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Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0923, K0321, K0353, K0761, K0901, and K0918 for additional information.

Based on observation, interview and document review, the facility failed to ensure the acting dietary manager had appropriate education to oversee food preparation and service(s) in 1 of 1 main kitchen. This had potential to affect all patients, visitors and staff who consumed food from the kitchen.

Findings include:

During a tour of the kitchen on 5/21/24 at 10:15 a.m., eggs were present in the dry storage room and were not labeled as being pasteurized. The dietary manager (DM)-A indicated they were pasteurized and the facility cooked eggs to order for patients, staff and visitors including sunny side up and over easy eggs (undercooked eggs). Upon further examination of the eggs, DM-B stated the eggs were not pasteurized and confirmed the facility should have used pasteurized eggs when serving undercooked eggs.

During an interview on 5/22/24 at 10:50 a.m., DM-A indicated she began her duties in October 2023 (was unsure of exact date) however, had not completed any safe food handling education yet. DM-A indicated she had some training in safe food handling in the past however, her previous experience was in restaurants.

During a follow-up interview on 5/23/24 at 1:20 p.m., DM-A indicated she supervised six staff members at the facility. DM-A stated the facility was short staffed and as a result, she has not had time to start the classes.

During an interview on 5/23/24 at 1:50 p.m., DM-B confirmed DM-A had been enrolled in AAA Food Handler, manager training and examination on 12/1/23, however, had not completed any of the training yet. DM-B confirmed the training was required to manage the facility kitchen and supervise staff members.

A policy and procedure for dietary manager qualifications was requested and none received. A Dietary Site Manager job description included:
- The Dietary Site Manager (DSM) planned, directed and coordinated activities of the dietary department to provide dietetic services to patients, hospital employees and guests.
- The DSM assisted in establishing policies and procedures for the site and supervises all dietary staff, plans menus, inspects work areas and meal service.
-Requirements included Certified Dietary Certificate or willing to obtain certificate within 2 years of employment. Bachelors or advanced degree with major in Food Service Administration preferred however, not required.

Based on observation, interview and document review, the critical access hospital (CAH) failed to maintain the safeguards against potential loss, destruction, or unauthorized use in the CAH medical record storage area.

Findings include:

On 5/22/24 at 1:00 p.m., quality and safety director (QSD) indicated very few medical records were being stored as medical information was being placed into the the patients electronic health record (EHR). QSD stated patient records were being stored in the basement at the fitness center downtown and would speak with the health information management (HIM) for a tour.

During an interview and observation on 5/22/24 at 3:49 p.m., QSD indicated HIM personnel had left for the day and the tour was going to be completed with QSD. Arrival at Anderson Fitness located at 15 East Division Street Elbow Lake, MN 56531 with QSD for clinical record storage tour. Anderson Fitness required access to the main entrance with a key fob. CAH did not have access to the building with the current key fob provided by the HIM department. The basement door was locked and only able to be accessed by a push button code. QSD received the code from HIM department and stated the code would need to be changed after the tour was completed. Entered the basement and walked down the steps into the storage area. Patient records were being stored in white and brown boxes on wooden and metal shelving units. Patient file boxes were dated from 2019, through earlier years. Patient file boxes were labeled with information that stated, "patient records, deceased patient records, patient payments, patient refunds, and additional items". Shelving units were approximately four to six inches from the floor and extended four to six inches from the ceiling. Each shelving unit had boxes stacked three to four high and contained approximately 30-35 boxes stacked. A total of 27 shelving units and four smaller shelving units were counted. The basement felt damp and had a foul wet damp smell. A cord was observed plugged in on the back wall and was laying the length of the basement. A dehumidifier was sitting at the bottom of the basement steps however, was not plugged in and the water reservoir was full. No sprinklers or fire reducers were present. Standing water was observed on the floor in the front part of the basement and extended to the back of the basement. The large puddle of water extended approximately two feet wide by ten feet long and extended under the shelving against the back wall of the basement. A small area on the floor noted to be higher where water was not standing. A puddle of water began again and was approximately one inch deep and extended the width of the walkway and extended under shelving units on both sides. Walked to the right and entered another room with more patient files being stored on shelving that extended the entire length of the room. Turning to the right again, another room was filled with shelving units that contained boxes of patient records. When entering that room, there was a puddle of water that extended through the middle of the room and under the storage shelves in the entire room. QSD indicated HIM staff could not recall the last time any staff had been in the basement. QSD confirmed the current storage area for patient records was concerning and needed to be addressed.

