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The Critical Access Hospital (CAH) reported a census of three acute inpatients and one skilled swing bed patient. Based on observation, staff interview and policy review 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 deficient practice has the potential to place all patients and visitors at risk for food contamination.

Findings include:

- Observation of the CAH kitchen on 6/6/2017 at 2:45 PM revealed the sink used to prepare fresh food 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 Manager Staff K on 6/6/17 at 3:00 PM confirmed the sink had an installed garbage disposal and they did not have an air gap. Staff K stated they thought an air gap was supposed to be installed.

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

- Policy reviewed on 6/6/2017 the CAH failed to have a policy regarding the regulation of the Kansas State Food Code 2012.

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one skilled swing bed patient. Based on observations, staff interview and policy review, the facility failed to ensure Emergency room supplies did not exceed the manufacturers' safe use date for 1 of 3 Emergency Department (ED) rooms (Procedure Room) and 1 of 1 ED supply room. This deficient practice has the potential to cause unsafe supplies to be used during the care and treatment of emergent patients.

Findings include:

- Emergency Room Procedure Room observation on 6/5/2017 at 2:41 PM revealed one package of Povidone Iodine swabs (medicated swab sticks used to clean skin) in the right hand drawer with an expiration date of 4/2017.

- Emergency Room Clean Supply Room observation on 6/5/2017 at 2:55 revealed four Povidone Iodine swab stick packages with an expiration date of 4/2017 in a plastic bag labeled "Cricothyrotomy (emergency procedure to obtain an airway) kit".

Director of Nursing Staff I interview on 6/5/2017 acknowledged the supplies were outdated.

- Policy titled "Outdated Supply Management" reviewed on 6/8/2017 directed Staff " ...Nursing staff will check for outdated supplies, on a monthly basis, in the following areas ...clean supply cart in hallway ...outdated materials will be gathered during the monthly check and logged onto the Expired Supplies log with the requested information ...If needed, nursing shall replace the outdated supplies in a timely manner from Central Supply ..."

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one skilled swing bed patient. Based on observations, staff interview, and policy review, the CAH failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations for one of one supply cart at the nursing station, one of one ultrasound room, one of one CT Scan room and one of two Operating Rooms (OR #1). This deficient practice or the failure of the facility to dispose of expired supplies places all patients at risk for receiving ineffective supplies.

Findings include:

- Nursing station supply cart observed on 6/5/2017 at 1:00 PM revealed the five IV (Intravenous) Administration sets (used to provide IV fluid to patients) with expiration dates of 3/2017.

RN Staff A interviewed on 6/5/2017 at 1:15 PM acknowledged the IV sets were expired and should have been disposed.


- Ultrasound Room cabinet observed on 6/5/2017 at 1:59 PM revealed the following outdated supplies:

1. Two Povidone -Iodine swab sticks (to kill bacteria on skin) packets with expiration dates of 10/2013.
2. One Ultrasound transmission gel with expiration date of 6/2014.
3. Four sterile 2x2 gauze sponges with expiration dates of 3/2017.
4. One Sterile 4x4 dressing sponges with expiration date of 4/2013.
5. Six Tegaderm dressings 2x2 with expiration dates of 11/2014.
6. One sterile size 6 ½ gloves with expiration date of 12/2015.
7. Two Tegaderm dressings (protect wounds or catheter sites) 4x4 with expiration dates of 5/2015.


- CT Scan Room counter observed on 6/5/2017 at 2:16 PM revealed one Cavi Wipes with expiration date of 10/2015.

Director of Radiology Staff B interviewed on 6/5/2017 at 2:20 PM acknowledged the outdated supplies should have been disposed.


- Operating Room 2 observation on 6/6/2017 at 2:07 PM revealed one 4-0 Chromic Gut (used to close wounds) suture kit with an expiration date of 1/2015.

RN Staff AA interviewed on 6/6/2017 at 2:15 PM acknowledged the outdated suture kit.

