HospitalInspections.org

Based on observation, staff interview and policy review the (CAH) failed to ensure the Kansas State food code regulations were implemented for preventing the potential contamination of food when an airgap was not installed on the kitchen preparation sinks to prevent the backflow of sewage, gas, or other contaminates. This failed practice potentially placed all patients and visitors at risk for food contamination.

Findings include:

- Observation of the CAH kitchen on 6/12/2017 at 3:30 PM revealed the sinks used to prepare fresh food prep area 1 and prep area 2 did not have an air gap to prevent contamination of the sink and food in the event of a backflow of sewage, gas, or other contaminates.

Kitchen Cook Staff R on 6/12/17 at 3:30 PM stated they has worked here for 40 years and has never heard of an air gap.

Chief Operation Officer (COO) Staff P stated we don't have air gaps in the kitchen. It's been the new requirement in the last few years.

According to the Kansas State Food Code 2012 regulation 5-203.14 Backflow Prevention Device stated "A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to ...cafeterias, public or nonprofit organizations routinely serving food ...")

The CAH failed to provide a policy regarding the regulation of the Kansas State Food Code 2012.

Based on observations, interview and policy review, the facility failed to ensure Emergency room medications did not exceed the expiration date for 1 of 2 Emergency Department Rooms (Emergency Department Room #1). This deficient practice has the potential to cause unsafe medications to be given during the care and treatment of emergent patients.

Findings include:

- Observation of Emergency Room #1 on 6/13/2017 at 8:00 AM revealed one IV bag of Dobutamine (used to treat emergency heart failure) with an expiration date of June 1, 2017.

Pharmacy Staff D interview on 6/12/2017 at 2:37 PM communicated expired medications are disposed of by the pharmacy, and if found after hours, the staff destroy any expired medications.

Pharmacy Technician Staff SS interview on 6/13/2017 at 12:30 acknowledged the medications were outdated, and explained the medication is on backorder. Staff SS indicated there were more IV bags of expired Dobutamine in the hospital and she would pull those as well.

On 6/15/2017 the facility failed to provide a policy on expired medications.

Based on observation, interview, and record review, the Critical Access Hospital (CAH) failed to remove and replace outdated emergency pediatric equipment in the 2nd floor Broselow Cart and failed to remove expired, open, and non-sterile supplies from surgical room #1 and #2. The deficient practice of failing to dispose of expired supplies by the facility places all patients at risk for receiving ineffective, unsafe supplies leading to harmful treatment.

Findings include:

- Observation in the medication room of the 2nd floor nursing station on 6/12/2017 at 12:00 PM revealed the following outdated supplies on the Broselow Pediatric Emergency Cart (color coded system used to determine pediatric medication dosages and equipment sizes in emergencies):
1-Yellow Intubation Module, located in the yellow drawer, expired 2/2017
1-White Intubation Module, located in the white drawer, expired 2/2017
1-Green Intubation Module, located in the green drawer, expired 2/2017

Staff RN Q acknowledged the outdated supplies and removed them from the medication room.

Policy "Broselow Cart", issue date 8/28/2013 directed " ...Nursing duties, Check and document the last 3 numbers of the outer lock daily, Check and replace expired items: if the seal is not broken or damaged it is considered sterile ..."

- Observation in the surgical suite on 6/14/2017 at 1:10 PM revealed the following outdated and open supplies in surgery room #1:
1- Eye pad expired 9/2016 located on the Vantage Cart
1-7.0 endotracheal (ET) (tube used to keep the airway open), on the anesthesia cart. The packaging was compromised.

- Observation in the surgical suite on 6/14/2107 at 1:48 PM revealed the following outdated supplies in surgery room #2:
1-3.5 ET tube on the anesthesia cart with outdate of 1/2017

CRNA Staff EE acknowledged the outdated supplies.

- Observation in procedure room on 6/12/2017 at 11:37 AM revealed the following outdated supplies:
3-Mepilex AG (medicated gauze) packages with an expiration date of 12/2016 stored in the wound care cart.
1-bottle of benzoin solution (used to cleanse skin) with an expiration date of 4/2016 stored on the wound care cart.
1-bottle of Cavicide disinfectant cleaner with an expiration date of 2/2002.

Unknown Staff interviewed on 6/12/2017 at 11:45 AM confirmed the supplies were expired.

The CAH failed to provide policy regarding removal of open or outdated supplies.

Based on documentation review, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure their air exchanges in the Operating rooms (OR) were properly maintained for 2 of 2 OR's (OR #1 and OR #2). This deficient practice has the potential of microbial growth and increased risk of infections to their patients.

Findings Include:

- Maintenance records reviewed on 6/12/2017 at 2:00 PM revealed the CAH failed to ensure the air exchanges in all Operating Rooms were maintained and functioning properly. The CAH had no evidence that the air exchanges had preventative maintenance from an outside company.

COO Staff P interviewed on 6/13/2017 at 4:30 PM indicated the air exchanges were not maintained properly. Staff P stated they have no evidence of preventative maintenance on the air exchanges.

