HospitalInspections.org

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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff maintain supplies and equipment to meet patient needs during an emergency for 3 of 3 emergency carts/bags inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings Included:

1. Document review of the hospital policy and procedure titled, "Emergency Medication Crash Cart and Medication Storage in the Emergency Depart (ED)," PolicyStat ID# 11762860, last revised 05/22, showed that the hospital maintains a mobile crash cart which contains medications and supplies needed for emergencies. Non-medication items will be checked for upcoming out-dates by the second week of the month. Medications in the crash cart shall be checked monthly for outdates by the pharmacy department.

Document review of the hospital policy and procedure titled, "Acute/Swing Bed Medication Crash Cart and Medication Storage," PolicyStat ID# 11763143, last revised 05/22, showed that the hospital maintains a mobile crash cart which contains medications and supplies needed for emergencies. Non-medication items will be checked for upcoming out-dates by the second week of the month. Medications in the crash cart shall be checked monthly for outdates by the pharmacy department.

2. On 05/25/22 at 9:25 AM, Surveyor #3 and the Nurse Manager (Staff #301) inspected the Emergency Department's crash cart and pediatric emergency bag during a tour and found the following:

a. One package of one-step pediatric Zoll defibrillation pads with an expiration date of 05/23/22.

b. Three ampules of epinephrine 1:1000 injectable with an expiration date of 04/22.

c. Four pediatric intravenous delivery module kits in the pediatric emergency bag (Broselow) with an expiration date of 04/30/22.

3. On 05/25/22 at 10:15 AM, Surveyor #3 and the Nurse Manager (Staff #301) inspected the acute care unit's crash cart and found three ampules of epinephrine 1:1000 injectable with an expiration date of 05/23/22.

4. Immediately following the observations, Surveyor #3 interviewed the Nurse Manager (Staff #301) about the checking of the emergency carts and bags. Staff #301 stated that hospital staff will inspect the emergency carts and bags looking for an intact seal tag lock and then document the tag number on the inspection log. She did not know why the pediatric emergency bag was not on the checklist. Staff #301 confirmed the observation of the expired supplies and medications and stated they would replace the items immediately.
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Based on document review and interview, the hospital failed to ensure that medical equipment preventative maintenance (PM) was conducted per policy and that all equipment used in the facility was inventoried into the medical equipment database.

Failure to conduct preventative maintenance on medical equipment and ensure that all equipment is inventoried risks patient injury from equipment that might be ill functioning or not calibrated per requirements.

Findings included:

1. Review of the hospital policy titled, "Preventative Maintenance Program," PolicyStat 6087068, approved 03/19, showed that CAH staff will make an inventory of all equipment and categorize it into groups, including biomedical equipment. Staff should create equipment checklists using manufacturer's recommendations to track inspection frequencies, signatures of completion, and date requirements. The policy did not describe the process for developing work orders or tracking when medical equipment maintenance is due.

2. Record review of the Philips IntelliVue MX40 telemetry monitoring system instructions for use showed that full performance checks should be done by qualified service personnel after every repair or upgrade. The instructions mention implementing a "satisfactory maintenance schedule," but do not indicate what the frequency of maintenance is.

3. Record review of PM documentation for randomly selected medical equipment showed the following:

a. A Chattanooga Ultrasound machine in the physical therapy unit had an inventory addition date of 05/31/22. The PM record showed that the scheduled maintenance was pending with a date of 12/31/22.

b. A Hamilton Medical T1 Ventilator in the overflow ED room had an inventory addition date of 06/01/22. The PM record showed that testing for this device was pending.

c. No inventory checklist was found for the Philips IntelliVue MX40 telemetry monitoring system.

4. On 06/01/22 at 11:00 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the preventative maintenance program and the items recently inventoried in the system. Staff #1701 stated that the Hamilton ventilator was not put into the system by GE Biomed, who is the contracted service provider for biomedical equipment maintenance. Staff #1701 confirmed that the maintenance records provided were the most current. Staff #1701 stated that the MX40 telemetry system is not monitored by the maintenance contractor.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report found at Shell ZRUZ21.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff followed the hospital's policy when caring for the patients placed in restraints for 1 of 1 medical records reviewed (Patient #301).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints-Chemical and Physical," PolicyStat ID# 11108545, last approved 01/22, showed that the patient must be continually assessed, monitored, and reevaluated. Restraints applied for emergency situations will be checked every thirty minutes.

