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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on March 15, 2022, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C930.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on March 15, 2022, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 15, 2022.

Based on observation, document review, and interview it was determined that the facility failed to ensure staff followed patient care polices concerning patient safety. This has the potential to affect all patients who receive care. Therefore, the Condition of Participation 42 CFR 485.635 Provision of Services was not met, as evidenced by:


1. The Hospital failed to ensure medical staff members who provided direct patient care had completed r estraint and seclusion education and were competent for the application of restraints and care of a patient in restraints per policy (See C1006)

2. The Hospital failed to ensure patients were monitored and appropriate interventions implemented per the suicidal precautions policy. (See C 1026- A)

3. The Hospital failed to ensure patients were monitored and appropriate interventions implemented per the elopement policy. (See C 1026- B)

4. The Hospital failed to ensure patients were monitored and appropriate interventions implemented per the fall precaution policy. (See C 1026- C)

Based on document review and interview, it was determined for 8 of 8 (MD#1, MD#2, MD#3, MD#4, MD#5, MD#6, MD#7, MD#8) Physicians files, 1 of 1 (PA#1) Physician Assistant and 1 of 1 (NP#1) Nurse Practitioners files reviewed the Hospital failed to ensure medical staff members who provided direct patient care had completed restraint and seclusion education and were competent for the application of restraints and care of a patient in restraints per policy. This has the potential to affect all inpatients and outpatients who require the use of restraints.

Findings include:

1. The policy titled, "Restraints: Use of Physical and/or Chemical" (reviewed by Hospital 05/2021) was reviewed on 3/10/22 at approximately 1:15 PM. The policy noted:
a)"Hospital and medical staff members shall receive education in the following subjects as appropriate to assigned duties preformed under this policy... Hospital staff members who assess patients for restraint or who apply restraint shall receive education in the following topics as appropriate to the patient population served ...."
b) "Restraint education and training is documented and maintained in the educational profile."

2. The Physician and Mid-level provider files were reviewed on 3/9/22 at approximately 2:45 PM. The following Physicians and Mid-Levels provider files lacked documentation of restraint and seclusion training and competency conducted initially upon hire or annually
a) MD#1, Initial Appointment Date (IAD): 9/11/20
b) MD#2, IAD: 8/26/20
c) MD#3, IAD: 10/28/16
d) MD#4, IAD: 3/10/20
e) MD#5, IAD: 7/18/19
f) MD#6, IAD: 12/17/21
g) MD#7, IAD: 2/18/14
h) MD#8, IAD:
i) PA#1, IAD: 3/5/19
j) NP#1, IAD: 12/6/21

3. During an interview on 3/9/22 at approximately 3:00 PM, the Administrative Assistant (E#7) reviewed the Physicians and Mid-Level providers files and verbally agreed restraint and seclusion training had not been conducted and should have been. E#7 stated "We give our Physicians and Mid-Level providers a binder and tell them to read it but we do not track who has or has not completed it."

Based on observation, document review, and interview, it was determined the Hospital failed to ensure outdated supplies in the Physical Therapy Department, were not available for patient use. This has the potential to affect all patients serviced by the Physical Therapy Department. with an average monthly census of 225 patients.

Findings include:

1. On 3/8/2022 at approximately 12:30 PM, an observational tour of the Physical Therapy Department was conducted with the CEO (Chief Executive Officer) E #1. It was observed in treatment room #1 there were 7 packages of reusable and self adhering electrodes which expired on 7/3/2021, available for patient use.

2. On 3/9/2022 at approximately 2:00 PM a request was made for a policy related to expired supplies. The CAH was unable to provide the policy.

3. During an interview on 3/8/2022 at approximately 12:45 PM, E#1 verbally agreed the electrodes were expired and stated the electrodes should not have been available for patient use.

A. Based on document review, observation and interview, it was determined for 6 of 6 (Pt #1, Pt #4, Pt #5, Pt #12 Pt #21, Pt #22) suicidal patients in the Emergency Department (ED) and 1 of 2 (Pt #12) suicidal patient on the Medical Surgical floor records reviewed, the Hospital failed to ensure patients were monitored and appropriate interventions implemented per the Suicidal Precautions policy. This has the potential to affect all patients who receive care in the Emergency Department (ED) with an average of 202 patients per month and an average daily census of 1 patient.