- Policy reviewed on 6/13/2017 revealed the CAH failed to provide a policy that directed staff to ensure air exchanges are functioning and maintained properly.

Based on observation, interview, and document review the Critical Access Hospital (CAH) failed to provide orders for the use of a local anesthetic (medication that provides for lessened sensation in a small area) when initiating an intravenous (IV) site. Failure of the facility to provide orders for the use of all medications can lead to inappropriate medication administration resulting in unsafe patient care and possible death.

Findings Include:

- Observation in the 2nd floor nursing station medication room on 6/12/2017 at 12:00PM revealed 2 supply carriers with IV start supplies including 4 vials of 1% lidocaine in each carrier and one unopened box of 25 vials 1% lidocaine on a storage shelf in a closed cabinet. No patient prescription label was found on the lidocaine vials.

Interview on 6/12/2017 at 12:10 PM with Staff RN Q confirmed the unopened lidocaine vials and acknowledged they were not patient specific, but the lidocaine is used discriminately by the nursing staff if necessary to use to numb an area when starting an IV.

- Observation of emergency department (ED) nursing station on 6/12/2017 at 4:10 PM revealed six vials of bacteriostatic water (used to dilute medications) and two bags of normal saline for IV use (used to treat dehydration) on a bookshelf stored with various office supplies, books and manuals.

Interview with ED Staff MM on 6/13/2017 at 8:16AM acknowledged the storage of medications with office supplies and stated, "Because it is so small in here".

The facility failed to provide a policy regarding the use of local anesthetic for IV initiation.

Based on observation, interview, and document review, the Critical Access Hospital (CAH) failed to ensure staff perform hand hygiene during 2 of 4 observed patient care activities (Certified Registered Nurse Anesthetist - CRNA Staff #EE). The CAH failed to ensure patient supplies are cleaned between each patient use in 1 of 1 observations in the outpatient area (RN Staff #O). The CAH failed to ensure all expired patient care supplies are removed from possible use in 1 of 1 Broselow carts, surgery room #1, and surgery room #2. The CAH failed to ensure 2 of 2 biohazard containers were secure in surgery room #1. The CAH failed to ensure splash guards are installed in 1 of 1 surgical hoppers observed and failed to have PPE equipment available in 1 of 1 rooms with a hopper installed (surgery area). The CAH failed to ensure staff wore surgical attire appropriately in 1 of 4 observations (Physician Staff #GG). The CAH failed to provide personal protective equipment (PPE) in all areas that cross contamination of body fluids is possible (surgery work room). The CAH failed to dispose of open patient care supplies in 1 of 1 wound cart, and 1 of 1 procedure room supply closet. The CAH failed to store disinfecting cleaning supplies in a designated area away from patient care storage in the outpatient area and 1 of 2 emergency rooms (room #408). The CAH failed to ensure the sterility of 3 of 3 laryngeal mask airway (LMA) (a medical device that keeps a patient's airway open during anesthesia). The CAH failed to remove expired food from 3 of 3 refrigerators (#1, #2 and #3), 1 of 1cabinet in tray line area, 1 of 1 baking prep area, 2 of 2 prep tables (#1 and #2), 1 of 1 food cart, and 1 of 1 main storage room. The CAH failed to ensure the kitchen sink where staff performs hand hygiene next to the ovens had a barrier to protect from contaminating prepared foods for 1 of 4 sinks. The CAH failed to ensure the spice shakers were proper cleaned after use for 2 of 2 spice shakers. The CAH failed to ensure the dishwasher room ceiling vent was properly cleaned for one of one ceiling vent. These deficient practices have the potential to expose all patients and healthcare workers to hazardous waste, harmful bacteria contamination, and cross contamination resulting in bacterial, viral, and fungal illnesses.

Findings include:

- Observation on 6/14/2017 at 7:40 AM revealed CRNA Staff #EE entering and exiting outpatient room #403 without performing hand hygiene.

- Observation on 6/14/2017 at 8:10 AM revealed CRNA Staff #EE entering and exiting outpatient room #405 without performing hand hygiene.

Policy "Handwashing" directs " ...hand washing with soap and water, and/or hand sepsis using alcohol-based hand rubs ... ...before and after contact with patients ..."


- Observation on 6/14/2017 at 7:45 AM revealed RN Staff #O taking an unlabeled specimen cup into room #403. RN Staff #O set the cup on the over-bed table and using sterile forceps, removed a medicated gauze from the cup and placed the gauze on the eye of patient #4. Staff RN #O replaced the lid of the specimen cup and removed it from room #403.

Interview with RN Staff #O confirmed the contents of the cup consists of multiple medicated sterile gauze pads that are used for pre-operative eye preps. The gauze pads are not patient specific and the cup is taken to the bed side of each patient requiring the gauze application per physician order. RN Staff #O acknowledged she did not clean the exterior cup after removing it from the patient's bedside and that she "had not really thought about the need to do so."
Interview with unknown RN Staff acknowledged the cup is "supposed to be cleaned off with alcohol between patient uses."

The CAH failed to supply a policy regarding cleaning of multi-use patient equipment and supplies.