2. On 05/26/22 between 1:00 PM and 5:00 PM, Surveyor #3 and the Nurse Manager (Staff #301) reviewed the medical record of a patient who was restrained during care received at the hospital. The review showed:

a. Patient #301 was a 48-year-old patient who presented to the Emergency Department on 01/01/22 with complaints of disorientation, confusion, and symptoms of post-traumatic stress disorder thought to be related to fireworks being set off for the New Year Day's holiday. The patient became verbally aggressive toward the hospital staff and provider and was placed in soft four-point restraints on 01/01/22 at 1:15 AM. The patient was released from restraints on 01/01/22 at 2:20 AM. The surveyor could find no documentation that showed how the patient was continually assessed and monitored while in restraints.

3. At the time of the review, Surveyor #3 interviewed the Nurse Manager about monitoring of patients who are in restraints. The Nurse Manager (Staff #301) confirmed and acknowledged that there was no documentation in the medical record which showed how the patient was monitored and assessed while in restraints.
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Item #1 - Controlled Substance Management & Accountability

Based on document review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to follow its policy for controlled substance management and accountability.

Failure to maintain accurate records for controlled substances distribution and accountability risks medication errors and potential diversion.

Findings included:

1. Document review of the hospital policy and procedure titled, "Controlled Substances - Permanent Swing," PolicyStat ID# 7741309, last approved 05/21, showed that a controlled substance record book for schedule II, III, IV, and V controlled substances will be established so that the receipt and withdrawal of controlled substances can be recorded.

At change of shift, there shall be an actual count performed by two authorized licensed persons. When it is necessary to destroy small amounts of controlled substances, the destruction shall be witnessed by a second nurse who shall countersign the records of destruction. Periodic monitoring of controlled substance records shall be performed by a nurse or pharmacist.

Document review of the hospital policy and procedure titled, "Patient Own Medications," PolicyStat ID# 9875460, last approved 09/21, showed that all patient-own-medications being used by permanent swing patients will be stored in the medication room until they are verified by pharmacy. Once verified, they will have a green "verified" sticker placed on the drug container and then can be placed in the medication cart.

If the patient- own-medication is a controlled substance, the medication will be logged in the bound logbook and then stored in the locked cabinet in the medication room until verified by a pharmacist. The on-site pharmacist will countersign the initial entry of all patients-own-medication controlled substances. Controlled substance patient own medications will be signed out in the bound narcotic logbook and routed to the pharmacy for destruction.

2. Document review of the current controlled substance bound logbook showed the following:

a. Morphine ER 15 mg showed a quantity remaining balance of 88 tablets. The section titled "drug destroyed" showed 88 tablets with no date documented for when destroyed.

b. Hydrocodone 5 mg and Acetaminophen 325 mg showed a quantity remaining balance of 32 tablets. The section titled "drug destroyed" showed no amount for quantity destroyed but had a date of 12/24/21 annotated.

c. Hydrocodone (no strength indicated) showed a quantity remaining balance of 47 tablets. The section titled "drug destroyed" was left blank.

d. Tramadol 50 mg showed a quantity remaining balance of 46 tablets. The section titled "drug destroyed" was left blank.

e. Morphine 20 mg per ml liquid showed a quantity remaining balance of 5 ml. The section titled "drug destroyed" was left blank.

f. Lorazepam 2mg per ml liquid showed a quantity remaining balance of 19.5 ml. The section titled "drug destroyed" was left blank.

g. Lorazepam 0.5 mg showed a quantity remaining balance of 82 tablets. The section titled, "drug discontinued" showed a date of 10/03/21 but no releasing nurses signature annotated.

h. The controlled substance inventory shift counts for the period of 05/03/22 to 05/26/22 showed the following:

a. On 05/04/22, no shift count was performed on the night shift (6:00 PM - 05/04/22).

b. On 05/21/22, no shift count was performed on the day shift (6:00 AM - 05/21/22)

3. On 05/26/22 between 12:00 PM and 1:00 PM, Surveyor #3 interviewed the Pharmacy Director (Staff #309) about controlled substance management and accountability. Staff #309 stated that no audits are performed of any controlled substance which is not located in the automated dispensing machines (Omnicell).

