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On the days of the recertification survey based on observations, review of patient charts, interviews, and review of the hospital policy and procedures, the hospital failed to provide documentation that patients received their "Patient Rights" information for 4 of 9 concurrent patient charts and for 6 of 12 closed patient charts, patient signature for consent for health treatment for 1 of 9 concurrent patient charts, and posting of "Patient Rights" information in public areas. (open Patient chart 1, 4, 5, and 6) (closed Patient chart 6, 7, 8, 9, 11, and 12).


The findings are:


On 02/04/13 at 12:25 p.m., random observations of the Emergency Department (ED) revealed there was no "Patient Rights" information posted. On 02/04/14 at 12:30 p.m., Staff Member 26 stated, "we have a copy of the Patient Rights that we give the patient, but there is not a Patient Rights notice posted in the ED".

On 02/04/14 at 2:15 p.m., review of Patient (Pt) 4's concurrent chart revealed there was no documentation that Pt 4 or Pt 4's designee received a copy of "Patient Rights" information.

On 02/04/14 at 2:00 p.m., review of Patient (Pt) 5's concurrent chart revealed there was no documentation that Pt 5 or Pt 5's designee received a copy of "Patient Rights" information.

On 02/04/14 at 9:00 a.m., review of Patient (Pt) 6's concurrent chart revealed there was no documentation that Pt 6 or the Pt 6's designee received a copy of "Patient Rights" information.

On 02/05/14 at 2:30 p.m., Staff Member 14 revealed, "if the patient or designee received a copy of the "Patient Rights", then the "Acknowledgement of Patient Rights" form would have their signature prior to scanning into the computer". Staff Member 14 verified the findings.

Hospital policy, titled, "Patient Rights", reads, "...Patient or their designee are asked to sign a copy for the patient record...Patient Rights are posted in public area."



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On 2/4/14 at 12:35 p.m., review of Patient 1's closed chart revealed there was no authenticated consent to treat in the patient's chart. On 2/4/14 at 1:00 p.m., Licensed Practical Nurse (LPN) 1 revealed that it had probably been scanned in, but had not been placed in the patient's chart yet.





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On 02/05/2014 at 11:15 a.m., Patient 2's concurrent chart revealed there was no "Acknowledgement Receipt of Patient Rights and Responsibilities" form signed by Patient 2. On 02/05/2014 at 11:30 a.m., the Director of Nursing verified the finding. On 2/05/2014 at 11:30 a.m., review of a closed chart for Patient 10 revealed there was no "Acknowledgement Receipt of Patient Rights and Responsibilities" form signed by the patient. On 02/05/2014 at 2:30 p.m., the Registrar verified the finding.


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On 2/05/2014 at 10:00 a.m., review of Patient 6's closed chart revealed the patient's chart did not have the acknowledgement form showing the patient received the list of patient rights on admission. On 2/06/2014 at 10:40 a.m., the Registrar verified the finding.

On 2/05/2013 at 9:30 a.m., review of Patient 7's closed chart revealed the patient did not have an acknowledgement form showing the patient received a list of patient rights on admission. On 2/06/2014 at 10:45 a.m., the Registrar verified the finding.

On 2/5/2014 at 10:45 a.m., review of Patient 8's closed chart revealed the patient did not have an acknowledgement form showing the patient received a list of patient rights on admission. On 2/06/2014 at 10:46 a.m., the Registrar verified the finding.

On 2/5/2014 at 10:30 a.m., review of Patient 9's closed chart revealed the patient did not have an acknowledgement form showing the patient received a list of patient rights on admission. On 2/06/2014 at 10:47 a.m., the Registrar verified the finding.

On 2/5/2014 at 3:00 p.m., review of Patient 11's closed chart revealed the patient did not have an acknowledgement form showing the patient received a list of patient rights on admission. On 2/06/2014 at 10:50 a.m., the Registrar verified the finding.

On 2/5/2014 at 3:15 p.m., review of Patient 12's closed chart revealed the patient did not have an acknowledgement form showing the patient received a list of patient rights on admission. On 2/06/2014 at 10:52 a.m., the Registrar verified the finding.

On the days of the critical access hospital's recertification survey based on observations and interview, the hospital failed to ensure preventative maintenance testing was completed on all of the ventilation systems.

The findings include:

On 02/04/2014 at 1:00 p.m., an interview was conducted with the Maintenance/Safety Officer and the Environmental Director. Review of the hospital's preventative maintenance program revealed no preventative maintenance of the ventilation system had been documented since 08/29/2008, and this was only preventive maintenance for the ventilation system in the operating room. No other documentation was presented for preventative maintenance of the ventilation system. The Maintenance/Safety Director stated, "I have only been in this position for six months, and was not aware of the testing since the previous Director did not train him". On 02/04/2014 at 1:15 p.m., the Maintenance/Safety Officer verified the findings.