- Observation in the medication room of the 2nd floor nursing station on 6/12/2017 at 12:00 PM revealed the following outdated supplies on the Broselow Pediatric Emergency Cart (color coded system used to determine pediatric medication dosages and equipment sizes in emergencies):
1-Yellow Intubation Module, located in the yellow drawer, expired 2/2017
1-White Intubation Module, located in the white drawer, expired 2/2017
1-Green Intubation Module, located in the green drawer, expired 2/2017
Staff RN Q acknowledged the outdated supplies and removed them from the medication room.

Policy "Broselow Cart", issue date 8/28/2013 directs " ...Nursing duties, Check and document the last 3 numbers of the outer lock daily, Check and replace expired items: if the seal is not broken or damaged it is considered sterile ..."

- Observation in the surgical suite on 6/14/2017 at 1:10 PM revealed the following outdated and open supplies in surgery room #1:
1- Eye pad expired 9/2016 located on the Vantage Cart
1-7.0 endotracheal (ET) (tube used to keep the airway open), on the anesthesia cart. The packaging was compromised.

- Observation in the surgical suite on 6/14/2107 at 1:48 PM revealed the following outdated supplies in surgery room #2:
1-3.5 ET tube on the anesthesia cart with outdate of 1/2017

CRNA Staff EE acknowledged the outdated supplies.

The CAH failed to provide policy regarding removal of open or outdated supplies.

- Observation in surgery room #1 on 6/14/2017 at 2:30 PM revealed 2, 5 gallon unsecured and open biohazard containers setting on the floor.

Interview with surgery scrub tech #PP on 6/14/2017 at 2:30 PM acknowledged the biohazard containers were on the floor and the tops were open for easy access. S/he acknowledged the containers were unsecure and could be knocked over.

The CAH did not provide a policy related to securing and disposing of biohazard containers.


- Observation in the surgery dirty work room revealed an open hopper (device used to flush contaminated liquids and solids) and no personal protection equipment (PPE) consisting of eye protection, nose and mouth protection, gown, and gloves readily available when flushing liquids or solids.

Interview with surgery scrub tech #PP confirmed the hopper is used regularly and no protection is readily available.

The CAH did not provide a policy related to PPE attire.


- Observation in Outpatient Hallway on 6/14/2017 at 9:14 AM revealed Physician Staff #GG walking down the hallway with her/his surgical mask untied at the top and hanging below her/his chin.

Interview with Physician Staff #GG on 6/14/2017 at 9:14 acknowledged the presence of the hanging mask and states, "I take it down to dictate between cases and I am not in the habit of changing it every time".

Policy "Surgery. Clothing Apparel of People Entering Operating Room" review on 6/15/2017 at 10:35 AM directed " ...If you leave the department and take your mask down, discard and use a new mask ..."


- Observation of Procedure Room wound care cart on 6/12/2017 at 11:45 AM revealed a can of Sani-Guard sanitizing spray stored with clean supplies, and an opened coccyx foam dressing without original packaging lying on top of the wound care cart.


- Observation of Procedure Room supply closet on 6/12/2017 at 11:45 AM revealed one open package of gauze sponges, two open packages of Melgisorb (absorbent wound dressing), and a bottle of Cavicide disinfectant (medical grade disinfectant cleaner) stored next to sterile packaged wounds supplies with an expiration date of 6/2002.

Interview with Outpatient Nursing Staff #KK on 6/12/2017 at 11:45 acknowledged the items presented an infection control risk and stated the coccyx foam dressing was "used for teaching purposes." RN Staff #KK indicated s/he believed the Cavicide cleaner was refilled from a larger bottle.


Packaging of Melgisorb reviewed on 6/12/2017 at 11:45 AM directed "do not use if package is opened or damaged".

The CAH failed to provide a policy regarding storage of clean and sterile supplies.


- Observation of outpatient room #401 on 6/12/2017 at 1:52 PM revealed two boxes of Wound-Vac supplies (negative pressure wound drainage system) stored in a visibly soiled bathtub located in the patient bathroom.

Interview with Outpatient Services Director Staff #I on 6/12/2017 at 1:52 PM indicated the supplies were left over from a previous patient and now will be used for educational purposes.

The CAH failed to provide policy regarding removal of open or outdated supplies.


- Observation of outpatient room #403 on 6/12/2017 at 2:00 PM revealed the wood finish had come off of patient chair rendering it non-cleanable.

Outpatient Services Director Staff I interview on 6/12/2017 at 2:00 PM acknowledged wood finish had come off of patient chair.

- Observation in the Therapy Treatment Room on 6/13/2017 at 8:33 AM revealed wood finish had come off of patient chair.

Therapy Gym observation on 6/13/2017 at 8:45 AM revealed wood finish had come off of patient chair.

The CAH failed to provide a policy regarding cleanable surfaces.


- Observation of Emergency Department Room #408 on 6/12/2017 at 3:38 revealed a container of Cavicide wipes and a spray bottle (disinfectant) stored on a cart of supplies used to perform pelvic exams.

Interview of Emergency Department Staff #LL on 6/12/2017 at 3:38 acknowledged the presence of the cleaner among clean pelvic exam supplies.

