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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on March 29 - 30, 2011, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on March 29 - 30, 2011, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 30, 2011.

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A. Based on observation and staff interview it was determined that the CAH failed to ensure all dietary practices are followed as per food service standards to ensure safe food is prepared for all patients in the CAH.

Findings include:

1. During a tour of the dietary department on 3/22/11 at 2:00 PM, it was observed in the refrigerator an unidentified container of a white substance without a label or date. An open container of cheese cubes and carrots were observed without dates. This surveyor observed signs posted on the freezers and refrigerators to "label and date" all foods.

2. During an interview with the Dietary Manager on 3/22/11 at 2:30 PM, it was confirmed that it is their practice to label and date all foods.

A. Based on policy, record review, and staff interview it was determined that in 2 of 3 (Pt. #2, #3) in patients receiving blood that the CAH failed to ensure that policies were followed in administering blood.

Findings include:

1. The CAH policy titled, "Blood Transfusion" under "Documentation 1. Complete Blood Bank Transfusion Requisition. " was reviewed on 3/23/11.

2. The medical record of Pt. #2 was reviewed on 3/21/11. Documentation indicated that Pt. #2 was admitted to the CAH on 6/18/10 with the diagnoses of Hypercalcemia and Anemia. Documentation indicated that Pt. #2 received the first unit of blood on 6/19/10. The nurse's signature and time were not completed on the requisition form.

3. The medical record of Pt. #3 was reviewed on 3/21/11. Documentation indicated that Pt. #3 was admitted to the CAH on 2/3/10 with the diagnoses Gastrointestinal hemorrhage and Sepsis. Documentation indicated that Pt.#3 received one unit of blood. It was completed with no post transfusion vitals recorded on the requisition form.

4. During an interview with the Chief Nursing Officer on 3/23/11 at 3:00 PM, the above findings were confirmed.

A. Based on policy, record review, and staff interview it was determined that in 5 of 20 (Pt. #2, #3, #5, #11, #16) medical records reviewed that the Critical Access Hospital (CAH) failed to ensure that all physician orders were authenticated.

Findings include:

1. The CAH Medical Staff By-Laws were reviewed on 3/22/11. The policy titled, "Medical Records" under "Entries: a. All clinical entries in the patient's record shall be accurately dated and authenticated,...".

2. The medical record of Pt. #2 was reviewed on 3/21/11. Documentation indicated that Pt. #2 was admitted to the CAH on 6/18/10 with the diagnoses of Hypercalcemia and Anemia. Documentation indicated that two telephone orders dated 6/18/10 did not have the date or time of the physician's signature.

3. The medical record of Pt. #3 was reviewed on 3/21/11. Documentation indicated that Pt. #3 was admitted to the CAH on 2/3/10 with the diagnoses of Gastrointestinal Hemorrhage and Sepsis. Documentation indicated that telephone orders for admission dated 2/3/10 did not have the date or time of the physician's signature.

4. The medical record of Pt. #5 was reviewed on 3/21/11. Documentation indicated that Pt. #5 was admitted to the CAH on 3/21/11 with the diagnoses of Pulmonary Edema and Congestive Heart Failure. Documentation indicated that multiple telephone orders dated 3/19/11 had no time by physician signature.

5. The medical record of Pt. #11 was reviewed on 3/22/11. Documentation indicated that Pt. #11 was admitted to the CAH on 2/14/11 for Laparoscopic Cholecystectomy. The discharge orders signed by the physician had no date or time by physician signature.

6. The medical record of Pt. #16 was reviewed on 3/22/11. Documentation indicated that Pt.# 16 was admitted for outpatient services on 6/11/10 for blood transfusions. Documentation indicated that a physician order dated 6/12/10 was signed by the physician with no date or time.

7. During an interview with the Chief Nursing Officer on 3/23/11 at 3:00 PM, the above findings were confirmed.