On the days of the recertification survey based on observation and interview, the facility failed to ensure the premises was kept clean, uncluttered, and safe in the general facility, the emergency department, and the rehabilitation area.

The findings include:

On 02/04/2014 at 11:45 a.m., a tour of the hospital revealed the ceiling vents in the waiting room bathroom, rehabilitation area, ultrasound room, traction room had thick layers of dust. On 02/04/2014 at 1:00 p.m., the Maintenance Director/Safety Officer and the Environmental Director verified the findings.




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On 02/04/13 at 1:00 p.m., random observations in the Rehabilitation Department revealed the counter top in the whirlpool room was cluttered with two (2) continuous passive motion (CPM) machines, five (5)baseball size balls, and seven (7) medium size cones. Staff Member 15 verified the findings.

On the days of the critical access hospital recertification survey based on record review and interview, the hospital failed to ensure a systolic blood pressure was obtained prior to the administration of Lisinopril for 2 of 4 concurrent patient charts reviewed for medication administration, and to manage the storage and expirations of drugs and biologicals in the emergency department. (Patient 7 and 8)

The findings are:

On 02/04/14 at 1:00 p.m., review of Patient 7's concurrent chart revealed a patient admitted to the swing bed unit on 01/25/14. Review of medication administration records (MAR) revealed "Lisinopril 10 mg (milligram) PO (by mouth) daily, one dose =10 mg =1 tab (tablet), Hold for SBP (systolic blood pressure) less than 90 degrees, and the medication scheduled for 0900 a.m. daily. Review of the patient's medication administration record
revealed Lisinopril was administered within the hour before and/or the hour after the dosage time without any documentation of the patient's systolic blood pressure prior to administration from 01/25/14 to 02/04/14. Further review of the patient's graphic chart revealed the patient's vital signs were documented only at 4:00 p.m. daily on the patient's flow chart. On 02/05/14 at 10:30 a.m., Staff Member 9 revealed, "vital signs are checked at 4:00 p.m. on swing bed patients each day. The vitals are to be written under the time where it(Lisinopril) was administered". On 02/06/14 at 10:45 a.m., Staff Member 7 revealed, "per the pharmacy admission orders, antihypertensive meds (medications):....Zestril (Lisinopril)____mg (milligram) PO (by mouth) daily; hold for SBP less than 90...." is on the formulary for this medication.

On 02/05/14 at 11:00 a.m., review of Patient 8's concurrent chart revealed the patient was admitted to the swing bed unit on 02/03/14. Review of the patient's medication administration record revealed, "Lisinopril 20 mg PO every morning, one dose = 20 mg = 1 tab, Zestril 20 mg tabs, Hold for SBP less than 90", and the medication was scheduled for 09:00 a.m. daily. Review of the patient's medication administration record revealed Lisinopril 20 mg tablet was administered within one hour before medication administration period without any documentation of the systolic blood pressure prior to administration on 02/03/14 and 02/04/14. Review of the graphic sheet in the patient's chart revealed vital signs were obtained only at 4:00 p.m. daily on the flow chart. The findings were verified on 02/05/14 at 11:30 a.m. by Staff Member 9.







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On 02/04/14 at 12:35 p.m., random observations in the Emergency Department revealed an opened expired vial of Gastroccult Developer dated 06/21/12 as the opened date, opened vial of Hemoccult Developer without an opened date, time and initial, an opened vial of Humalog without an opened date, time, and initial, and an opened Novolin 70/30 vial dated 11/09/13 as the opened date. On 02/04/14 at 12:50 p.m., Staff Member 12 revealed the Gastroccult Developer is good for three (3) months and the insulin is good for 28 days after opening. The findings were verified with Staff Member 12.

On 02/04/14 at 1:00 p.m., observations revealed three (3) Sodium Chloride l liter bottles and one (1) Sterile Water 1 liter bottle opened without date, time and initials.

On 02/05/14 at 7:40 a.m., random observations of the anesthesia cart revealed one (1) syringe with white substance, and two (2) syringes filled with clear substance with no label and time, and one (1) vial of opened Lidocaine with no date, time and initials.