On 6/15/2017 the CAH failed to provide a policy regarding storage of clean and sterile supplies.


- Observation in surgery room #2 on 6/14/2017 at 1:45 PM in the anesthesia cart 3 of 3 LMA in envelopes used for sterilization with a chemical indicator used for sterilization in each envelope. All 3 LMA envelopes were open at the end rendering them unsterile.

Interview with scrub tech Staff PP on 6/14/2017 at 1:45 PM confirmed the open envelopes and acknowledged the envelopes are never sealed and the sterilization process is for immediate use.

CRNA Staff EE acknowledged the open envelopes.

The CAH failed to provide a policy regarding sterilization of LMA's.

Manufacturer's guidelines for the LMA reviewed on 6/15/2017 at 10:45 AM directed " ...LMA Classic are supplied non sterile and must be cleaned and sterilized before initial use and before each subsequent use ..." and " ...failure to properly clean rinse and dry a device may result in retention of potentially hazardous residues or inadequate [sterilisation].


- Observation of the Outpatient Service nursing station patient food refrigerator on 6/12/2017 at 11:50 AM revealed two containers of pudding with an expiration date of 4/2017.

- Observation of the Kitchen on 6/12/2017 at 3:00 PM revealed the following expired food in the H.S. (bedtime snack) refrigerator #1:
1) Two Sara lee bread loaves with best used by 5/22/2017 and 6/2017.
2) Four Boost Breeze Nutritional Drink 8 ounces with expiration dates of 2/14/2017.
3) Five Sour Cream 1ounce packets with expiration dates of 5/15/2017.
4) Two open Heinz 57 sauce 10 ounce bottles open with no date.
5) Eight Yoplait 4 ounces with expiration date of 6/7/2017.

- Observation of the Kitchen on 6/12/2017 at 3:00 PM revealed the following expired food in the tray line area cabinet:
1) One Peanut Butter jar with expiration date of 5/22/2017.
2) Two clear containers of cookies, one with 8 animal crackers and the other container 17 vanilla wafers not labeled.
3) Seven Crystal light drink mix .6oz with expiration dates of 10/5/2015.

- Observation of the second refrigerator next to tray line on 6/12/2017 at 3:15 PM revealed the following prepared foods without dates:
1) One sandwich with no date.
2) One dish of Apricots with no date.
3) One dish of Strawberry's with no date.

- Observation of the baking prep area on 6/12/2017 at 3:15 PM revealed the following expired food and no date on a food item:
1) One open box of baking soda on the table with no date.
2) Three Dark Chocolate Frosting 16 ounces with expiration dates 8/8/2016, 1/11/2017 and 1/18/2017.

- Observation of the prep table 2 on 6/12/2017 at 3:35PM revealed two large closed containers one contained cornstarch and the other rice with no date.

- Observation of the cabinet next to prep table 2 on 6/12/2017 at 3:35 PM revealed an open container labeled Parsley with no date.

- Observation of the food cart next to prep table 2 on 6/12/2017 at 3:45 PM revealed the following expired food:
1) One bag Pretzel bag 20 ounces with expiration date 5/15/2017.
2) One bag of Fritzel corn chips with expiration date of 3/14/2017.
3) Santitas corn chips with expiration date of 3/2017.
4) Two loaves of bread with best used by 6/6/17 and 6/7/2017.

- Observation of the main walk in refrigerator on 6/12/2017 at 3:50 PM revealed 3 open loaves of bread with best used by 6/6/2017 and 6/7/2017.

- Observation of the Kitchen main storage room on 6/12/2017 at 3:55 PM revealed the following expired food:
1) Seven chicken noodle soup cans 7 ¼ ounces with expiration dates of 5/14/2017.
2) Eleven Tomato soup cans 7 ¼ ounces with expiration dates of 3/3/2017.
3) Ten chocolate chip muffin mix boxes 5lb (pounds) 9 ounces with expiration dates of 1/2016 and 5/31/2017.

Outpatient Director Staff I interview on 6/12/2017 at 11:50 AM acknowledged the food items were expired.

Kitchen Cook Staff R interviewed on 6/12/2017 at 3:55 PM acknowledged the food has expired and should have been disposed.

- Policy reviewed on 6/12/2017 revealed the CAH failed to have a policy to direct their staff on proper disposal of expired food.


- Observation of the Kitchen prep table 1 on 6/12/2017 at 3:15 PM revealed a handwashing sink with no barrier to protect prepared food.

Kitchen Cook Staff R interviewed on 6/12/2017 at 3:55 PM stated they use the sink for handwashing only and been doing that for some time.


- Observation of prep table 2 on 6/12/2017 at 3:30 PM revealed two spice shakers dirty looking and sticky.
Kitchen Cook Staff R interviewed on 6/12/2017 at 3:55 PM acknowledged the shakers should have been clean after use.

- Observation of the dishwasher room on 6/12/2017 at 2:45 PM revealed an air vent on ceiling rusted and lint build up where clean dishes are stored.

