HospitalInspections.org

Based on observation, staff interview, and document review it was identified the Critical Access Hospital (CAH) uses succinylcholine (a medication used as a muscle relaxant during rapid sequence intubation (a procedure where a tube is placed into the patients airway to manage breathing) and failed to follow professional guidelines for stocking the emergency medication Dantrium/Revonto (a medication used to treat Malignant Hyperthermia, which is a rare potentially fatal condition associated with the use of the muscle relaxing medication succinylcholine). (Refer to C-0203). Failure to have Dantrium/Revonto could cause patient harm or death in the event of Malignant Hyperthermia.

Findings include...

An Immediate Jeopardy (IJ) (a situation that has or is likely to cause patient harm) was identified on 03/05/18 at 2:30 PM when Director of Nursing Staff D confirmed the facility stocks and uses succinylcholine and confirmed the Dantrium/Revonto on hand was expired as of 02/18/18. Director of Nursing Staff D suspended the use of succinylcholine until the 36 vials were obtained by the hospitals pharmacist and provided information to the Emergency Department Providers. Director of Nursing Staff D confirmed the hospital does not provide surgical or obstetric services at this time.

Pharmacist Staff F arrived at the hospital on 03/05/18 at 5:00 PM with 36 vials of Dantrium/Revonto.
The facility removed the IJ with the arrival of the 36 vials of Dantrium/Revonto on 03/05/18 at 5:00 PM.
Refer to C-0203 for further information.

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) failed to ensure emergency medications were readily available in the emergency department (ED) by failing to have medication on hand to treat Malignant Hyperthermia (a rare life-threatening condition causing a severe high body temperature triggered by medications that act as depolarizing muscle relaxants such as succinylcholine (a muscle relaxant administered in ED's when breathing is compromised requiring intubation (a procedure where a tube is placed into the patients airway to manage breathing). Failure to have enough of the rescue drug Dantrium/Revonto immediately available for use has the potential for delays in responding to a medical emergency causing a worsening of a patient's condition or death.

Findings include...

- Emergency Department refrigerator observed on 03/05/18 at 11:30 AM revealed two vials of succinylcholine.
Director of Nursing Staff D interviewed on 03/05/18 at 2:30 PM confirmed they use succinylcholine for rapid sequence intubation of emergency department patients.

Rapid Sequence Intubation Protocol reviewed on 03/05/18 at 3:00 PM directed, administer single dose Succinylcholine 1/5mg (milligrams)/kg (kilogram) (100mg for 70kg average adult) IVP (IV push - inject through a catheter in the vein).

Pharmacy Storage Area observed on 03/05/18 at 2:30 PM revealed 30 vials of Dantrium/Revonto with an expiration date of 02/18/18.

Pharmacy Formulary Document reviewed on 03/05/18 at 2:15 PM revealed the facility stocked the medication succinylcholine 200 milligrams/10 milliliters.

Director of Nursing Staff D interviewed on 03/05/18 at 2:30 PM confirmed they would remove succinylcholine from stock and not return it until they had 36 vials of unexpired Dantrium/Revento on hand. Staff D indicated the pharmacist was expected to return with the medication in less than two hours as their supplier was located 30 miles away.

Pharmacist Staff D returned with the 36 vials of Dantrium on 03/5/18 at 5:00 PM.

Malignant Hyperthermia Association of the United States website reviewed on 12/04/17 directed, the patient experiencing a Malignant Hyperthermia (MH) episode must be stabilized before being transported. Stabilization of an MH episode may take 30 minutes or more with multiple doses of Dantrium/Revonto because, in some cases, MH progresses with explosive rapidity. The full 36 vials of Dantrium/Revonto is inexpensive insurance against patient injury or death and a malpractice claim, which the facility will lose. The full 36 vials of Dantrium/Revonto should be available within five minutes of the diagnosis of MH.

Based on observation and interview the Critical Access Hospital (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 sink 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...

- Dietary kitchen observed on 03/06/18 at 10:19 AM revealed one of one food utility sinks lacked placement of an airgap to the drainage system.

Maintenance Staff E interviewed in the team conference room on 03/06/18 at 11:18 AM verified the dietary utility sink lacked placement of an airgap to the drainage system.

The CAH failed to develop and implement a policy and procedure concerning the placement of an airgap to the kitchen utility sink to prevent backflow of food, gases and other contaminates.

According to the Kansas State Food Code 2012 regulation 5-203.14 Backflow Prevention Device read, 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).

Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure the governing body selected the appropriate action for five of six credential files reviewed (Staff F-J). This deficient practice has the potential to allow unqualified physicians and Allied Health Providers (Advanced Practice Registered Nurses (APRNs) and Physician Assistants) to provide care which could cause patient harm or death.

Findings include...

- APRN Staff F's credentialing file reviewed on 03/06/18 at 4:00 PM revealed the Recommendation and Approval Form failed to have a recommended action for Staff F's September 2017 reappointment.

- APRN Staff G's credentialing file reviewed on 03/06/18 at 4:00 PM revealed the Recommendation and Approval Form failed to have a recommended action for Staff G's February 2018 reappointment.

- Physician Staff H's credentialing file reviewed on 03/06/18 at 4:00 PM revealed the Recommendation and Approval Form failed to have a recommended action for Staff G's September 2017 reappointment.

- Physician Staff I's credentialing file reviewed on 03/06/18 at 4:00 PM revealed the Recommendation and Approval Form failed to have a recommended action for Staff I's February 2016 reappointment.

- Physician Staff J's credentialing file reviewed on 03/06/18 at 4:00 PM revealed the Recommendation and Approval Form failed to have a recommended action for Staff J's September 2017 reappointment.