Hospital Policy, titled, "Open Vials and Containers of Floor-Stock Medications", reads, "...dates must be recorded immediately after vials are opened by clinical staff and vials should not be used beyond these dates...for open vials of Insulin on Nurse's medication carts, ER and OR: 28 days...for open multi-dose vials (MVD) of Lidocaine, Bacteriostatic and Sterile waters, and Bacteriostatic Sodium Chloride at Nurse's Station, ER and OR: seven days...".

On the days of the hospital's recertification survey based on observations, interview, review of governing body minutes, and review of the hospital's policy and procedures, the hospital staff failed to minimize the potential transmission of infections in the emergency room, in the rehabilitation area, and during blood draws. The governing body failed to document the designation of the Infection Control Officer.

The findings are:

On 02/04/14 at 12:00 p.m., random observations of the Emergency Department Triage room revealed Staff Member 12 and 27 failed to perform hand hygiene for 15-30 seconds during patient care activities.

On 02/04/14 at 12:00 p.m., random observations of the Triage room revealed the staff failed to disinfect the blood pressure cuff, pulse oximetry, and oral thermometer after patient use. On 02/04/14 at 12:30 p.m., the findings were verified with Staff Member 12.

On 02/06/14 at 11:15 a.m., review of the hospital's governing body minutes revealed no evidence of the designation of an Infection Control Officer.
On 02/06/14 at 12:00 p.m., Staff Member 24 revealed "there is documentation only in the "Infection Control Manual" that I am the Infection Control Officer.

Hospital Policy, titled, "Clean Equipment Management", reads, "...when equipment is shared, disinfection of equipment should take place prior to next patient use...".

Hospital policy, titled, "Hand Hygiene", reads, "...Hand washing should not take any longer than 15-30 seconds...".






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On 02/04/2014 at 11:45, a tour of the rehabilitation area revealed a sink in the whirlpool room with dirty scissors, clamps (8-9), and 4 tweezers in the sink. PT(Physical Therapist) 1 stated, "those were probably used in a wound debridement (cleaning of the wound) on a patient", but PT 1 could not state how long the items had been in the sink. PT 1 verified the findings on 02/01/2014 at 12:35 p.m.


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On 02/04/14 from 1:15 p.m.-1:25 p.m., observations of a phlebotomy draw revealed the phlebotomy tray with supplies was placed on the patient's bed, and not disinfected after removal from the bed.

On 02/04/14 at 1:15 p.m., observations of a phlebotomy draw revealed Staff Member 29 entered and exited the patient's room without performing hand hygiene after touching the patient.

On 02/04/14 from 1:15-1:25 p.m., observations of a phlebotomy draw revealed Staff Member 28 palpated the patient's intravenous site with gloved hands but failed to remove the gloves and perform hand hygiene prior to disinfecting the intravenous site.

On 02/04/14 at 1:30 p.m., Staff Member 28 revealed,"the phlebotomy tray is not to be placed on the bedside table. Since the big tray was not needed that's why I bought the small one....".

On the days of the recertification survey based on observations, interview and policy and procedure review, the hospital failed to ensure a clean and sanitary kitchen and failed to ensure nutritional assessments were completed on all patients requiring assessment upon admission to the hospital for 2 of 12 closed patient records. (Patient 1 and 2).

The findings include:

On 2/04/2014 from 11:30 a.m. - 12:30 p.m., random observations of the dietary department revealed:
stained ceilings throughout the dietary department with brownish residue on the walls in the department;
50 pound bags of flour and sugar, and (3) 35 pound containers of cooking oil were sitting on the floor in the dry storage area;
vents across the top of the wall in the dry storage were dusty and discolored with brown residue and the ceiling tiles discolored with yellowish spots;
a plastic container with cornmeal had a ladle for removing cornmeal in the cornmeal in the dry storage area; and
racks used for storing dry food in the dry storage area, the freezer, the refrigerator, and the pot storage area were discolored with brownish residue and had peeling finishes.
The hood over the stove area had a brownish residue and peeling paint throughout.
The large cook stove and the small cook stove were covered with a brownish residue and were stained with a blackish residue.
The oven on the left side of the large stove had racks were present, but the bottom covering the heating element was missing.
Ovens in the small and large stove were covered with a brownish residue. The floor and sides of the stoves were covered with a yellowish/brown residue.
The 2 deep fryers contained a black liquid. Replacement racks for the fryers were sitting on the floor and covered with a brownish sticky residue, and the floors beneath the fryers were stained with rust.
The mats in front of the stoves and in the tray area were sticky and discolored.
The grout throughout the kitchen floor was discolored and stained and sticky.
The floor in the refrigerator and the freezer were yellowish with food residue on the floor and boxes sitting on the floor not on a pallets.
The kitchen's ice maker seal had a black discoloration and the plastic guide for the ice had a pinkish discoloration.

