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Based on the Life Safety Code Substantial Allegation survey completed on 4/15/10, the facility was found not in compliance with Life Safety from Fire found at CFR 485.623(d).

Refer to Life Safety Code deficiencies.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation and interview, the facility failed to ensure that toxic chemical cleaning solutions were stored in a safe manner.

The findings include: The facility failed to store cleaning solutions in locked cabinets.

During an environmental tour with the Environmental Services Director on 4/16/10 at 1:25 p.m., it was observed that cleaning solutions were available for use in the soiled utility room in the inpatient care area. The following products were observed on the counter just inside the unlocked utility room: 3 bottles of Omega disinfectant, 2 containers of AF315, and 2 spray cans of Lysol disinfectant spray. An unlocked cupboard inside the same utility room contained: Germ Guard deoderant spray, a gallon of liquid household bleach, Swat bug spray, and Molecule deoderizer- one bottle of liquid for drains and one aerosol spray.

Material Safety Data Sheets (MSDS) were reviewed for each of these products. The MSDS information verified that the products could be harmful if ingested, could cause skin and eye irritation and could be irritating to the respiratory system.

The Environmental Services director confirmed these findings at the time of the tour and stated the products should have been locked up.

Based on observation, interview and policy review, the facility failed to ensure that medications were stored securely in the operating room and in the cardiac room.

The findings include: During a tour of the operating room on 4/14/2010 at 1:45 p.m. with the Director of Patient Care Services, it was noted that there were 36 vials of Dantrium stored on a shelf in the unlocked operating room. During a tour of the cardiac care room on 4/14/2010 at 2:30 p.m., the cart containing a variety of cardiac medications was noted to have been unlocked. This room was located near the entrance to the building.

The Director of Patient Care Services confirmed on 4/14/2010 at the time of these observations that medications were supposed to be securely stored.

The facility's Pharmaceutical Storage policies stated that the pharmacist would conduct monthly inspections. The policy stated that the inspections would include checks for proper storage conditions.

Based on record review and staff interview the CAH failed to ensure that each medical entry by the physician included authentication of dates/time of the medical entry for 17 of 20 inpatient records (P6,7,8,9,10,11,12,13,14,15,16,17,18,19 and 20); and for 10 of 11 emergency room patients' records reviewed (P1, 2, 3, 4, 5, 21, 22, 23, 24 and 25).
The findings include:

Medical records that included in-patient, and emergency patient records, lacked physican signature authentication including date and/or time the entry had been made. Physician signatures were not consistently authenticated with the date and/or time in the following types of documents contained in medical records: physician progress notes, physician orders, transfers, laboratory and EKG reports and discharge summaries.

Upon interview with the Director of Health Information on 4/15/2010 at 2:00 p.m. it was verified that entries in the medical records reviewed lacked consistent authentication of the time the entry had been made by the author.

Based on review of quality assurance information and staff interview the CAH (Critical Access Hospital) failed to evaluate services provided by agreement or by arrangement as part of the overall quality improvement program.

The findings include:

The CAH did not routinely evaluate all patient care services. Its ambulance service was provided by contract/agreement through the city. The Director of Nursing was interviewed on 4/14/2010 at 2:25 PM. She confirmed that the arranged services for ambulance services had not been evaluated as a part of the hospital's quality assurance program.