- Policy titled "Outdated Supply Management" reviewed on 6/8/2017 directed Staff " ...Nursing staff will check for outdated supplies, on a monthly basis, in the following areas ...clean supply cart in hallway ...outdated materials will be gathered during the monthly check and logged onto the Expired Supplies log with the requested information ...If needed, nursing shall replace the outdated supplies in a timely manner from Central Supply ..."

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one swing patient. Based on observation, staff interview and policy review, the CAH failed to provide for the safety of patients in two of two ED supply closets (ED #1 and ED #2) with unlocked cabinet containing Hydrogen Peroxide and Isopropyl alcohol bottles were found in a unlocked drawer and accessible to anyone in the room and for one of two Labor/Delivery Rooms (Labor Room #1) with an unlocked sink cabinet with disinfectant cleaner sprays. The CAH failed to secure potentially hazardous solutions and lifesaving medications from patients and visitors. This deficient practice has the potential to cause harm to patients and visitors.

Findings Include

- Emergency Department trauma room #1 observed on 7/25/2016 at 12:50 PM revealed the CAH failed to secure keys accessible to the locked cabinet containing one bottle of Hydrogen Peroxide and one bottle of Isopropyl Alcohol.

- Emergency Room 1 observation on 6/5/2017 at 2:05 PM revealed an unlocked cabinet with three shelves containing one single-use foil package of Neosporin ointment (antibiotic ointment) and 17 single-use foil packages of Bacitracin ointment (antibiotic ointment), scalpels, various sized needles, syringes, and dressing supplies

- Emergency Room 2 observation on 6/5/2017 at 2:27 PM revealed an unlocked cabinet with three shelves containing three single-use foil packages of Neosporin ointment (antibiotic ointment) and five single-use foil packages of Bacitracin ointment (antibiotic ointment), scalpels, various sized needles, syringes, and dressing supplies.

Director of Nursing Staff I interview on 6/5/2017 at 3:20 PM stated, "we used to have these [cabinets] locked when we had meds [medications] in them, but now we only have the TAO [triple antibiotic ointment]". Staff I then acknowledged the antibiotic ointment was in fact a medication, and that having the cabinets unlocked presents open access to needles and sharps to patients and visitors.

On 6/7/2017 the facility failed to provide a policy regarding supply storage in the emergency room.


- Observation of Labor/Delivery #1 on 6/7/2017 at 8:15 AM revealed one can of One Step Disinfectant Germical Detergent spray bottle and one can of Preklenz 13.5 ounces (pre-cleaning disinfectant to soak dirty instruments) spray can under the unlocked sink. Each can had a label stating "Keep out of reach of children".

RN Staff EE interviewed on 6/7/2017 at 8:15 AM acknowledged the disinfectant products were under the sink unlocked. Staff EE stated they have also had those disinfectants under the sink unlocked in case of blood spills

- Policy reviewed on 6/7/2017 revealed the CAH failed to have a policy directing their staff to keep chemical products locked under all sinks.


- Observation on 6/5/17 at 12:00 pm revealed an unlocked chiller used to cool the facility with approximately 200 feet outside of the emergency room doors. Two doors open into the chiller with an electrical panel located behind the doors.

Interview with maintenance Staff Q on 6/5/17 at 12:00 pm confirmed the doors were unsecured.

- Policy reviewed on 6/7/2017 revealed the CAH failed to have a policy on securing the chiller panel.

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one skilled swing bed patient. Based on observation and document review, the Critical Access Hospital (CAH) failed to provide documentation of corrections for out of range humidity and temperature readings in one of one endoscopy room and one of one surgical room. Failure to correct and maintain humidity levels can create a moist environment resulting in increased presence of bacteria in the OR resulting in poor patient outcomes.