Director of Nursing Staff D interviewed on 03/06/18 at 4:50 PM, confirmed the signed form lacked a recommendation from the governing body. Staff D indicated they were unsure why the document was not completed correctly.

Document titled "Governing Body Bylaws" reviewed on 03/06/18 at 5:50 PM directed, the trustees shall be delegated the responsibility by the Board for the functions enumerated below, subject to these Bylaws. 3.9.1 Staff Appointments and Reappointments, and the granting of staff privileges. 8.1.5 The trustees shall make decisions upon recommendations from the Staff as to the types and extent of professional work permitted to be done by each appointee.

Based on staff interview and policy review the Critical Access Hospital (CAH) failed to ensure a Medical Doctor (MD) or Doctor of Osteopathy (DO) participated in the periodic review of hospital policies. This deficient practice has the potential to cause ineffective guidance for hospital staff, which could lead to poor patient outcomes.

Findings include...

- Document titled, "Kingman County Hospital CAH Annual Program Evaluation" for the period of 05/01/16 to 04/30/17, reviewed on 03/07/18, directed, The CAH reviews all policies on an annual basis by department. However, this Annual Program Evaluation showed only two departments were reviewed; the therapy and emergency preparedness department. The Evaluation also included review of one dietary policy regarding diabetic meal preparation. The Program Evaluation review lacked evidence the review was completed in collaboration with an MD or DO.

As of 3/08/18, the CAH failed to provide evidence of the participation of an MD or DO in the development of hospital policies.

CEO Staff A interviewed on 03/07/18 at 2:35 PM explained there is no formal policy review process at the CAH, and when asked if MDs or DOs were involved in the policy development and review process, they exclaimed, "obviously not!"

As of 03/08/18, the CAH failed to provide a policy directing staff on the annual review of policies and procedures including an MD or DO.

Based on medical record review, staff interview, and document review the Critical Access Hospital (CAH) failed to ensure nine of nine patients (Patient #'s 1-9) treated by Allied Health Professionals (Physician Assistants and Advanced Practice Registered Nurses) (Staff F, M, and O,) were countersigned by their overseeing physician (Physician Staff H) as required by the CAH's Medical Staff Rules and Regulations.

Findings include...

- Patient # 1-9's medical records reviewed on 03/06/18 revealed them to be emergency department patients that were treated by an Allied Health Professional and lacked documentation of a physicians' co-signature.

During an interview on 03/06/18 at 11:30 AM, Health Information Manager, Staff C, stated that they have not required co-signatures in the medical records for patients treated by Allied Health Professionals.

- Document titled, "Medical Staff Rules and Regulations" reviewed on 03/07/17 at 1:00 PM directed, Orders by Allied Health Professionals. An allied health professional (AHP) my write orders only to the extent, if any, specified in the position description developed for that category of AHP's and consistent with the scope of services individually defined for them. Any authorized order by an AHP must be countersigned by the responsible supervising practitioner within the time frame required in said position description or defined scope of services and, in all circumstances, within 24 hours.

Based on staff interview and policy and procedure review the Critical Access Hospital failed to ensure Allied health providers (Physician Assistants, Nurse Practitioners, or Clinical Nurse Specialists) participated in periodic review of hospital policies. This deficient practice has the potential to cause ineffective guidance for hospital staff, which could lead to poor patient outcomes.

Findings include...


- Document titled "Kingman County Hospital CAH Annual Program Evaluation" for the period of 05/01/16 to 04/30/17, reviewed on 03/07/18, directed, The CAH reviews all policies on an annual basis by department. However, this Annual Program Evaluation showed only two departments were reviewed; the therapy and emergency preparedness departments. The Evaluation also included review of one dietary policy regarding diabetic meal preparation. The Program Evaluation review lacked evidence the review was completed in collaboration with an allied health professional.


CEO Staff A interviewed on 03/07/18 at 2:35 PM explained there is no formal policy review process at the CAH, and when asked if allied health professionals were involved in the policy review process, they exclaimed, "obviously not!"

As of 03/08/18, the facility failed to provide a policy directing staff on the annual review of policies and procedures by allied health staff.

Based on staff interview and policy and procedure review the Critical Access Hospital (CAH) failed to provide evidence of an advisory group consisting of at least one physician and allied health member (Physician Assistant or Nurse Practitioner) to review the CAH's written policies governing patient care services at least annually. This deficient practice has the potential to cause ineffective guidance for hospital staff, which could lead to poor patient outcomes.

Findings include...

As of 03/08/18, the CAH failed to provide evidence that policies and procedures were developed or reviewed annually by an advisory group consisting of at least one physician and allied health member.

During an interview on 03/07/18 at 2:35 PM, Chief Executive Officer (CEO), Staff A, explained there is no formal policy review process at the CAH, and when asked if allied health professionals were involved in the policy review process, they exclaimed, "obviously not!"

As of 03/08/18, the facility failed to provide a policy directing staff on the annual review of policies and procedures to include allied health staff.

Based on policy review, observations and staff interviews the Critical Access Hospital (CAH) failed to dispose of all expired medications in one of two emergency department (ED) rooms (three bed ED room) and one of one labor and delivery rooms, failed to ensure all opened and punctured multi-use vials of medications were dated and disposed of within 28-days in one of two emergency rooms (three bed ED), failed to ensure medications placed in one of two fluid warmers (ED fluid warmer) were dated for appropriate removal, and failed to ensure all medications were kept in a secured in one of two emergency rooms (three bed ED room) and one of one pharmacy rooms. These deficient practices place all patients at risk for receiving ineffective medications and allow access to potentially harmful or fatal medications.

Findings include:

- Labor and Delivery room observed on 03/05/18 at 10:15 AM revealed the following outdated medications:

- One bag of Lactated Ringers 1000 milliliters (ml) (a medication used to increase fluid in the body) with an expiration date of 03/01/18.