Findings include:

1. The policy titled "Suicidal Precautions" (revised by the facility, 1/22) was reviewed on 3/10/22. The policy noted "Purpose:... guidelines to be followed for the use of interventions to ensure close supervision and monitoring. Define the level of observation for patients who have been identified to be at risk for suicide or self-injurious behavior... LEVELS: Suicide Precautions with every fifteen (15) minute observation/monitoring. 1. Close observation, within visual range every fifteen (15) minutes and documentation on suicidal precaution log every fifteen minutes. Suicide Precautions with 1:1 observation. 1. Continuous observation of patient and documentation on suicide log every fifteen minutes... 2. In the absence of the physician or physician orders, the charge or primary nurse will initiate the suicidal precautions until physician orders are received... Environmental Patient Safety Checklist- Suicide Precautions... Room inspection completed at the beginning of each shift." This guidance listed 17 interventions to be completed at the beginning of each shift. "

2. Pt #1 Date of Service (DOS): 11/8/21
The record was reviewed on 3/8/22 at approximately 1:50 PM. The providers ED note dated 11/8/21 noted "Diagnostic Considerations... Suicidal... Impression: Attempt at Self-Harm." The record lacked documentation suicide precautions were assessed, ordered and/or implemented. The record lacked a suicide precaution log with documentation of observation every 15 minutes and a completed Environmental Safety Checklist.

3. Pt #4 DOS: 2/2/22
The record was reviewed on 3/8/22 at approximately 3:03 PM. The ED Nurses Note dated 2/2/22 noted "The voices woke pt (patient) up telling her/him to kill herself/himself, per ambulance patient was choking herself/himself with her/his hands when they got there..." The record lacked documentation suicide precautions were assessed, ordered and/or implemented. The record lacked a suicide precaution log with documentation of observation every 15 minutes and a completed Environmental Safety Checklist.

4. Pt #5 DOS: 1/14/22
The record was reviewed on 3/9/22 at approximately 2:00 PM. The ED Nurse Note dated noted "01/14/2022 1:36 PM ... Family called police stating the patient was trying to kill himself/herself ... 1/17/2022 10:38 AM, Pt did tell her he/she did put a sheet around his/her neck to hang himself/herself..." The ED physician note dated 1/14/22 noted "Comments: suicidal ideation... Pt was found trying to hang himself/herself with a bed sheet..." The record lacked documentation suicide precautions were assessed, ordered and/or implemented. The record lacked a suicide precaution log with documentation of observation every 15 minutes and a completed Environmental Safety Checklist.

5. Pt #12 DOS: 3/8/22
The record was reviewed on 3/8/22 at approximately 2:50 PM. The record noted Pt #12 was admitted to room #243 of the Medical Unit on 3/8/2022 with the diagnosis of Suicidal Ideation. A review of Pt #12's record lack documentation that the environmental room inspection was completed for the 3/9/2022 5:00 AM-5:00 PM shift.

6. Pt #21 DOS: 12/5/21
The record was reviewed on 3/10/22 at approximately 11:00 AM. The ED Physician's note noted "The patient currently admits to suicidal ideation. The patient admits to Jump off a bridge." The record lacked documentation suicide precautions were assessed, ordered and/or implemented. The record lacked a suicide precaution log with documentation of observation every 15 minutes and a completed Environmental Safety Checklist.

7. Pt #22 DOS: 12/9/21
The record was reviewed on 3/10/22 at approximately 11:15 AM. The ED nurses note noted Pt#22 arrived at the ED via EMS (Emergency Medical Services) for a psychiatric evaluation at 3:44 PM. The Nurses Emergency Department note noted Pt #22 eloped at 3:50 PM. The record lacked documentation suicide precautions were assessed, ordered and/or implemented and a completed Environmental Safety Checklist.