Kitchen Cook Staff R interviewed on 6/12/2017 at 2:45 PM acknowledged the vent did have a lot of lint. Staff R stated it probably has not been cleaned for some time.

Policy reviewed on 6/12/2017 revealed the CAH failed to have a policy to direct staff to properly clean the kitchen.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to safeguard confidentiality, and prevent possible destruction of patient records in one of one therapy supply closet. This deficient practice has the potential for unauthorized use and loss of patient's medical information necessary for continuity of care.

Findings include:

- Observation of the Therapy Department Storage Closet on 6/13/2017 at 8:32 AM revealed an unlocked closet containing therapy supplies, a corner mop sink, and a large banker's box (box for storing files) on the shelf containing therapy billing records bundled together with rubber bands with patient's names exposed.

Therapy Secretary Staff NN interview on 6/13/2017 at 8:32 AM acknowledged the presence of the records and stated, "I'll take care of that".

On 6/15/2017 the facility failed to provide policies regarding the storage of medical records.

The Critical Access Hospital (CAH) reported performing an average of 1 surgical procedure per day. Based on observation, document review, and staff interview, it was determined that the CAH failed to ensure surgical procedures were performed in a safe manner by failing to have enough Dantrolene or Revonto (a type of muscle relaxant) available to treat Malignant Hyperthermia (MH) (a rare life-threatening condition causing a severe high body temperature and inability to supply oxygen and remove carbon dioxide) usually triggered by exposure to general anesthesia drugs and/or succinylcholine (an neuromuscular blocking agent). The facility's failure to ensure a minimum amount of Dantrolene is available when anesthesia or succinylcholine are administered, consisting of 36, 20mg vials, has the potential of delays in responding to medical emergencies causing a worsening of a patient's condition or death. The critical access hospital (CAH) also failed to provide a physical environment for the cleaning, decontamination, and storage of endoscopes (illuminated tube inserted into the intestinal tract), failed to have a procedure in place for cleaning endoscopes, failed to have sufficient surgical instruments available to prevent the need for immediate use sterilization, failed to maintain a sterile field for surgical instruments, and failed to ensure and maintain sterility of sterilized equipment and supplies. Failure to provide an appropriate physical environment for scope cleaning and storage, failure to have specific cleaning procedures, failure to have sufficient instruments available, and failure to maintain a sterile field, can lead to cross contamination of infectious organisms including bacteria, viruses, and fungus through aerosolization (dispersing particles into the air) and direct touch contamination resulting in increased infections, increased morbidity, and possible death.

Findings Include:

- Observation on 6/12.2017 at 2:45 PM revealed the surgical malignant hyperthermia box contained 18 vials of 20mg Dantrolene and 12 vials of 20mg Revonto (specific medication used to treat Malignant Hyperthermia). OR Supervisor RN Staff I interviewed on 6/12/2017 at 2:45 PM revealed s/he was unaware the box contained only 30 vials. OR Supervisor Staff RN I spoke with Pharmacy Director Staff D to verify no other Dantrolene was available in the pharmacy. Pharmacy Director Staff D verified no other Dantrolene or Revonto was available in the facility.

- Document review on 6/12/2017 at 3:30 PM revealed an invoice for 6, 20mg vials of Dantrolene ordered from vendor on 6/12/2017 at 15:27 with unknown delivery date.

- Observation on 6/12/2017 at 2:50 PM revealed 2 vials of 200mg succinylcholine in the rapid intubation box located in the 2nd Floor Nursing Station medication room and 2 vials, 200mg succinylcholine in the rapid intubation kit located in the emergency department (ED).

All vials of succinylcholine were removed from the floor supply and returned to pharmacy by Director of Nursing Staff C on 6/12/2017 at 4:30 PM.

Policy review "Malignant Hyperthermia" directed " ...A malignant hyperthermia cart containing drugs, equipment, supplies and forms necessary during a Malignant Hyperthermia crisis kept in recovery room ... ...the recovery room RN will be responsible for checking and maintaining the malignant hyperthermia cart. Monthly checking of the malignant hyperthermia cart will include: checking of any outdates of medication and supplies, verification of cart security and essential equipment ... ...Storing Dantrium: Minimum supply of at least 36 vials. To treat average adult (70mg) at a maximum dosing limit of 10mg/kg ..."

Document review according to the Malignant Hyperthermia Association of the United States (MHAUS), Malignant Hyperthermia is a potentially fatal disease passed down through families. The signs of MH include muscle rigidity, rapid heart rate, high body temperature, muscle breakdown and increased acid content. Immediate treatment with the drug Dantrolene usually reverses the signs of MH. It is recommended that 36 vials of Dantrolene be available for use within 10 minutes of the decision to treat a patient for MH.