- One bag of Sodium Chloride 1000 ml (a medication used to increase fluid in the body) with an expiration date of 02/01/18.

- Three bags of 5% Dextrose 250 ml (a medication used to provide fluids and carbohydrates to the body) with an expiration dates of 11/01/17, 01/01/18, and 09/01/17.

During an interview on 3/05/18 at 10:15 AM, Human Resources Director, Staff B, confirmed the items were expired and indicated the room is used "just in case" they had an emergent delivery.


- Three bed emergency room observed on 03/05/18 at 10:35 AM revealed the following outdated medications:

- One Lidocaine and Procaine cream (medications used for locally numbing) with an expiration date of 02/18.
- Six tablets of Ibuprofen 800 milligrams (mg) (a medication used to treat pain) with an expiration date of 02/18.
- Two tablets of Cephalexin 250 mg (a medication used to treat infections) with an expiration date of 01/18.
- Six tablets of Azithromycin 250 mg (a medication used to treat infections) with an expiration date of 02/18.

- One bottle of liquid Children's Acetaminophen (a medication used to treat pain and fever) with an expiration date of 4/17.
- Two bags of 5% Dextrose 250 ml with expiration dates of 01/17.
- One bag 5% Dextrose 1000 ml with an expiration date of 01/17.
- One bag Sodium Chloride 50 ml with an expiration date of 03/17.
- One vial of Sterile Water 50 ml with an expiration date of 01/18
- One syringe of Saline 10 ml with an expiration date of 10/16.

During an interview on 03/05/18 at 10:40 AM, Human Resources Director, Staff B, confirmed all the identified medications were expired medications. Staff B indicated they were unsure who was responsible for inventory in the emergency department.

Policy titled, "Routine Checking for Outdated Medication," reviewed on 03/07/18 at 10:00 AM directed, A. Medication dates shall be checked monthly, B. RN's shall be assigned to this task.

- Upper medication cabinet located in the 3 bed emergency room observed on 03/05/18 at 10:45 AM revealed the following unsecured medications:

- One bag Sodium Chloride 50 ml
- One vial of Sterile Water 50 ml
- One syringe of Saline 10 ml
- One TNKASE kit (a medication used to treat blood clots)
- Two vials of Tranexamic 1000 mg/10 ml (a medication used to promote blood clotting)
- Seven vials of Amiodarone 150 mg/3 ml (a medication used to treat heart rhythm problems)

During an interview on 03/05/18 at 10:30 AM, Human Resources Director, Staff B interviewed on 03/05/18 at 10:45 AM confirmed the medication stored in the cabinet was not secured and acknowledged that medications should be securely stored.

- Unlocked emergency department refrigerator observed on 03/05/18 at 11:30 AM revealed the following unsecured medications:

- Two vials Succinylcholine 20 mg/ 10 ml (a medication used to relax muscles during procedures)
- One Humalog Pen 100 units (insulin, a medication used to treat diabetes)
- One Lantus Pen 100 units (insulin, a medication used to treat diabetes)
- One vial of Tetanus vaccine 0.5 ml (a medication used to prevent tetanus)
- Two suppositories of Promethazine 25 mg (a medication used to treat motion sickness, nausea, and vomiting) with an expiration date of 01/18
- Three bags of Sodium Chloride 1000 ml with an expiration date of 08/17

During an interview on 03/05/18 at 10:30 AM, Human Resources Director, Staff B interviewed confirmed there was not a lock of the refrigerator leaving all medications stored in there unsecured.

- Locked upper cabinet located in the 3 bed emergency room observed on 03/05/18 at 10:45 AM revealed the following open and undated and open and expired items:

- One vial of Bupivacaine 25milligrams (mg)/10ml (a medication used to numb an area of the body) opened and undated
- One vial of Epinephrine 1mg/10 ml opened on 01/25/18 (39 days) (a medication used to treat life threatening allergic reactions)
- One vial of Lidocaine 200 mg/20 ml opened and undated.

During an interview on 03/05/18 at 12:05 PM, Director of Nursing, Staff D, indicated medications should be dated when they have been opened and discarded within 28 days. Staff D confirmed that one of the two RN staff members (Staff K and L) that are responsible for pharmacy should have caught the outdated items and removed them from stock.

Policy titled, "Labeling for Outdates and Automatic Discarding of Meds," reviewed on 03/07/18 at 9:50 AM directed, all medications shall be labeled with the date of expiration upon opening. 1. The date shall be: a) Multi-dose vials is 28 days. C) All medications that have been open for greater than the posed expiration date shall be discarded.

- Fluid Warmer located in the three bed emergency room observed on 03/05/18 at 11:15 AM revealed the following undated items:

- Two 1000 ml bags of Sodium Chloride
- One bottle of Sodium Chloride irrigation solution

During an interview on 03/05/18, Director of Nursing, Staff D, confirmed the items should be labeled with a date in the fluid warmer.

The hospital failed to provide a policy directing staff to ensure all fluids placed in fluid warmers were dated.

- Narcotic drawer located in the 3 bed emergency room observed on 03/05/18 at 10:55 AM revealed the following items in a single locked drawer in an unsecured room:
- 44 Lortab 5 mg/325 (a narcotic medication used to treat pain)
- 10 Percocet 5 mg/325 (a narcotic medication used to treat pain)
- Four vials of Midazolam 2 mg/ ml (a sedative medication used to help patients feel relaxed)
- Three vials of Morphine 10 mg/ ml (a narcotic medication used to treat pain)
- One vial of Hydromorphone 4 mg/ ml (a narcotic medication used to treat pain)

During an interview on 03/05/18 at 11:15 AM, RN, Staff K interviewed on indicated they were not aware narcotic medications should be secured by two locks.