Findings Include:

- Review of humidity logs for the surgical area revealed the humidity level was outside the required level of 30-60% on the following dates:

OR Room-

12/9/16 - 27%; 12/12/16 -29%; 12/13/16 - 23%; 12/14/16 - 28%; 12/15/16 - 27%;12/19/16 - 13%; 1/4/17 - 27%; 1/6/17 - 18%; 1/12/17 - 29%; 2/2/17 - 28%; 2/3/17 - 26%; 2/22/17 - 27%; 3/15/17 - 26%;


- Review of temperature logs for the OR and endoscopy rooms revealed the temperature level was outside the required 68-73 degrees on the following dates:

OR Room-

12/6/16 - 66.8 degrees; 12/9/16 - 29 degrees; 2/1/17 - 65.8 degrees; 2/6/17 - 66 degrees; 2/22/17- 67.9 degrees; 3/14/17 - 67 degrees;

Endoscopy Room-

2/6/17 - 67.9 degrees; 2/20/17 - 74 degrees; 2/27/17 - 66.7 degrees; 3/27/17 - 66.3 degrees.

Notations of notification to maintenance were documented on 12/16/16, 12/19/16, 1/4/17, 1/6/17, 2/2/17, and 2/3/17.

Interview with OR Supervisor Staff #E on 6/6/17 at 2:00 pm confirmed the out of range temperature and humidity documentation and stated the staff use the QA form to notify maintenance of the varying ranges.


Interview with maintenance Staff P on 6/7/17 at 3:00 pm confirmed awareness of the out of range humidity and temperatures and stated "I have no paper trail showing any maintenance was done to correct any of the issues. Usually the problem is a door that has been left open. There is really no problem."

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one skilled swing bed patient. Based on observation, staff interview and policy review the CAH failed to ensure that outdated medications are not available for patient use for one of one Post Anesthesia Care Unit (PACU) and for one of one Inpatient Emergency Crash Cart. This deficient practice may cause patients to receive ineffective medications which has the potential to cause harm to all patients.

Findings include:

- PACU observation on 6/5/2017 at 12:22 PM revealed one 1,000 ml bag of normal saline (used to treat dehydration) with an expiration date of 4/2017 and three vials of Oxytocin (medication used to induce childbirth) with an expiration date of 11/2016.

Operating Room Supervisor RN interview on 6/5/2017 at 12:32 PM acknowledged medications were expired and removed them from the cabinet.


- Inpatient Emergency Crash Cart observation on 6/5/2017 at 12:45 PM revealed one Glutose 15 37.5 grams tube (to increase patients blood sugar) with expiration date of 5/2017.

RN Staff A interviewed on 6/5/2017 at 1:00 PM acknowledged the medication was outdated.

- Policy titled "Medication Outdates. Unit: Surgery" review on 6/8/2017 at 11:00 AM directs "...expired meds or soon to expire are taken to the pharmacy and placed in the expired meds container..."

The Critical Access Hospital (CAH) reported a census of three acute inpatients and one swing patient. Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) failed to ensure staff perform hand hygiene for eight of nine observed patient care activities (Staff Registered Nurse (RN) D, Certified Registered Nurse Anesthetist (CRNA) L, Staff RN O, Certified Nurses Assistant (CNA) Staff R, Staff RN H, Director of Lab Staff N, and Lab Staff BB). The Infection control officer failed to monitor infection control surveillances.hand hygiene, for staff practices which could contribute to healthcare acquired infections of patients and personnel. The facility failed to ensure staff were informed of Juvenal dwell time (time a cleaning product needs to be wet to ensure disinfection occurs) during one of one staff interviews (Lab Staff BB). The facility failed to ensure patient care equipment is cleaned between each patient use in one of one observations (Director of Lab Staff N). The facility failed to ensure four of four biohazard containers were secure in the laboratory (lab). The facility failed to provide personal protective equipment (PPE) in all areas that cross contamination of body fluids is possible. The facility failed to document water temperatures for one of one hydrocullator and one of three washing machines. The facility failed to ensure medical supplies were stored separate from employee food in one of one employee refrigerators. The facility failed to remove expired food from one of one kitchen pantries. The facility failed to remove patient care items and biohazard materials from beneath the sink in three of three emergency rooms and one of two Labor/Delivery Rooms. The facility failed to dispose of open patient care supplies in one of one emergency rooms and one of two surgical rooms. The Facility failed to keep clean sterilized equipment separate from contaminated items for one of one Disinfectant Room. These deficient practices have the potential to expose all patients and all employees to harmful bacteria resulting in disease and exposure to hazardous waste and materials.