8. During a tour on 3/11/22 at approximately 10:00 AM, ED Room #1 and #5 were observed to be safe rooms used for behavioral health patients and at the nurse's station a monitor displayed the inside of room #1 and #5 for patient observation. During the tour, Pt #1 was observed to be in ED Room #5 with the safe room interventions implemented, in a gown, the monitor was monitored by an ED RN at all times and staff were observed intermittently outside the rooms door.

9. During an interview on 3/9/2022 at approximately 3:30 PM, the Medical Surgical Registered Nurse (RN, E#5)assigned to Pt #12 on 3/9/2022 for the 5:00 AM - 5:00 PM stated that E#5 was unaware that documentation of the environmental check was required.

10. During an interview on 3/11/22 at approximately 10:00 AM, the Emergency Department RN (E#9) reviewed Pt #1, Pt #4, Pt #5, Pt #21, Pt #22's records and verbally agreed suicide precautions were not ordered and should have been. E#9 verbally agreed the ED did not complete a suicide precaution log with documentation of observation every 15 minutes. E#9 stated patients were continually monitored by video at the nurses station. E#9 stated the ED was always staffed with 2 RN's and a Physician in-house, as well as the EMS staff will assist with monitoring if they are not in the field. E#9 stated if the ED had 2 patients and required both nurses, a Certified Nurse Aide (CNA) could be borrowed from the Medical Surgical Unit.

B. Based on document review, observation and interview, it was 5 of 5 (Pt #1, Pt #4, Pt #5, Pt #21, Pt #22) ED patients records reviewed, the Hospital failed to ensure patients were monitored and appropriate interventions implemented per the elopement policy. This has the potential to affect all patients who receive care in ED with an average of 202 patients per month.

Findings include:

1. The policy titled "AMA (Against Medical Advice)/LWBS (Left Without Being Seen)/Elopement" (not dated) was reviewed on 3/11/22. The policy noted "Some Risk factors to look for to determine whether a patient is at risk and requires very close supervision: -The patient exhibits confusion related to... *Dementia *Traumatic Brain Injury *History of alcohol or drug abuse... history of elopement... history of substance abuse and may be craving the substance..."

2. Pt #1 DOS: 11/8/21
The record was reviewed on 3/8/22 at approximately 1:50 PM. The record noted Pt #1 arrived in the ED at 5:12 AM for "Diagnostic Considerations... Suicidal... Impression: Attempt at Self-Harm." The record lacked documentation elopement precautions were assessed, ordered and/or implemented.

3. Pt #4 DOS: 2/2/22
The record was reviewed on 3/8/22 at approximately 3:03 PM. The record noted Pt#4 arrived in the ED at 7:15 AM with suicidal ideation's. The ED Nurses Note noted at 10:47 AM "PT (patient) eloped from building... 10:56 AM PT returned to ER." The ED Doctor Note noted "Pt just assaulted ED RN (hitting), threw her ice water and ran out of the ER in her patient gown, no shoes into sub zero temps (temperatures)..." The record noted Pt #4 had a history of elopement. The record lacked documentation elopement precautions were assessed, ordered and/or implemented.

4. Pt #5 DOS: 1/14/22
The record was reviewed on 3/9/22 at approximately 2:00 PM. The record noted Pt #5 arrived in the ED at 1:36 PM for alcohol intoxication and suicidal. The record noted at 2:13 AM "Pt pushed staff, knocked over some tables, and ran out the front door of the ER (Emergency Room)... 2:25 AM Brought back by PD (Police Department." The record noted at 5:49 AM "Patient up pounding on doors. States that he/she wants to leave and he/she is sober... 12:25 PM, Patient eloped through back door... 12:35 PM, Patient returned..." The record lacked documentation elopement precautions were assessed, ordered and/or implemented.

5. Pt #21 DOS: 12/5/21
The record was reviewed on 3/10/22 at approximately 11:00 AM. The record noted Pt #21 arrived in the ED at 1:31 AM for suicidal ideation's. The record noted "0415 (4:15 AM) patient became very manic started yelling and pushed and hit nurse started running got out door... 14:01 (2:01 PM) Pt friend called and said... is safe." The record lacked documentation elopement precautions were assessed, ordered and/or implemented.