- Pharmacy room observed on 03/06/18 at 1:50 PM revealed the pharmacy door to be unlocked, open and unattended. At 1:51 PM, RN, Staff L, entered the room startled to find a person in the room.

During an interview on 03/06/18 at 1:52 PM, RN, Staff L confirmed the door was unlocked and stated, "I was just around the corner and only gone for a minute".

The CAH failed to provide a policy directing staff to ensure all medications were stored in a secure manner in all locations of the hospital.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure the following:

- A system for removing outdated supplies from: the labor and delivery room; the emergency room; the pediatric emergency supply cart; and the anesthesia cart. This deficient practice has the potential to cause supplies to be in deteriorated packaging which could cause contamination.

- Fluid resistant gowns were available for laundry staff handling infected laundry. This deficient practice puts all staff at risk for acquiring illness, infections and communicable diseases.

- Cleaning of equipment in the dietary kitchen was completed for one of one plastic black box under the dishwasher. This deficient practice puts all patients and staff at risk for acquiring bacteria, illness and diseases.

- Expired food in the kitchen was discarded, food containers were dated upon being opened and prepared food placed in the freezer for future use was dated. This deficient practice puts all patients and staff at risk for food poisoning, illness and infections.

- The ice machine in the staff cafeteria was free from water build up and corrosion. This deficient practice puts all staff at risk for infections, illness and diseases.

- Three large crates used to places dishes prior to going into the dishwasher were clean. This deficient practice puts all patients and staff at risk for infection, illness and diseases.

- The cabinet under the sink in the physical therapy room and the sink in the outpatient treatment room were free from storage of supplies. This deficient practice puts all staff and patients at risk for receiving care and treatment from supplies and equipment that is contaminated and exposure of supplies and cleaning agents to visitors and patients causing harm, allergic reactions and infections.

- Two of two pink lab tubes located in the outpatient treatment room were discarded after expiration on 02/28/18. This deficient practice puts all patient at risk for incorrect lab results, incorrect treatment and harmful outcomes.

Findings include...

- Labor and delivery room observed on 03/05/18 at 10:15 AM revealed the following expired items:
- One bottle PVP prep solution (antiseptic for preparation of the skin prior to surgery) with an expiration date of 07/17
- Two packages of sterile gloves with an expiration date of 08/17
- One Nitra test paper (used to test the acidity of body fluids) with an expiration date of 01/18
- One tube of EZ lube ( used to help with the insertion of catheters, surgical instruments and gloves into body orifices with an expiration date of 07/16

During an interview on 03/05/18 at 10:15 AM, Human Resources Staff B, indicated the labor and delivery room hasn't been used in a very long time, but one of the nurses should still be checking for out dated supplies.


- Emergency department supply cabinets observed on 03/05/18 at 10:35 AM revealed the following expired supplies:
- One tube of Lidocaine and Prilocaine cream (used to numb the skin) with an expiration date of 02/18
- Two Nasopharyngeal airways (a tube inserted into the nasal passageway to secure an open airway) with an expiration date of 04/17
- Three 24 gauge IV (intravenous -through the veins) needles with an expiration date of 08/15
- Two 18 gauge spinal needles with an expiration date of 06/09
- One Chest drainage Unit with an expiration date of 09/17
- Two Infant feeding tubes with an expiration date of 09/17
- One package of pedi padz (pediatric pads used for defibrillation)

- Pediatric Emergency Supply Cart observed on 03/05/18 at 11:00 AM revealed the following expired supplies:
- One Quick trach (a quick airway access via a one-step procedure. An incision by scalpel isn't necessary) with an expiration date of 02/18
- One Illinois bone marrow needle (a sharp lancet point that penetrates easily into the bone to help ensure a safe and simple aspiration of marrow. An adjustable depth guard provides depth control for greater patient safety and the twist-off cap holds the stylet securely in place) with an expiration date of 11/17
- Three Stomach tubes with an expiration date of 01/18
- One coiled suction catheter with and expiration date of 01/18
- Two Endotracheal tubes (placed into the windpipe (trachea) through the mouth or nose to secure an airway with expiration dates of 12/17 and 06/17
- One Foley catheter (placed in the bladder to drain urine) pediatric with an expiration date of 06/17
- Three Intubating stylets (used to assist in the placement of an endotracheal tube) with an expiration date of 11/17
- One IV start kit with an expiration date of 02/17
- One small bore IV extension set with an expiration date of 07/17
- One mini spike needle with an expiration date of 02/04


During an interview on 03/07/18 at 10:30 AM, Infection Control Officer Staff N, indicated the inventory of supplies are supposed to be conducted by the nursing staff on a monthly basis. Staff N reported she believed the nurses were confused as to who was assigned to ensure outdated supplies were removed from the emergency department and the labor/deliver room.

- Policy titled, "Expired supplies" directed, Items will be removed prior to their expiration date and destroyed.

- Laundry room observed on 03/06/18 at 9:31 AM revealed two yellow cloth gowns that were to be worn when handling infected laundry items.

During an interview on 03/06/18 at 9:31 AM, Laundry Staff P, explained the yellow gowns are worn when handling soiled and infected laundry items. Staff P hoped the gowns would protect him/her, but failed to know if they would protect him/her from infected laundry. Staff shared the gowns are washed after daily use.

During an interview on 03/6/18 at 9:57 AM, Laundry Manager Staff Q, interviewed in the team conference room, clarified she is not sure if the cloth gowns are fluid resistant to protect staff from infectious laundry.