Findings Include:

- Observation in patient room #121 on 6/5/2017 at 3:30 pm revealed CNA Staff # R entering and exiting the room three times without performing hand hygiene, providing direct patient care to Patient # 25. A hand hygiene foam dispenser was mounted on the wall directly inside the patient room and hand washing facilities were located inside the patient room.

- Observation in patient room #121 on 6/5/2017 at 3:30 pm revealed RN Staff # Q providing direct patient care while wearing non sterile gloves. S/he then adjusted the patient bed, adjusted her/his glasses, moved the over bed table, charted on the computer, removed the gloves, performed hand hygiene and left the room.

- Observation in patient room #121 on 6/5/2017 at 3:30 pm revealed RN Staff # O leaving the room after reviewing written information with the patient without performing hand hygiene.

-Observation of Staff RN #H on 6/7/2017 at 8:31 AM revealed the staff member failed to use hand hygiene upon entering the room and prior to administering medications.

- Observation of CRNA Staff L on 6/6/2017 at 10:10 AM revealed Staff L failed to perform hand hygiene after rubbing his eyes and face during Patient # 5's surgical procedure.

- Observation of CRNA Staff L on 6/6/2017 at 10:45 AM revealed Staff L leaving preoperative bay #1 (patient #5) and entering preoperative bay #2 (patient #22) without performing hand hygiene.

CRNA Staff L interviewed on 6/6/2017 at 10:55 AM stated "Maybe I should have washed my hands" then walked away.

- Preoperative bay # 1 obsered RN Staff D on 6/6/2017 at 9:30 AM revealed Staff D leaving patient #5's bay area after having contact with Patient #5, leaving and reentering room three times to get equipment/supplies without performing hand hygiene.

RN Staff D interviewed on 6/6/2017 at 9:50 AM acknowledged they did not perform hand hygiene and should have.

- Observation in the mammography room on 6/6/2017 at 9:00 am revealed Director of Lab Staff # N performing lab draw on an unknown patient. Director of Lab Staff # N put non sterile gloves on, drew lab, marked the blood tube, and left the room. Director of Lab Staff # N returned to the room with gloves on, removed the gloves, and left the room pushing the lab draw cart. Hand hygiene was not observed. Cleaning of the cart was not observed.

Interview with Lab Staff #BB on 6/6/17 at 10:00 am acknowledged that the patient care areas in the lab including the lab cart are wiped down as time permits either with the Cavi-wipes or sprayed with the Rejuvenal. Lab Staff #BB stated "I am not sure of the dwell time, I think it might be a minute or two and then we go ahead and wipe the surface." She/he further acknowledged the patient draw station chairs and lab cart handles are to be cleaned regularly.

Interview with Infection Control RN Staff # J on 6/5/2017 at 4:30 pm acknowledged hand hygiene has not been a priority and has not been observed in the patient care areas recently.

Policy "Patient Care Guidelines Infection Control" directs " ...When To Clean Hands ...Upon entering and exiting the patient environment, before and after patient contact, including dry skin contact, after removing gloves ... ...Hand Hygiene Monitoring ...Compliance with hand hygiene policy will be monitored on a regular basis, monitoring will be accomplished using "secret shoppers" who will monitor staff employees while they are performing their job duties. Results of the monitoring will be recorded using the Hand Hygiene Audit Tool, the Infection Preventionist will compile the results of the audits. The results will be kept in the Infection Control Office ..."

- Observation in the laboratory on 6/6/17 at 8:30am revealed an emergency eye wash station however, lacked evidence of personal protective equipment (PPE) (eye protection, gloves, mask, and gown) intended to be used when potential contamination resulting from splash back of body fluids exists and lacked evidence of table top splash guards used to protect health care workers from possible splash back when opening containers with body fluids for the purpose of transferring fluids in the laboratory.