On 2/04/2014 at 1:00 p.m., the Food Service Director reported, "...I do not make out a specific schedule. I put a sticky note on the schedule and remove it if the scheduled chore is performed by the employee."

On 2/05/2014 at 12:40 p.m., review of Patient 1's closed medical record revealed the patient scored a 16 on the nutritional screen on the nursing assessment without a dietary consult. On 2/05/2014 at 2:30 p.m., verification was received by the Dietary Manager.

On 2/05/2014 at 12:50 p.m., review of Patient 9's closed medical record, revealed the patient scored a 11 on the nutritional assessment without a dietary consult. On 2/05/2014 at 2:45 p.m., verification was received by the Dietary Manager.

Guidelines on the nutritional assessment, reads, "...A score of 6 or more should be considered at risk...Send request for Nutritional Assessment to Dietary within 12 hours of admission or at any time there is a change during admission..."

Hospital policy, titled, DIETARY SCREENING AND ASSESSMENT, states: "...Upon admission (within 12 hours) all patients will be assessed by nurse for:...weight loss/gain in last 30 days...nausea/vomiting in last 2 days...swallowing or chewing difficulty...tube feedings...pressure sores...if one of the above five is noted on admission or during hospital admission, Dietary Supervisor will be notified and Dietary Supervisor or R. D. (Registered Dietician) will complete a nutritional assessment within 24 hours after notification...".

On the days of the hospital's recertification survey based on interview and review of patient charts, the Critical Access Hospital (CAH) failed to ensure the patient's 24 hour plan of care review and revision was completed for 1 of 21 patient records review for care plans. (Patient 1).

The findings are:

On 2/4/14 at 12:35 p.m., review for Patient 1's chart showed the patient was admitted on 2/1/14 for Congestive Heart Failure (CHF) Exacerbation. Review of the patient's chart revealed there was no twenty-four (24) hour plan of care review and revision completed on 2/2/14 and 2/3/14. The findings were verified on 2/4/14 at 1:00 p.m. with Licensed Practical Nurse (LPN )1.

On the days of the critical access hospital recertification survey based on patient record review,interview, and review of hospital policy and procedure, the hospital failed to ensure nutritional assessments were completed for 2 of 3 swing bed patients. (Patient 7 and 9).


The findings are:


On 02/04/14 at 1:00 p.m., review of Patient 7's chart revealed the patient was admitted to the swing bed unit on 01/25/14. Review of the patient's hospital discharge summary revealed the patient's final diagnoses were dehydration, malnutrition, chronic obstructive pulmonary disease, anemia, anxiety disorder, reflux, peripheral vascular disease, tremor, hypertension and failure to thrive. Review of the nursing admission assessment performed on 01/21/14 revealed a nursing nutritional screen performed by Staff Member 10. The nutritional screen stated "a score of 6 or more should be considered at risk. Send request for nutritional assessment to dietary within 12 hours of admission or at any time there is a change during admission....". Further review of the patient's chart revealed no nutritional assessment was completed as of 02/04/14.

On 02/05/14 at 1:05 p.m., interview with Staff Member 8 revealed, "the nursing assessment is done by the staff and based on the scoring, we send a special services slip for consult. We have 24-48 hours in which to do the consult".

On 02/05/14 at 12:20 p.m., review of Patient 9's chart revealed the patient was admitted to the swing bed unit on 01/15/14. Review of the hospital's History and physical dated 01/15/14 revealed chief complaints of lumbar spinal stenosis with leg weakness, pulmonary fibrosis with recent hospital-acquired pneumonia, history of urinary tract infection, generalized weakness, osteoarthritis/degenerative joint disease, hypothyroidism and hyperlipidemia. Review of the nursing admission assessment dated 01/15/14 showed the patient's nutritional screen assessment was performed with a score of 6. The nutritional screen stated, "a score of 6 or more should be considered at risk. Send request for nutritional assessment to dietary within 12 hours of admission or at any time there is a change during admission....". Review of the patient's chart revealed a special services slip sent for a "nutritional screening dated 01/17/14". Review of the patient's chart revealed no nutritional assessment was completed as of 02/05/14.
On 02/05/14 at 1:05 p.m., Staff Member 8 revealed, "I don't know why it wasn't done but its not done".

Hospital policy, titled, "Dietary Screening and Assessment", reads, "....Registered Dietician will provide on site assessment within 24 hours. R. D. (registered dietician) provides consultant to dietary, nursing, MD (medical doctor) monthly and/or as needed during the month".