- Policy titled, "Categories For Use of Personal Protective Equipment (PPE)" directed, appropriate personal protective equipment will be available to and utilized by the...staff to provide a barrier against pathogens transmitted via blood and body fluids...all procedures or other job related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues or a potential for spills or splashes of them are Category I tasks. Use of gloves, gowns, mask and eye protection is required.

- Policy titled, "Isolation Precautions" directed, contact precautions...this is used for patient that are known or suspected to be infected with an organism that can be transmitted by direct contact hand or skin to skin contact that occurs during normal patient care activities. In addition to all standard precautions you must also...wear a clean non sterile gown...if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces or items, in the patient's room, or if the patient is incontinent or has diarrhea, an ileostomy colostomy, or wound drainage no contained by a dressing. Remove the gown before leaving the patient's room. After gown removal be careful that your clothing does not touch any potentially contaminated equipment.

- Dietary kitchen observed on 03/06/18 at 10:19 AM revealed:

- A plastic black box under the dishwasher machine that was wiped with a glove and large amounts of dust rolled off.
- Two bananas loose in the freezer that failed to be included in the zip lock freezer bag.
- Prepared biscuits in a freezer bag that failed to have a date on it.
- One large bag of at least 15 prepared rolls in a freezer bag that failed to have a date on
- One large bag of at least 10 jalapenos in a freezer bag that failed to have a date on it.
- One box of Cream of Wheat opened without an opened date on the box.
- Six - 64 ounce cans of Salmon with an expiration date of 02/07/18.
- One staff ice machine with large amounts of white water build up on the outside panel of the machine, and thick white water building up on the lower drain and grill (also containing corrosion).
- Three plastic crates used to place dishes in the dishwasher covered with white water build up outside and inside.

During an interview on 03/06/18 at 10:19 AM, Laundry Manager Staff Q, verified the black plastic box with a large amount of dust, two loose bananas that failed to be included in the freezer bag, prepared biscuits and rolls that failed to have a date on the freezer bag, jalapenos that failed to have a date on the freezer bag, a box of Cream of Wheat that failed to have a date on the box of when it was opened, six cans of expired Salmon, the water build up and corrosion on the staff ice machine, and the 3 plastic crates for dishes with large amounts of white water build up on the inside and outside.

- The CAH failed to develop and implement a policy concerning cleaning of kitchen equipment, dating food items placed in freezer bags and placed in the freezer, ensuring all food items are secured in the freezer bags, dating opened boxes, discarding expired foods and cleaning water build up off the ice machine and dishwashing crates.

- Physical Therapy room observed on 03/07/18 at 9:45 AM revealed the cabinet under the sink with 3 rolls of paper towels, two spray cleaning bottles and soap refills. The supplies were accessible to the general public, unsecured and stored in an unclean environment.

Rehabilitation Manager Staff U interviewed on 03/07/18 at 9:45 AM verified the cabinet under the sink failed to be secured/locked and contained paper towels and cleaning supplies.

- Outpatient Treatment room observed on 03/07/18 at 9:18 AM revealed the cabinet under the sink with a flower vase, several plastic bags, Vindicator germicide (one bottle), Butchers Breakdown Odor Elements (one bottle), two blood collection sets and 4 biohazard bags were accessible to the general public, unsecured and stored in an unclean environment.

During an interview on 03/07/18 at 9:18 AM, Registered Nurse Staff T, verified the flower vase, plastic bags, germicide, odor element bottles, blood collection sets and biohazard bags were unsecured from the general public and stored in an unclean environment.

- The CAH failed to develop and implement policy and procedures for ensuring cabinets under the sinks were free from supplies and cleaning supplies were locked and secured from the general public.

- Outpatient treatment room observed on 03/07/18 at 9:18 AM revealed two pink top lab tubes with an expiration date of 02/28/18.

During an interview on 03/07/18 at 9:18 AM, Registered Nurse Staff T, verified the two pink top lab tubes with an expiration date of 02/28/18.

Based on observation, interview, document, policy and procedure review the Critical Access Hospital (CAH) failed to ensure the nutritional needs of patients are met according to recognized dietary practices, policy and procedures, and that diets are implemented according to a current dietary manual for seven of 30 records reviewed (Patients # 11, 12, 14, 18, 23, 24 and 25). This deficient practice puts all patients at risk for poor healing, allergic reactions to foods, illness and severe medical complications.

Findings include...

- Dietary kitchen observed on 03/06/18 at 11:08 AM revealed a blue notebook with various recipes printed from the internet and written in hand used for patient meals, recipes from "Taste of Home", a book titled "Food for Fifty" published in 2001 from Kansas State University and a spread sheet with various diets (puree, soft/mechanical, 1,200; 1,500; 1,800 calorie diabetic diet, 2 gram sodium, low cholesterol and limited concentrated sweets (LCS) diet).

Patients # 11, 12, 14, 18, 23, and 24's medical records reviewed in the nursing station on 03/07/18 revealed six patients with diabetic diets ( #11, #12, #14, #18, #23, and #24) and one patient with a low salt diet (Patient #25).

During and interview in the dietary kitchen on 03/06/18 at 11:08 AM, Dietary Manager Staff Q, explained she has been in this position and received training at the community college for Dietary Manager, and Serv Safe Certification. Staff Q shared she works with the registered dietician, Staff R on a monthly basis and can call her any day and time for consultation and direction. Staff Q stated concerning meal preparation "it's mainly in my head." Staff Q further explained on a monthly basis she collaborates with the Dietician Staff R and a spread sheet based on a point system is created according to the menu for the various diets required to meet the needs of each patient.