- Review of the endoscope cleaning procedure with Surgery Technician Staff LL on 6/14/2017 at 1:20 PM revealed the current process for scope processing is to perform the initial rinse of the scope with distilled water in the procedure room using the disposable bag in the cleaning kit. Then the scope is transported in the bag to the common hallway (hallway used to transport patients to and from surgery and for all staff passing between surgery rooms) to perform the initial cleaning process and to prepare it for the Steris washing machine (equipment manufactured for the use of cleaning and processing scopes). Once the cleaning is complete, the endoscope is moved to a room containing the Steris machine and loaded into the machine. After the endoscope is removed from the Steris machine, it is hand carried, uncovered across the common hallway to the recovery room and oxygen is run through the scope for drying the internal diameter, followed by pouring 70% alcohol through the scope. The alcohol is allowed to flow through the scope onto a towel that is laundered after the process. The scope is then hand carried, uncovered across the common hallway to the room containing the Steris machine and hung on the wall, uncovered, until the next procedure. The facility had 3 scopes hanging in the room.

Interview with Scrub Tech Staff PP acknowledged that the scopes are used at least once nearly every day surgery is scheduled.

Interview with Surgical RN Staff QQ and Scrub Tech Staff PP on 6/15/2017 at 2:00 PM acknowledged that the scope cleaning had been previously discussed and a sink and storage cabinets had been purchased by the CAH to be installed in a room to be designated specifically for scope cleaning and storage.

Policy "Nursing Care of Colonoscopy Patients" directed " ...immediately rinse colonoscope or sigmoidoscope with distilled water and place on table ... ...clean colonscope or sigmoidoscope according to manufacturer instructions and hang in proper receptacle." The CAH failed to provide other cleaning documentation regarding scope cleaning.

- Observation on 6/14/2017 at 10:30 AM in the surgical sterilization room revealed Scrub Tech Staff PP washing instruments and placing them in a rigid side instrument container for sterilization. Staff PP placed a chemical indicator (device used to determine complete penetration of heat into container) into the container and placed it into the sterilizer.

Interview with Scrub Tech Staff PP on 6/14/2017 at 10:30 AM confirmed "We only have 3 sets of instruments for the eye cases. 8 cases are scheduled for today, so the process of sterilization is to immediate use sterilize and run the load for 4 minutes with a 5 minute drying time. We leave the 3rd set in the sterilizer all of the time in case we need an extra instrument because something gets dropped. Then we always have a back-up ready."

Interview with Surgical Director Staff I on 6/14/2017 at 3:00 PM acknowledged there are only 3 sets of instruments available. "I have been requesting more instruments be purchased for the past 6 months and am still waiting."

The CAH was unable to provide a policy regarding immediate use sterilization.

Association for periOperative Nurses (AORN) guidelines recommended the following: "Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner. Immediate use steam sterilization may be associated with increased risk of infection to patients.1 Time constraints may result in pressure on personnel to eliminate or modify one or more steps in the cleaning and sterilization process ... ...Immediate use steam sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory ... ...Items to be steam sterilized for immediate use should be subjected to the same decontamination processes as described in AORN's Guideline for Cleaning and Care of Surgical Instruments. Decontamination should be performed in an area intended, designed, and equipped for decontamination activities ... ...As with terminal sterilization, proper decontamination is essential for removing bioburden and preparing an item for IUSS. Failures in instrument cleaning have resulted in transmission of infectious agents ..."

- Observation in surgery room #2 on 6/14/2017 at 10:30 AM revealed OR RN Staff TT, in surgical attire including sterile gloves, sterile gown, mask, bonnet, and booties, laying instruments and supplies onto a sterile field for the next scheduled surgery to be performed by Surgeon Staff GG. Surgeon Staff GG was performing surgery in surgery room #1 at the time of this observation. The surgical field remained open after completion of the set up.

Interview with RN Staff TT confirmed the current process is to prepare the sterile field for the next surgery while the surgeon is performing surgery in another surgery room. Once the previous surgery is complete, the patient is taken to recovery and the surgery room is cleaned. The table with the sterile field is moved, uncovered by the scrub staff in surgical attire, from surgery room #2 through the pass connecting surgery room #1 and #2 into surgery room #1 and the next surgery is started. The sterile field is not covered. The scrub RN does not change sterile attire. "The sterile field could be open to air for as long as 20 minutes before the next surgery starts."

Interview with Surgical Director RN Staff I acknowledged the sterile field set up and movement.

The CAH failed to provide a policy regarding sterile field set up.

AORN Guidelines recommend the following: "Preparing a sterile field for patients undergoing surgical or other invasive procedures reduces the risk of microbial contamination and is a cornerstone of infection prevention. Failure to adhere to aseptic practices during invasive procedures has been associated with surgical site infections ... The sterile field should be prepared in the location where it will be used and should not be moved ...Moving the sterile field from one location to another increases the potential for contamination ...The sterile field should be prepared as close as possible to the time of use ..."

- Observation in surgery room #2 on 6/14/2017 at 1:45 PM in the anesthesia cart 3 of 3 laryngeal mask airway (LMA) (a medical device that keeps a patient's airway open during anesthesia) in envelopes used for sterilization with a chemical indicator used for sterilization in each envelope. All 3 LMA envelopes were open at the end rendering them unsterile.

Interview with scrub tech Staff PP on 6/14/2017 at 1:45 PM confirmed the open envelopes and acknowledged the envelopes are never sealed and the sterilization process is for immediate use.

