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Based on observation, review of facility documentation, staff interview and verification, the critical access hospital (CAH) failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings include:

The CAH failed to have appropriately rated fire doors, failed to have either fire rated construction or a sprinkler system in hazardous areas, failed to store medical gas appropriately, and failed to appropriately inspect emergency generators.
Please see C0231.

Based on observation and staff interview on 01/04/12 and 01/05/12, it was determined that the critical access hospital (CAH) failed to ensure the facility kitchen and medical storage area was kept clean and orderly.

Findings include:

The facility had a census of 18 patients at the time of the survey completed on 01/06/12.
Observation of the dietary department by two surveyors on 1/4/12 at 4:35 PM revealed a large mixer on a metal shelf that had a thick yellow brown substance at the area that hold the beaters. The metal shelf holding the mixer was dusty and had white loose substances on it. This finding was confirmed by Staff D at that time.

Observation on 1/05/12 at 12:30 PM revealed that neither the mixer or shelf had not been cleaned although this had been pointed out to Staff D on the previous day. Staff D confirmed the cleaning had not been completed as of this time.




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Tour of room 234, an equipment storage area, on 01/05/12 at 1:05 PM with employee H revealed four pieces of floor cleaning equipment. Stored within three feet of the soiled floor cleaning equipment was a portable C arm (portable X-rays equipment taken into the operating room during procedures). Also noted in the storage room were two ventilators cleaned, covered, and ready for use, and one pediatric crib.

Interview of employee C at 1:15 PM on 01/05/12 verified clean equipment should not be stored with dirty equipment for infection control purposes.

Employee C reported at 3:00 PM that floor equipment had been removed and other equipment had been recleaned.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure the critical access hospital met the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings include:

On 01/04 through 01/06/12, a Life Safety Code survey was conducted at the facility. At this survey, the facility was found not in substantial compliance with the requirements for Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) Life Safety Code, Chapter 19 Existing Health Care.

Review of facility documentation for weekly, monthly, quarterly and annual maintenance of safety and emergency systems was completed on 01/04/12. Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. The following observations and findings were noted:

K18, Which addressed facility failure to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors were provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.

K29, Which addressed the facility failure to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas.

K76, Which addressed the facility failure to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

K144, Which addressed the facility failure to ensure that generators were inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99.

Please see the Life Safety Code report for more complete information.

Based on medical record review, policy review for medical records, and staff interview, it was determined that the critical access hospital (CAH) failed to follow its policies on timely completion of medical records following patient discharge.
The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings include:

Interview of employee J on 01/05/12 and 01/06/12 revealed 31 delinquent medical records in October, 33 delinquent medical records in November, and 48 delinquent medical records in December 2011. Review of the CAH policies defined delinquent medical records as records not completed within 25 days of a patients hospital discharge, and stated "all medical records must be completed within 25 days following discharge." Employee J stated the CAH has an average monthly discharge rate of 228 and that the percentage of delinquent records for October and November was 14% and December's delinquent rate was 48%.