During a phone interview on 03/07/18 at 8:30 AM, Registered Dietician, Staff R explained she is scheduled to come to the CAH one time a month to look at temperatures on foods and equipment, and is available on phone for any dietary consults or concerns. Staff R explained the portions and diets are produced on a spread sheet that was designed by Staff H, MD who does not want the diets to be too strict. Staff R and Staff Q collaborate each month with the menu's to determine a point system for each diet. This surveyor asked how you determine the points and Staff R explained that it is an old system that was taken from a Kansas diet manual where they look up calories and convert them into points. When asked how you determine the portions size for each therapeutic diet Staff R stated, "I am not sure how to convert points into portions."

During an interview in the team conference room on 03/06/18 at 3:17 PM, Dietary Manager Staff Q brought in a policy she had typed today as they failed to have dietary policy and procedures that are current and updated.

The CAH failed to develop and implement policies and procedures for dietary services.

Based on medical record review, staff interview and document review, the Critical Access Hospital (CAH) failed to ensure that hospital staff completed a discharge for one of 30 (Patient #24) medical records reviewed. Failure to complete and authenticate a discharge summary within 30 days of discharge, deems the medical record incomplete and inaccurately documented.

Findings include...

Document titled "Medical Staff Rules and Regulations," directed, in general: A discharge summary must be recorded for all patients.

- Patient #24's medical record showed an admission date of 10/09/17 with a diagnosis of T11 and T12 fractures (fractures of the bones of the thoracic spine) and discharged on 10/12/17. The record further revealed as of 03/08/18, the record lacked a discharge summary, rendering the medical record incomplete for 148 days exceeding the 30 day requirement.

During an interview on 03/07/18 at 4:00 PM, Registered Nurse Staff N, acknowledged Patient #24's record lacked a discharge summary.

Based on staff interview, medical record and document review the Critical Access Hospital (CAH) failed to ensure the Allied Health Providers' (Staff M and O) orders were authenticated (the process or action of proving or showing something to be true, genuine or valid) for verbal orders in four (Patient #'s 1, 2, 5 and 25) of 30 medical records reviewed. Failure to authenticate orders places patients at risk for receiving medications, treatments and care that is unsafe with the potential of causing harm.

Findings include...

Document titled "Medical Staff Bylaws" reviewed on 03/07/18 at 1:00 PM directed, all verbal orders shall be transcribed in the proper place in the medical record, shall include the date, time, name, and signature of the person transcribing the order and the name of the practitioner, and shall be countersigned by the prescribing practitioner within 24 hours.

- Patient #1's medical record review on 03/06/18 revealed the Patient was admitted to the emergency department on 03/01/18. The record revealed verbal orders failed to be signed within the timeframe as follows:
Seven verbal orders for Patient #1, given on 03/01/18 revealed Provider Staff M failed to authenticate the orders.

- Patient # 2's medical record review on 03/06/18 revealed an ED visit on 02/26/18. Seven verbal orders for Patient #2, given on 02/26/18 revealed Provider Staff M failed to authenticate the orders.

- Patient #5's record review on 03/06/18 revealed an ED visit on 03/01/18. The record revealed verbal orders failed to be signed within the timeframe as follows: Eight verbal orders for Patient #5, given on 3/01/2018 revealed Provider Staff O failed to authenticate the orders.

- Patient #25's medical record review on 03/07/18 revealed an admission date on 01/09/18 with a diagnosis of congestive heart failure and discharged to swing bed status on 01/12/18. The medical record review revealed a verbal order was placed by nursing staff on 01/09/18 for vital signs monitoring. Medical record review reveals the order was not signed by the physician until 01/12/18, three days after the order was placed, exceeding the 24 hour requirement.

During an interview on 03/06/18 at 11:30 AM, Health Information Manager Staff C, confirmed the medical records for Patients # 1, 2, 5, and 25 lacked signatures for verbal orders. Staff C stated, "I spoke with Allied Health Professional Staff M and was told she signs their history and physicals so they don't have to sign the verbal orders".

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to safeguard confidential patient information from unauthorized use in one of one radiology film storage areas and failed to ensure 4 of 4 boxes of Laboratory records sitting on the floor of the lab were safeguarded against destruction. This practice has the potential allow confidential patient information to be viewed by unauthorized people and fails to protect medical records from loss or damage.

Findings include...


- Radiology film storage area observed on 03/05/18 at 10:30 AM revealed an unlocked radiology department with an open and unattended radiology film storage room containing multiple shelves of radiology films with the patients name marked on them.

During an interview on 03/05/18 at 10:30 AM, Human Resources Director Staff B, confirmed the radiology films were in an unattended and unlocked room. Staff B agreed they would be considered medical records and should be secured.

- Laboratory observed on 03/06/18 at 2:11 PM revealed four boxes of lab orders from 2017 sitting on the floor of the lab.

During an interview on 03/06/18 at 2:11 PM, Night Laboratory Director Staff S, verified the four boxes of lab records for 2017 were sitting on the floor of the lab and waiting to be picked up to go into storage.

Policy titled, "Maintenance of Medical Records" reviewed on 03/07/17 at 10:00 AM directed, the medical record should be protected against loss, damage, destruction, or unauthorized access regardless of the media in which it is maintained.

Based on interview and document review, the Critical Access Hospital (CAH) failed to complete a Periodic Evaluation and Quality Assurance Review. The facility failed to: evaluate a sample of both active and closed clinical records; failed to ensure the CAH's annual program evaluation reviewed and revised the CAH's health care policies; failed to ensure the quality and appropriateness of diagnosis and treatment furnished by practitioners at the CAH are evaluated by an outside entity as part of their quality assurance program.

The cumulative effect of the hospital's failure to ensure a sample of both open and closed records were reviewed, ensure the CAH's policies were reviewed, ensure the quality and appropriateness of diagnosis and treatment furnished by the CAH was evaluated by an outside entity places all patients at risk for poor quality and unsafe care.