CRNA Staff EE acknowledged the open envelopes.

The CAH did not provide a policy regarding sterilization of LMA's.

Manufacturer's guidelines for the LMA (laryngeal Mask Airway) reviewed on 6/15/2017 at 10:45 AM directed " ...LMA Classic are supplied non sterile and must be cleaned and sterilized before initial use and before each subsequent use ..." and " ...failure to properly clean rinse and dry a device may result in retention of potentially hazardous residues or inadequate [sterilisation]."

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to perform an annual Quality Assessment and Performance Improvement (QAPI) program evaluation for the years 2012 through 2016. Failure to perform an annual evaluation of all elements of the services provided, failure to evaluate current practice against the results, and updating policies and procedures based on the quality results puts all patients at risk of substandard care.

Findings Include:

- Document review on 6/13/2017 at 9:00 AM revealed the most recent QAPI program evaluation was performed in 2012.

Interview on 6/13/2017 at 10:55 AM, Administrative Staff T verified the QAPI program has not been occurring annually and that currently there is no coordinator responsible for the program. Administrative Staff T acknowledged s/he is only responsible for collecting the information.

Interview on 6/13/2017 at 10:55 AM, Risk Management Director Staff S verified the facility had not performed an annual review of the QAPI program and there is no formal process for quality currently in place. Staff S acknowledged every hospital department sets their own quality measures and collects data quarterly. That data is presented to the Board every quarter with different departments presenting on a rotating basis. Staff S stated s/he has developed a proposal to take to the June hospital board meeting to propose the development of a quality program putting Staff S as the point person.

The CAH failed to produce a policy for the development and review of the annual quality program.

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to perform an annual Quality Assessment and Performance Improvement (QAPI) program evaluation for the years 2012 through 20016. Failure to perform an annual evaluation of all elements of services provided including the quality and appropriateness of the diagnosis and treatment of the CAH patients, failure to evaluate current practice against the results, and updating policies and procedures based on the quality results puts all patients at risk of substandard care.

Findings Include:

- Document review on 6/13/2017 at 9:00 AM revealed the most recent QAPI program evaluation was performed in 2012.

Interview on 6/13/2017 at 10:55 AM, Administrative Staff T verified the QAPI program has not been occurring annually and that currently there is no coordinator responsible for the program. Administrative Staff T acknowledged s/he is only responsible for collecting the information.

Interview on 6/13/2017 at 10:55 AM, Risk Management Director Staff S verified the facility had not performed an annual review of the QAPI program and there is no formal process for quality currently in place. Staff S acknowledged every hospital department sets their own quality measures and collects data quarterly. That data is presented to the Board every quarter with different departments presenting on a rotating basis. Staff S stated s/he has developed a proposal to take to the June hospital board meeting to propose the development of a quality program putting Staff S as the point person.

The CAH failed to produce a policy for the development and review of the annual quality program.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include in their Swing Bed rights that the facility will provide notice to patients eligible for Medicaid at the time of admission or when they become eligible the services and associated fees for 4 of 4 swing bed medical records reviewed (Patient #2, 22, 23 and 24). Failure to provide notification puts all swing bed patients at risk of excessive charges.

Findings Include:

- Patient #2's medical record review at 6/14/2017 at 9:00 AM revealed they were admitted to a swing bed on 5/19/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the notice to patients eligible for Medicaid requirement.

- Patient #22's medical record review 6/14/2017 at 10:00 AM revealed they were admitted to a swing bed on 11/18/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the notice to patients eligible for Medicaid requirement.

- Patient #23's medical record review 6/14/2017 at 10:30 AM revealed they were admitted to a swing bed on 12/13/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the notice to patients eligible for Medicaid requirement.

- Patient #24's medical record review 6/14/2017 at 12:30 PM revealed they were admitted to a swing bed on 2/7/2017 and the facility provided swing bed rights to the patient during their admission, which lacked the notice to patients eligible for Medicaid requirement.

Swing Bed Coordinator Staff Q interview on 6/13/2017 at 2:40 PM acknowledged the absence of notice to patients eligible for Medicaid requirement.

- Document "Swing Bed Patient Rights" reviewed on 6/13/2017 at 2:40 PM revealed the document lacked the notice to patients eligible for Medicaid requirement.

On 6/15/2017 the facility failed to provide a policy regarding swing bed including the notice to patients eligible for Medicaid requirement.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include in their Swing Bed rights compensation rights for residents who work as part of their plan of care for 4 of 4 swing bed medical records reviewed (Patient #2, 22, 23 and 24). Failure to provide notification puts all swing bed patients at risk of inadequate compensation.

Findings Include:


- Patient #2's medical record review at 6/14/2017 at 9:00 AM revealed they were admitted to a swing bed on 5/19/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the compensation rights for residents who work requirement.

- Patient #22's medical record review 6/14/2017 at 10:00 AM revealed they were admitted to a swing bed on 11/18/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the compensation rights for residents who work requirement.

- Patient #23's medical record review 6/14/2017 at 10:30 AM revealed they were admitted to a swing bed on 12/13/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the compensation rights for residents who work requirement.