6. Pt #22 DOS: 12/9/21
The record was reviewed on 3/10/22 at approximately 11:15 AM. The record noted Pt#22 arrived in the ED via EMS (Emergency Medical Services) for a psychiatric evaluation at 3:44 PM. The Nurses Emergency Department note noted 3:50 PM "Patient presses the call light, I answer, and ask if I can help her. She/he said, "Does no one care?"... will be with you shortly... hear patients main door open... patient is at the ambulance bay door, and walks out." The record lacked documentation elopement precautions were assessed, ordered and/or implemented.

7. During an interview on 3/11/22 at approximately 10:00 AM, E#9 reviewed Pt #1, Pt #4, Pt #5, Pt #21, Pt #22) records and verbally agreed elopement precautions were not ordered and should have been. E#9 stated patients were continually monitored by video at the nurses station. E#9 stated "We have physically been injured before. Sometimes there is just nothing you can do. We have to protect ourselves." E#9 stated the ED was always staffed with 2 RN's and a Physician in-house, as well as the EMS staff will assist with monitoring if they are not in the field. E#9 stated if the ED had 2 patients and required both nurses, a Certified Nurse Aide (CNA) could be borrowed from the Medical Surgical Unit.


C. Based on document review, observation and interview, it was 2 of 2 (Pt #2, Pt #5) ED patients records reviewed who required Fall Precautions, the Hospital failed to ensure patients were monitored and appropriate interventions implemented per the Fall Precaution policy. This has the potential to affect all patients who receive care in ED with an average of 202 patients per month.

Findings include:

1. The policy titled "Fall Precautions" (reviewed by Hospital 6/21) was reviewed on 3/10/22. The policy noted "All Adult patients will be assessed for fall risk upon admission to the emergency department. Fall precautions will be implemented as appropriate and documented in the EMR (Electronic Medical Record)... Persons at risk: 1. History of Falling 2. Medications and contributing physiological factors... 4. Dizziness... 8. Mental status..."

2. Pt #2 DOS: 12/28/21
The record was reviewed on 3/9/22 at approximately 11:00 AM. The record noted Pt #2 presented to the ED with back pain from "tripped and fell-ground level fall and had dizziness. The record noted "Functional screening: The patient denies falling unexpectedly... Fall risk assessment was completed... Morse Fall Risk screening: History of falling within 3 months: no... Total Fall score: 0"

3. Pt #5 DOS: 1/14/22
The record was reviewed on 3/9/22 at approximately 2:00 PM. The record noted Pt #5 presented to the ED for alcohol intoxication and suicidal ideation's. The record noted Pt #5 was intoxicated and received multiple doses of Haldol (This medicine may cause some people to become dizzy, drowsy, or may cause trouble with thinking or controlling body movements, which may lead to falls, fractures or other injuries). The record of Pt #5 lacked a Fall Risk screening.

4. During an interview on 3/11/22 at approximately 10:00 AM, E#9 reviewed Pt #2 and Pt #5's records and verbally agreed fall risks were not accurately assessed nor precautions implemented and should have been.

A. Based on document review, observation and staff interview it was determined the Hospital failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. This failure has the potential to effect all patients receiving laboratory services.

Findings include:

1. On 3/8/2022 at approximately 3:00 PM, the policy titled "Maintenance and Repair Equipment" (effective 6/16/2020) was reviewed. The policy noted "All equipment is inspected for operational integrity by facility personnel, prior to each use. It is the responsibility of each department director to inspect their equipment on a regular basis and report any malfunctions or infection control concerns to the Maintenance Director or Infection Control Coordinator."

2. On 3/8/2022 at approximately 1:30 PM, a tour of the laboratory was conducted with the CEO (Chief Nursing Officer) E#1. During the tour, in the laboratory blood draw area, it was observed the blood draw chair had a tear in the vinyl on the arm rest and seat of the chair exposing the foam padding.

3. Dring an interview onn 3/8/2022 at approximately 1:40 PM, E#1 observed the tears in the laboratory equipment and verbally agreed the need for repair.