Review of facility policy titled Medical Record Confidentiality, Security and Access Medical Records/HIM last review date 12/31/18, to provide guidelines for the confidentiality, security and access of medical records. Prairie Ridge Hospital & Health Services (PRHHS) assured any patient records containing clinical, social, financial or other data was treated in a confidential manner. Records were reasonably protected from loss and destruction. Deceased medical records were stored at the PRHHS Fitness Center in the basement in a secured area.

Requested for facility agreement with Anderson Fitness as PRHHS no longer owned the fitness center, however one was not provided.

Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient's death was being reviewed.

Findings include:

Review of the facility's patients expired dated 5/21/23 to 2/16/24, revealed nine patient deaths.

Review of the facility's 2023 Tissue & Eye Donation Activity Report and LifeSource referral data dated 12/31/23, the facility contacted the OPO for 10 facility deaths.

During an interview on 5/20/24 at 3:59 p.m., director of nursing (DON) confirmed the above findings and stated she received a quarterly and yearly report from the OPO. The DON stated she reviewed the report and would bring the reports to the quality meetings and annual meetings for review. DON indicated the report was reviewed for 100% calls from the facility to the OPO. DON indicated she had never cross referenced the OPO report with the facility's death report to ensure every death was reported. DON stated there were no QAPI goals associated with OPO at the time of survey.

During document review and interview on 5/22/24 at 1:15 p.m., P12 was pronounced deceased on 7/18/23, while admitted as a swing bed patient. P12's electronic health record (EHR) lacked documentation OPO had been contacted after P12 had been pronounced deceased. Quality and Safety Director (QSD) reviewed P12's record and confirmed the EHR lacked documentation OPO had been contacted. QSD verified the P12's medical record number (MRN) was not included in facility's 2023 Tissue & Eye Donation Activity Report and LifeSource referral data dated 12/31/23. QSD indicated documentation about the OPO was difficult to find and was not always being recorded in the record of death checklist for organ, tissue and eye donation form.

Review of facility policy titled Death in Hospital last reviewed 5/1/24, contact LifeSource within one hour of death. Complete the Record of Death Checklist for Organ, Tissue and Eye Donation form.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure Medicare Beneficiaries were provided the Important Message from Medicare regarding their rights as a patient for 10 of 10 medical records reviewed.

Findings include:

On 5/22/24 at 1:30 p.m., clinical analyst (CA-C) assisted with medical record review of patient's. During the process of medical record review ten patients medical records lacked evidence of an Important Message from Medicare provided to the patients.

On 5/22/24 at 2:45 p.m., CA-C stated the Important Message from Medicare should have been provided to Medicare Beneficiaries, so they were aware of their rights when they admitted to the hospital. CA-C stated the nurses provided the admission packets to the Medicare Beneficiaries.

On 5/22/24 at 4:38 p.m., two facility admission packets were reviewed. The admission packets lacked the Important Message from Medicare.

On 5/22/24 at 4:40 p.m., registered nurse (RN)-A stated the nurses prepared the packets for admission. RN-A stated she just learned the Important Message from Medicare could have been printed out and provided to the patients when they were admitted. RN-A confirmed the Important Message from Medicare had not been added to the admission packets.

A facility policy was requested however, was not provided.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the dental services agreement was current and signed by the dental provider for swing bed patients to have available to them. This had the potential to affect all swing bed patients that were admitted to the hospital.

Findings include:

A Lake Region Healthcare, Corporation and Affiliates Business Associate Agreement was provided on 5/21/24 at 3:47 p.m., from the director of nursing (DON). The agreement was dated 5/21/24, and signed by the DON at 1:16 p.m. The agreement lacked the dental provider signature.

On 5/22/24 at 9:10 a.m., the DON stated the dental provider received the new agreement to sign on 5/21/24. The DON confirmed the agreement had not been signed nor implemented yet.

A policy was requested however, not provided.

Based on a review of available documentation and staff interview, the facility failed to maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 4.2, 8.4.9, 8.4.9.1 and 8.4.9.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 5/22/2024 at 10:20 a.m., it was revealed by a review of available documentation the facility failed to provide documentation of a 36-Month 4-hour generator load bank test.

An interview with the Maintenance Tech (MT)-A verified this deficient finding at the time of discovery.