- Patient #24's medical record review 6/14/2017 at 12:30 PM revealed they were admitted to a swing bed on 2/7/2017 and the facility provided swing bed rights to the patient during their admission, which lacked the compensation rights for residents who work Medicaid requirement.

Swing Bed Coordinator Staff Q interview on 6/13/2017 at 2:40 PM acknowledged the absence of the compensation rights for residents who work requirement.

- Document "Swing Bed Patient Rights" reviewed on 6/13/2017 at 2:40 PM revealed the document lacked the compensation rights for residents who work requirement.

On 6/15/2017 the facility failed to provide a policy regarding swing bed including the compensation rights for residents who work requirement.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include in their Swing Bed rights that the facility will provide patient notification of swing bed transfer 30 days prior to the transfer in 4 of 4 swing bed medical records reviewed (Patient #2, 22, 23 and 24). Failure to provide notification puts all swing bed patients at risk of inappropriate transfer.

Findings Include:

- Patient #2's medical record review at 6/14/2017 at 9:00 AM revealed they were admitted to a swing bed on 5/19/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #22's medical record review 6/14/2017 at 10:00 AM revealed they were admitted to a swing bed on 11/18/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement

- Patient #23's medical record review 6/14/2017 at 10:30 AM revealed they were admitted to a swing bed on 12/13/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement

- Patient #24's medical record review 6/14/2017 at 12:30 PM revealed they were admitted to a swing bed on 2/7/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement

Swing Bed Coordinator Staff Q interview on 6/13/2017 at 2:40 PM acknowledged the absence of the 30-day notice from the swing bed rights.

On 6/15/2017 the facility failed to provide a policy regarding swing bed discharges.

Based on document review, record review, and staff interview the Critical Access Hospital (CAH) failed to include in their Swing Bed rights the right to be free from abuse requirement for 4 of 4 swing bed medical records reviewed (Patient #2, 22, 23 and 24). Failure to notify patients of this right has the potential to place all swing bed patients at risk for abuse.

Findings Include:

- Patient #2's medical record review at 6/14/2017 at 9:00 AM revealed they were admitted to a swing bed on 5/19/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the right to be free from abuse requirement.

- Patient #22's medical record review 6/14/2017 at 10:00 AM revealed they were admitted to a swing bed on 11/18/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the right to be free from abuse requirement.

- Patient #23's medical record review 6/14/2017 at 10:30 AM revealed they were admitted to a swing bed on 12/13/2016 and the facility provided swing bed rights to the patient during their admission, which lacked the right to be free from abuse requirement.

- Patient #24's medical record review 6/14/2017 at 12:30 PM revealed they were admitted to a swing bed on 2/7/2017 and the facility provided swing bed rights to the patient during their admission, which lacked the right to be free from abuse requirement.

Swing Bed Coordinator Staff Q interview on 6/13/2017 at 2:40 PM acknowledged the absence of the right to be free from abuse requirement.

- Policy "Use of Restraints and Seclusion" reviewed on 6/15/2017 1:15 PM directs " ...all patients have the right to be free from abuse of any form ..."

- Document titled "Swing Bed Patient Rights" reviewed on 6/13/2017 at 2:40 PM revealed the document lacked the right to be free from restraints requirement.

Based on observation, interview, and record review, the Critical Access Hospital, (CAH) failed to provide an activity assessment for three of four swing bed medical records reviewed (Patient #22, 23, and 24). Failure to perform an assessment and provide activities based on the assessment outcome prevents all swing bed patients from promotion of pleasure and comfort.

Findings include:

- Patient #22's medical record review at 6/14/2017 at 10:00 AM revealed they were admitted to a swing bed on 11/18/2016 and lacked evidence an activity assessment was completed.

- Patient #23's medical record review on 6/14/2017 at 10:30 AM revealed they were admitted to a swing bed on 12/13/2016 and lacked evidence an activity assessment was completed.

- Patient #24's medical record review on 6/14/2017 at 12:30 PM revealed they were admitted to a swing bed on 2/7/2017 and lacked evidence an activity assessment was completed.

Director of Nursing Staff C interview on 6/14/2017 at 4:45 PM revealed the activities position had been vacant for some time, and the current activities coordinator started in that position about March of 2017.

- Policy "Activities for Skilled" review on 6/15/2017 at 1:45 directs " ...the residents will be assisted in the completion of the skilled swing bed activity assessment upon admission."

Based on staff interview and policy review, the Critical Access Hospital (CAH) failed to ensure provisions for emergency dental care for swing bed patients (one current swing bed patient). This deficient practice has the potential to place all swing bed patients at risk for poor oral and overall health.

Findings include:

- Interview of Social Worker Staff VV on 6/13/2017 at 3:00 PM communicated they do not have an arrangements for 24-hour dental emergencies. Staff VV indicates if emergent dental care is needed they would call the two local dentists and make an appointment for the patient upon discharge.

-Policy titled, "SNU (Skilled Nursing Unit) Dental Services" directed " ...patients will be assisted in making arrangements to obtain routine and emergency [dental] care ..."