Findings include...

The CAH failed to include a review of a representative sample of both active and closed clinical records in their periodic evaluation (See further evidence at C-0333).

The CAH failed to include a review of their health care policies in their periodic evaluation (See further evidence at C-0334).

The CAH failed to have an effective quality assurance program by failing to use an outside reviewer such as a network hospital or a quality improvement organization to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes (See further evidence at C-0340).

Based on staff interview and document review the Critical Access Hospital (CAH) failed to ensure a review of active clinical records representing services furnished was conducted as part of the periodic annual review. Failure to ensure review of active clinical records in the periodic review places all patients at risk for not receiving quality, accurate and comprehensive care, as chart reviews alert all staff to potential problems and issues to ensure quality of care is provided.

Findings include...

- Document titled, "Kingman County Hospital CAH Annual Program Evaluation" for the period of 05/01/16 to 04/30/17, reviewed on 03/07/18, directed, the regulatory standards for review of open and closed medical records is being met. However, the program evaluation lacked documentation differentiating between open and closed charts.

During an interview on 03/07/18 at 2:32 PM, Health Information Manager Staff C, explained that chart reviews are done in house only and pulled from the previous month, so most of the records are closed. Staff C explained they do not track if the record was opened or closed when they are pulled for chart reviews.

As of 03/08/18, the CAH failed to provide a policy directing the hospital to conduct chart reviews on both open and closed records as part of the annual periodic review.

Based on staff interview and document review the Critical Access Hospital (CAH) failed to evaluate, review, and revise the CAH's health care policies as part of the annual program evaluation. Failure of the CAH to evaluate, review and revise health care policies places all patients at risk for receiving care that is unsafe and below the standard of care from each profession resulting in harm and poor outcomes.

Findings include:

- Document titled, "Kingman County Hospital CAH Annual Program Evaluation" for the period of 5/01/2016 to 04/30/17, reviewed on 03/07/18, directed, The CAH reviews all policies on an annual basis by department. However, the Annual Program Evaluation review showed only two departments were reviewed; the therapy and emergency preparedness department. The Review also included one dietary policy regarding diabetic meal preparation and lacked evidence of the review of all other departments' policies and procedures.

During an interview on 03/07/18 at 2:30 PM, Chief Executive Officer (CEO) Staff A, acknowledged the Annual Program Evaluation lacked evidence of all departments' policies being reviewed.

As of 03/08/18, the CAH failed to provide a policy directing hospital staff on the annual review of facility policies.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the quality and appropriateness of diagnosis and treatment furnished by practitioners at the CAH are evaluated by an outside entity as part of their quality assurance program. This deficient practice places all patients at risk for receiving care that is unsafe and below the standard of care, resulting in harm and poor outcomes.

Findings include...

- Document titled, "Kingman County Hospital CAH Annual Program Evaluation" for the period of 05/01/16 to 04/30/17, reviewed on 03/07/18, directed, all mortality charts and standard of care not met charts are reviewed in Medical Staff. All readmissions within 30 days are reviewed by the Medical Staff.

During an interview on 03/07/18 at 2:32 PM, Health Information Manager Staff C, explained that chart reviews are done in house only and pulled from the previous month. Staff C explains that the physicians review each other's records and the supervising physician reviews any charts by allied health professionals (nurse practitioners or physician assistants). An outside review is only done if there is a question regarding risk management.

During an interview on 03/07/18 at 2:40 PM, Chief Exectutive Officer (CEO) Staff A, interviewed explained the CAH does not have an agreement with a Quality Improvement Organization (QIO), and the CAH does not have an arrangement for an outside review of medical records for the purposes of periodic evaluation.

Document titled, "Ninnescah Valley Health Systems Governing Body Bylaws" directed, Due to the small size of KCH Medical Staff, outside peer review access has been obtained through a contract with [Name]. This plan also authorizes the use of [Name] as determined needed by the MEC [medical executive committee], Chief of Staff, Governing Body or CEO of this facility. All results of outside peer review activity shall be in writing and maintained with executive committee records.

Based on staff interview, medical record review, and policy and procedure review the Critical Access Hospital (CAH) failed to ensure notification of resident rights to 5 of 5 swing bed patients reviewed(Patients # 11, #12, #13, #14, and #15). This deficient practice has the potential to place all swing bed patients at risk for exploitation.

Findings include...

- Record review of swing bed Patients #11, #12, #13, #14, and #15 lacked documentation that they had received their swing bed patient rights either orally or in writing.

During an interview at the nursing station on 03/07/18 at 11:14 AM, Swing Bed Coordinator Staff V, explained the patients are given a packet when admitted to the swing bed unit and she reviews the packet with each patient educating them on certain areas. Staff V verified the medical records lack documentation that the patient has acknowledged receipt of the swing bed resident rights in writing or orally. Staff V voiced she fails to document in the medical record the initial process and findings covered after completing swing bed orientation.

During an interview at the nursing station on 03/07/18 at 1:24 PM, Admissions Staff W, verified the medical record lacked documentation of patients receipt of resident rights when admitted to swing bed.

The CAH failed to develop and implement a policy and procedure regarding patients receiving resident rights upon admission to swing bed.

Based on staff interview, medical record review, and policy and procedure review the Critical Access Hospital (CAH) failed to ensure hospital staff informed patients about completing advanced directives or provided written information about advanced directives for 5 of 5 swing bed Patients (Patients #11, #12, #13, #14, and #15) reviewed. This deficient practice has the potential to keep patients from expressing their wishes regarding their medical treatment when they are unable to communicate them to a doctor.

Findings include...

- Record review of Patients #11, #12, #13, #14, and #15 showed the advance directive section of the consent forms for these swing bed patients were left blank.