- Observation in the laboratory on 6/6/17 at 8:30 am revealed 4, 5 gallon unsecured and open biohazard containers setting at individual work stations.

Interview with Director of Lab Services Staff #N confirmed the absence of PPE and splash guards in the laboratory and stated the staff is very careful with the specimen handling including transferring body fluids between containers and test tubes or culture mediums and exposure is not an issue. Director of Lab Services Staff #N acknowledged the open, unsecured biohazard boxes have the potential of being knocked over and need to be secured.

Document "Sabetha Community Hospital, Inc. Infection Control Principles" reviewed 6/7/2017 at 9:00 am revealed "All personnel will ...Wear a mask, eye protection or face shield to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions ..."

- Observation in the outpatient physical therapy department on 6/6/7/2017 at 8:30 am revealed the hydrocullator temperatures were documented April, week 2 and May, week 1, week 3, and week 4. All documented temperatures were within policy range.

- Observation in the laundry on 6/5/17 at 12:00 revealed one of three washers (washer #3) lacked documentation of daily water temperature.

Interview with laundry Staff #P acknowledged the water temperature is not documented. "We have no way of knowing the temperature because there is no read out on the washer and we physically turn the water on and off at the valves along the wall. This washer is intended for industrial use."

Interview with Director of Laundry Staff #U on 6/8/17 at 9:00 am confirmed the temperature of the water has not been checked, but there is now a log and thermometer for daily water checks. "Maintenance did tell me the water source is the same for all three washers so the temperature should be the same as well."

Policy "Chemical Dispensation and Water Temperature" directs " ...Water temperature is checked every day by the Laundry Department Personnel to assure a minimum of 160 degrees. If temperature is below this level maintenance takes immediate corrective action."

Document "Quality Improvement List-Rx Room" directs "hydrocullator temperatures are to be checked weekly ..."

Interview with Director of Outpatient Therapy Staff T confirmed the temperature logs were not complete stating that "maybe the hydrocullator wasn ' t used the weeks the temperatures were not documented."

- Observation in the Outpatient Clinic on 6/6/17 at 7:45 am revealed an employee food refrigerator with 4 boxes of Hygienia Luminometer ATP Hygiene Monitoring System swabs (product used to test surfaces for contamination for infection control purposes).

Interview on 6/6/2017 at 4:30 pm with Infection Control Staff RN J confirmed the swabs were stored in the refrigerator "because the boxes were so large and there was no other refrigerator available to store them. I forgot they were in there."

- Observation of the kitchen pantry on 6/5/2017 at 3:39 PM revealed 12 boxes of Nilla Wafers with an expiration date of 5/9/2017 and four boxes of pineapple juice concentrate with an expiration date of 6/1/2017.

Interview of Dietary Staff #K on 6/5/2017 at 3:30 acknowledged the items were expired and removed them from the pantry.

Policy "Safe Food and Dry Food Storage" directs "...stock rotation-label and date. Oldest food to the front-new inventory behind. Use all foods by expiration date. Throw away if expired. Do not use ..."

- Observation of Emergency Room 1 on 6/5/2017 at 2:05 PM revealed one metal bedpan, two metal basins, one large plastic container, four rolls of paper towels, a pile of trash bags, and one bottle of Rejuvanal cleaner under the sink.

- Observation of Emergency Room 2 observation on 6/5/2017 at 2:17 PM revealed two metal basins, one large plastic container, one roll of toilet paper, one roll of paper towels, a pile of trash bags, and three bottles of various cleaners and one bottle of Rejuvanal cleaner under the sink.

- Observation of Emergency Room Procedure Room observation on 6/5/2017 at 2:41 PM revealed one bottle of air freshener, pile of trash bags and a roll of toilet paper under the sink.