B. Based on document review, observation and interview, it was determined the Hospital failed to ensure infection control supplies were labeled properly to ensure proper disinfection of patient care areas and equipment. This has the potential to affect all patients serviced by outpatient physical therapy with a monthly census of 225 patients.

Findings include:

1. On 3/10/2022 at approximately 9:00 AM the policy titled "Hazard Communication Program" (revised 11/12/2015) was reviewed. The policy noted "If a substance is transferred from one container to another, the new container must be labeled with the following information. d. Expiration Date."

2. On 3/8/2022 at approximately 12:30 PM, an observational tour of the Physical Therapy Department treatment areas was conducted with E#1. Two spray container labeled Oxivir Five, used for cleaning the physical therapy equipment, contained approximately 100 fluid ounces spray bottle, lacked an open/or expiration date.

3. During an interview on 3/8/2022 at approximately 12:45 PM, E#1 verbally agreed the spray bottles lacked an expiration date and should have been. E#1 stated the Oxivir was taken from a larger bulk container and put into the smaller spray containers.

A. Based on document review and interview, it was determined for 8 of 8 (MD#1, MD#2, MD#3, MD#4, MD#5, MD#6, MD#7, MD#8) Physicians files, 1 of 1 (PA#1) Physician Assistant and 1 of 1 (NP#1) Nurse Practitioners files reviewed the Hospital failed to ensure medical staff members who provided direct patient care had conducted infection prevention education and training per policy. This has the potential to affect all inpatients and outpatients who require the use of restraints.

Findings include:

1. The policy titled "Infection Prevention and Control Program" (reviewed by Hospital 07/2020) was reviewed on 3/10/22 at approximately 1:30 PM. The policy noted: "G. Education and training of Healthcare Workers 1.)... provides ongoing educational programs in infection prevention and control to healthcare workers. 3.) Educational Programs are evaluated periodically for effectiveness, and attendance is monitored by the ICC in cooperation with the department manager."

2. The Physician and Mid-level provider Files were reviewed on 3/9/22 at 2:45 PM. All Physician and Mid-Level provider files reviewed lacked documentation to indicate Infection Prevention and Control training and competency was accomplished Initially or annually.

3. An interview was conducted with the Administrative Assistant (E#7) on 3/9/22 at 3:00 PM. Staff reviewed the information in the Physician and Mid-level provider files and agreed there has been no training. E#7 stated, "We give our Physicians and Mid-Level providers a binder and tell them to read it. But we do not track who has or has not."

Based on document review and interview, it was determined for 8 of 8 (MD#1, MD#2, MD#3, MD#4, MD#5, MD#6, MD#7, MD#8) Physicians files, 2 of 2 (CRNA#1, CRNA#2) Certified Registered Nurse Anesthesia, 1 of 1 (PA#1) Physician Assistant and 1 of 1 (NP#1) Nurse Practitioners files reviewed, the Hospital failed to ensure emergency preparedness (EP) training was conducted at least every 2 years. This has the potential to affect all patients, staff, visitors and community persons.

Findings include:

1. The Physicians and CRNAs files were reviewed on 3/9/22 at approximately 2:45 PM. The following Physicians, Mid-level Practitioners, and CRNAs files lacked documentation of EP training and competency initially or every 2 years:
a) MD#1, Initial Appointment Date (IAD): 9/11/20
b) MD#2, IAD: 8/26/20
c) MD#3, IAD: 10/28/16
d) MD#4, IAD: 3/10/20
e) MD#5, IAD: 7/18/19
f) MD#6, IAD: 12/17/21
g) MD#7, IAD: 2/18/14
h) MD#8, IAD:
i) CRNA#1, IAD: 2/20/20
j) CRNA #2, IAD: 10/23/20
k) PA#1, IAD: 3/5/19
l) NP#1, IAD: 12/6/21

2. During an interview conducted on 3/9/22 at approximately 3:00 PM, the Administrative Assistant (E#7) reviewed the Physician and Mid-level Practitioners files and verbally confirmed the EP training had not been conducted and should have been. E#7 stated "We give our Physicians and Mid-Level providers a binder and tell them to read it but we do not track who has or has not completed it."