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Based on observation, record review of check sheets and interview, it was determined that the facility failed to ensure that all appropriate staff could be sure that all emergency equipment would be available in an emergency situation if needed.

Findings include:

Observation on 3/21/17 on tour of the main floor of the hospital revealed that the identification number of the lock tag on the crash cart did not match the corresponding number on the daily check sheet, which should be the same. The daily check sheet had been marked for each day in March. Based on the review of this documentation and the existing lock on the cart there was no way of being sure when or if the cart had been opened and if the equipment inside the cart had been removed.

Interview on 3/21/17 with Staff F (Unit Manager) review the above observation and Staff F confirmed the above finding.

Based on medical record review, review of facility rules and regulations and interview, it was determined that the facility failed to admit 2 out of 3 observation patients in a standard survey sample of 32 patients. (Patient identifiers are #10 and #27.)

Findings include:

Patient#10

Review on 3/22/17 of medical record revealed that Patient #10 was admitted to observation status on 1/30/17 for chest pressure, with a discharge plan for 23 hours.

Further review of the medical record revealed that under the nursing orders, on 1/30/17 the following: "change to med (medical) surg (surgical) status from observation". This order is signed by Staff C (Hospitalist) on 1/30/17. There is no distinct discharge order from observation and no admit order to the med surg floor.

Interview on 3/22/17 at approximately 11:00 a.m. with Staff B (Health Information Management) Staff B confirmed the above findings. Staff B confirmed that Patient #10's medical record should show 2 distinct orders, one for the discharge from the observation bed and one for the admission into the med surg bed.

Resident #27

Review on 3/22/17 of medical records revealed that Patient #27 was admitted to a level of care of observation status on 1/15/17 for "left leg cellulitis" by Staff D (Family Nurse Practitioner) and co-signed by Staff E (Medical Doctor) on 2/9/17.

Further review of Patient #27's medical record revealed under the nursing orders on 1/16/17 the following: "Level of care: Acute-Medical Surgical". This order is signed by Staff C on 1/16/17. There is no distinct discharge order from observation and no admit order to the med surgical floor.

Further review of Patient #27's medical record revealed a progress note dated 1/15/17, written by Staff C, with the "Current Level of Care: Acute Inpatient Anticipated Level of Care for tomorrow: Acute Inpatient" electronically signed on 1/16/17 by Staff C. A second progress note was written on 1/16/17 by Staff C, "Acute criteria (if patient is acute care)" electronically signed on 1/17/17 by Staff C.

Interview on 3/22/17 at approximately 11:30 a.m. with Staff B, confirmed the above findings, and that Patient #27's medical record should show 2 distinct orders, one for the discharge from the observation bed and one for the admission into the med surg bed.

Review on 3/22/17 of the facility's "Professional Staff Rules & Regulations" with revisions approved by the Board dated October 2016, revealed the following under section "6.5 Patient Admission Status changes New admission orders are required for admission status changes in accordance with Pharmacy policy New Orders are Required for a Current Patient as amended from time to time."

Patients receiving observation services are not included in the 25 inpatient bed maximum, and not in the calculation of the annual acute care patient length of stay. Observation services end when the physician or other qualified licensed practitioner orders an inpatient admission, a transfer to another health care facility, or discharge. The inpatient stay begins on the date and time of the new order.

Based on observation and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure that drugs and biologicals that are outdated are not available for patient use in the operating room (OR).

Findings include:

Observation on 3/22/17 at approximately 9:00 a.m. during tour in the core hallway of the OR revealed the following expired biologicals in the refrigerator:

3 - 1 mL [milliliter] vials of Vasostrict, expired 1/2017
2 - 10 mL vials Succinylcholine Chloride, expired 2/2017
1 - 1000 mL bag of 0.9% Sodium Chloride, expired 2/2017

Interview on 3/22/17 at approximately 9:00 a.m. with Staff A (OR, Registered Nurse) confirmed the above finding.

Based on record review and interview, it was determined that the facility failed to ensure that all medical records were accurately written as it pertains to patient code status for 1 resident in a standard survey sample of 20 inpatient records. (Patient identifier is #7.)

Findings include:

Patient #7

Review on 3/21/17 of the medical record revealed that Patient #7 had been admitted on 3/20/2017. Patient #7 was identified on the main patient information board and on Patient #7's door with a green heart which symbolizes that a patient is full code (Initiate all life saving measures in the event that they experience cardiac or respiratory arrest). In addition, Patient #7's medical record indicated that they were a full code.

Review of the electronic record which had been scanned in from documentation given to the facility from the patient/family in the advanced directive section revealed that Patient #7 wished to be a DNR (Do Not Resuscitate-No life saving measures would be initiated).

Interview 3/21/17 at 3:20 p.m. with Staff G (Director of Nursing) reviewed these findings and Staff G confirmed the above findings. Review of the Patient #7's medical record on 3/22/17 identified that the patient code status had been changed to DNR, which is the correct status based on the Patient #7's request.