During an interview at the nursing station on 03/07/18 at 11:14 AM, Swing Bed Coordinator Staff V, verified hospital staff failed to complete the advanced directive section of the admission consent forms for swing bed Patients # 11, #12, #13, #14, and #15.

The CAH failed to develop and implement a policy and procedure regarding advanced directives for swing bed patients.

Based on staff interview, record review, and policy and procedure review the Critical Access Hospital (CAH) failed to ensure hospital staff completed initial comprehensive assessments for 5 of 5 swing bed records reviewed (Patients #11, #12, #13, #14, and #15). This deficient practice puts all patients at risk for receiving care, medications and treatments unrelated to their current diagnosis, healing and recovery.

Findings include...

- Record Review of swing bed Patients #11, #12, #13, #14, and #15 revealed their medical records lacked evidence of an initial swing bed comprehensive assessment.

During an interview at the nursing station on 03/07/18 at 2:32 PM, Director of Nursing, Staff D and Swing Bed Coordinator, Staff V, explained when a patient transfers from inpatient/acute care to swing bed, a new comprehensive assessment is not completed. The computer system pulls over the initial inpatient/acute admission assessment and the hospital staff do not perform a separate swing bed initial comprehensive assessment.

During an interview at the nursing station on 03/07/18 at 2:32 PM, Director of Nursing, Staff D further explained the CAH used to meet and have a formal interdisciplinary meeting for each swing bed patient, but fails to meet together to discuss each patient at this time.

The CAH failed to develop and implement a policy and procedure concerning comprehensive assessments for swing bed patients.

Based on staff interview, record review, and policy and procedure review the Critical Access Hospital (CAH) failed to ensure hospital staff completed comprehensive care plans for 5 of 5 swing bed records reviewed (Patients #11, #12, #13, #14, and #15). This deficient practice puts all patients at risk for receiving care, medications and treatments unrelated to their current diagnosis, healing and recovery.

Findings include...

- Record review of swing bed Patients #11, #12, #13, #14, and #15 revealed these medical records lacked evidence of comprehensive care plans.

During an interview at the nursing station on 03/07/18 at 2:32 PM, Director of Nursing, Staff D, explained the CAH used to meet and have a formal interdisciplinary meeting for each patient, but fails to meet together to discuss each patient at this time.

During an interview at the nursing station on 03/07/18 at 2:49 PM, Swing Bed Coordinator Staff V, acknowledged the medical records for Patients #11, #12, #13, #14, and #15 lacked documentation of collaboration of the interdisciplinary care team. The Swing Bed Coordinator completed the care plans by herself. Staff V shared they used to meet formally but at this time just talk to each other.

The CAH failed to develop and implement a policy and procedure concerning comprehensive swing bed care plans.

Based on staff interview, medical record review, and policy and procedure review the Critical Access Hospital (CAH) failed to ensure hospital staff completed an Occupational Therapy (OT) order for 1 of 5 swing bed records reviewed (Patient # 13). This deficient practice puts all patients at risk for not receiving care for positive outcomes to ensure health and safety in their activities of daily living.

Findings include...

- Patient #13's record review on 03/07/18 revealed an admission date of 02/27/18 (8 days ago) with a physician's order for an Occupational Therapy Evaluation (OT) (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life). To date, Patient #13's record lacked documentation OT staff completed the evaluation.

During an interview at the nursing station on 03/07/18 at 12:47 PM, Director of Nursing, Staff N and Swing Bed Coordinator, Registered Nurse, Staff V, acknowledged the OT order from the physician failed to be completed at the time.

During an interview at the nursing station on 03/07/18 at 3:09 PM, Physical Therapist Staff X acknowledged the OT evaluation failed to be completed as ordered by the physician. Staff X explained that OT services are provided by contracted staff.

- Document review in the physical therapy room on 03/06/18 at 2:19 PM revealed the contract for OT services was effective for 2 years commencing 09/08/15. The contract did not automatically renew. The contract has been expired for about 6 months.

During an interview in the physical therapy room on 03/06/18 at 2:19 PM, Director of Therapy Staff U, verified the contract for OT services had expired, failed to be renewed but OT services continued to be provided.

Document titled, "Governing Body By-Laws" directed, Duties of the Authority of The Chief Executive Officer (CEO)...negotiating and finalizing professional, consultant and service contracts.

The CAH failed to develop and implement a policy and procedure regarding therapy orders.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to develop an emergency preparedness plan that specifies the population served and their vulnerabilities in the event of an emergency or disaster. This deficient practice affects the safety of all patients in the event of an emergency.

Findings include...

- Document titled, "Emergency Operations Plan" revealed the CAH failed to incorporate their patient population served and their accompanying vulnerabilities into their plan.

During an interview on 03/07/18 at 11:18 AM, Maintenance Staff E, explained the CAH has "kind of gone over that", but it has not been incorporated into the plan.

As of 03/08/18, the CAH failed to provide a policy related to the implications of the CAH's distinct patient population on the emergency preparedness plan.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to develop an emergency preparedness plan that specifies the use of volunteers. This deficient practice has the potential affects the safety of all patients and volunteers in the event of an emergency.

Findings include...

- Document titled, "Emergency Operations Plan" revealed the CAH failed to include staffing strategies related to the use of volunteers and their roles in the event of an emergency.

During an interview on 03/07/18 at 11:18 AM, Maintenance Staff E, acknowledged the plan lacked strategies for the use of volunteers in an emergency. Staff E explained any volunteers would have to go through the labor pool process (the assigning of a task during an emergency) before they could assist the facility.

As of 03/08/18, the CAH failed to provide a policy on the staffing strategies related to the use and roles for volunteers in the event of an emergency.