and 19). This failure results in an incomplete record of healthcare which may result in a delay in treatment and/or access to further treatment.

Findings include:

1) A review of the facility policy titled "Medical Staff Bylaws, Rules and Regulations", reviewed and approved 9/19/17, revealed in part: All entries in the record shall be legible, dated and authenticated. Discharge Summaries not documented within fifteen days of discharge will be considered delinquent. A physician's/dentist's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, dated and signed by the practitioner.

2) A review of the medical record for patient #1, date of service 9/14/17, revealed the patient was brought to the Emergency Department (ED) after being found face down inside her home, patient was deceased. Documentation of death by the physician was not timed.

3) A review of the medical record for patient #2, date of service 9/29/17, revealed the patient arrived at the ED unresponsive. Patient was on Hospice care and put on comfort measures only. On 10/1/17, the physician was notified by the Registered Nurse of the patient's death. No note of death by the physician was in the patient's chart.

4) A review of the medical record for patient #3, date of service 9/25/17, revealed the patient was brought to the ED by the Emergency Medical Service. Upon arrival at the ED, cardiopulmonary resuscitation was stopped, no note of death or pronouncement by the physician was in the chart.

5) A review of the medical record for patient #5, discharge date 12/19/17, revealed physician orders (verbal orders) not signed by the physician.

6) A review of the medical record for patient #12, discharge date 6/5/17, revealed a History and Physical (H&P) which was dictated and transcribed on 6/2/17. No physician signature or date was on the H&P.

7) A review of the medical record for patient #13, discharge date 6/11/17, revealed physician orders not timed.

8) A review of the medical record for patient #14, discharge date 6/17/17, revealed physician orders not dated and timed and physician notes not dated.

9) A review of the medical record for patient #15, discharge date 7/13/17, revealed an H&P with the signature of the physician not dated and physicians' orders not signed, dated or timed.

10) A review of the medical record for patient #16, discharge date 7/15/17, revealed an H&P with the signature of the physician but not dated.

11) A review of the medical record for patient #17, discharge date 6/21/17, revealed an H&P transcribed 6/9/17 with the signature of the physician but not dated. No discharge summary was noted in the chart.

12) A review of the medical record for patient #18, discharge date 7/21/17, revealed a discharge summary transcribed 7/21/17 with the physician signature but no date.

13) A review of the medical record for patient #19, discharge date 11/7/17, revealed progress notes for 10/28/17 and 11/5/17 not signed or dated by the physician and progress note for 10/23/17 signed by the physician but not dated. No discharge summary was noted in the chart.

14) A review of the above medical records was conducted by the Quality Assurance Director on 12/20/17, she acknowledged all entries and signatures in the medical records are required to be timed and dated and agreed with the findings.

Based on document review and staff interview it was determined the facility failed to maintain a clinical record in one (1) of twenty (20) clinical records reviewed (patient #7). This failure has the potential to negatively impact all patients who are provided services in the facility.

Findings include:

1. A list of open and closed clinical records were requested for review. Upon request for the clinical record of patient #7 the facility was unable to produce either a paper or electronic record.

2. In an interview with the Quality Assurance Director at 12:30 p.m. on 12/28/17, she concurred with the above finding.