- Observation of Operating Room 2 on 6/7/2017 at 2:07 revealed two open yank Auer (a suctioning tool used during procedures) packages on the anesthesia cart.

RN Staff AA interview on 6/7/2017 at 2:10 acknowledged the open yankauer being on the anesthesia cart.

- Observation of Emergency Room Procedure Room on 6/5/2017 at 2:30 PM revealed one open package of Keflex gauze (gauze wrap) in the upper cabinet. Packaging on Keflex gauze reviewed on 6/5/2017 at 2:30 directs " ... do not use if package is damaged or opened."

Interview with Director of Nursing Staff I acknowledge package was opened and removed it from procedure room.

- Policy "Outdated Supply Management" directs " ...Nursing staff will check for outdated supplies on a monthly basis ... ...outdated materials will be gathered during the monthly check and logged onto the expired supplies log with the requested information ...".

- Observed the cleaning of the Endoscopes on 6/6/2017 at 1:00 PM revealed two black hooks on the wall next to a garbage can and approximate 3-4 ft from a hopper.

LPN Staff DD interviewed on 6/6/2017 at 1:00 PM. This surveyor asked Staff DD what the two hooks were for that were near the garbage can and the hopper. Staff DD stated "We hang the clean endoscopes on the hooks to dry and then place them in OR #1 room in the closed cabinet to hang. Staff DD stated they use to hang them in the cabinet to dry but were told not too.

- Police reviewed on 6/6/2017 revealed the CAH failed to have a policy to separate the clean instruments from dirty side.

The Critical Access Hospital (CAH) reported a census of 3 acute inpatients and 2 swing bed patients. Based on observation, staff interview and policy review the CAH failed to ensure their Provider (M.D. Staff CC) performed a History and Physical prior to surgical procedures for 2 of 2 patient observations (Patient #5 and #22). The failure to ensure patients have a completed history and physical prior to surgery places the patients at risk for complications and medical errors.

Findings include:

- Observations of the preoperative and Operating Room (OR) procedures on 6/6/2017 at 9:00 AM and 9:15 AM revealed the CAH failed to ensure the physician performed a comprehensive History and Physical prior to patient's surgical procedures. Staff CC entered OR suite #1, met with patient #5 at 10:00 AM and met patient #22 at 11:30 AM, only asking a few medical questions prior to the start of their procedure.

- Observation of the medical records on 6/7/2017 at 10:00 AM revealed Staff CC signed the Outpatient History and Physical Examination. During the observations of Staff CC meeting and talking to patients #5 and #22, there is a lack of evidence that Staff CC completed a comprehensive history and no physical assessment was performed on either patient.

Patient #5 interviewed on 6/6/2017 at 9:30 AM mentioned that they have never met Staff CC who was performing their procedure until today.

- Policy titled "Form, signatures, and reports" reviewed 6/7/2017 directed the CAH providers " ...These requirements must be met: 1) History and physical examinations-there is a complete history and physical work-up on the chart of every patient prior to surgery (whether the surgery (whether the surgery is major or minor). If such as been dictated but not yet transcribed and recorded in the patient's chart, there is a statement to the effect and an admission note by the physician in the chart ... ...The history and physical is presumed to be on the chart within 24-48 hours, as provided by Staff Rules and Regulations: so a pre-anesthetic statement form the doctor must be written in the progress notes ..."

Based on observation, interview, and record review, the Critical Access Hospital (CAH) failed to provide an activity assessment for one of five swing bed medical records reviewed (Patient #7). 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:

- Document review on 6/7/2017 at 2:30 pm revealed Patient #7 medical record lacked evidence an activity assessment was completed.

Interview with Occupational Therapist (OT) Staff M on 6/7/2017 at 4:00pm acknowledged s/he is responsible for performing an activity assessment for every swing bed patient and then volunteers provide activities to the patients based on the outcome of the assessment. The only patients the volunteers are not able to work with are those that are in isolation.

- Policy review on 6/7/2017 at 4:00pm revealed the facility failed to provide a policy for activity assessments performed with swing bed patients.