When asked about how controlled substances are destroyed when no longer needed by "permanent swing" patients, Staff #309 stated they are generally destroyed by a pharmacist and a licensed nurse on the unit. The surveyor then showed Staff #309 some examples of the controlled substance bound logbook sheets. Staff #309 acknowledged the remaining inventory balances should be at zero after being destroyed or removed by pharmacy personnel. He confirmed that that hospital personnel were not consistently documenting in the logbook all the required areas needed when controlled substances are removed and destroyed.

4. 0n 06/01/22 at 11:00 AM, Surveyor #3 inspected the medication cart where patient-own-medications are stored for "permanent swing" patients. The surveyor found the following:

a. One bottle containing 30 tablets of a controlled substance labeled hydrocodone 5mg with 325 mg of acetaminophen with no green "verified" sticker to indicate that a hospital pharmacist had confirmed the bottle's contents as required by policy.

b. One package containing a controlled substance labeled tramadol 50 mg with no green "verified" sticker to indicate that a hospital pharmacist had confirmed the bottle's contents as required by policy.

5. At the time of the review, Surveyor #3 interviewed a Registered Nurse (Staff # 310) who confirmed the above findings showing that no green sticker to indicate they were verified by a hospital pharmacist had been applied. She stated she would have them verified immediately.

Item #2 - Unusable or Expired Medications

Based on observation, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that outdated or unusable medications were not available for administration to patients.

Failure to ensure medication storage areas do not contain outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, and efficacy.

Findings included:

1. Document review of the hospital policy and procedure titled, "Unusable and Outdated Drugs," PolicyStat ID# 8365440, last approved 05/21, showed that all drug storage areas of the hospital will be inspected at least monthly for outdated drugs, contaminated drugs and improperly stored drugs. All unusable drugs will be removed from the areas by the person conducting the inspection.

2. On 05/25/22 between 9:00 AM and 10:30 AM, Surveyor #3 and the Nurse Manager (Staff #301) inspected the emergency department (ED), acute care, observational, and swing bed areas and observed the following:

a. Three ampules of epinephrine 1:000 injectable with an expiration date of 04/22 in the ED crash cart.

b. Six acetaminophen 325 mg suppositories with an expiration date of 02/22 in the ED medication room refrigerator.

c. Three ampules of epinephrine 1:000 injectable with an expiration date of 04/22 in the acute care crash cart.

3. On 05/26/22 between 12:00 PM and 1:00 PM, Surveyor #3 interviewed the Pharmacy Director (Staff #309) about expired medications found in the hospital. Staff #309 confirmed the findings and stated the on-site pharmacist performs monthly inspections of all medication storage areas and whenever in a clinical area for deliveries.

Item #3 - After Hours Access to the Pharmacy

Based on interview and document review, the Critical Access Hospital failed to ensure that medications were kept secure from potential unauthorized access.

Failure to secure medications risks potential diversion, medication errors, and patient safety.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Access to Pharmacy in Absence of Pharmacist," PolicyStat I # 10473265, last approved 05/22, showed that only the designated charge nurse will have access to the pharmacy. No other person shall accompany the charge nurse into the pharmacy. Only a quantity sufficient to meet the immediate needs of the patient is removed. Items removed from the pharmacy will be recorded on the sign out sheet labeled "Medication Disposition Log - Pharmacy Pulls".

2. Document review of the Pharmacy log titled, "Medication Disposition Log - Pharmacy Pulls," for 05/11/22 to 05/25/22 showed the following:

a. On 05/23/22 two different hospital staff accessed the pharmacy during the same shift when a pharmacist was not available.

b. On 05/23/22 the medication disposition log showed the pharmacy was accessed at 10:00 AM and 8:15 PM, respectively. Later, the surveyor noted three entries documented for 05/23/22 at 9:00 AM after the 8:15 PM entry on 05/23/22 had been written.

3. On 05/25/22 at 1:40 PM, Surveyor #3 interviewed the Nurse Manager (Staff #301) about access to the pharmacy by non-pharmacy personnel. The surveyor and Staff #301 reviewed the most current medication disposition log. Staff #301 acknowledged that more than one person accessed the pharmacy on the same shift. She did not know why the medication log showed earlier entries documented after later entries on the log sheet.
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Based on observation, interview, record review, and review of hospital policy and procedure, the Critical Care Access Hospital failed to ensure staff members followed policies and procedures for safe medication administration for 1 of 3 records reviewed (Patient #302).

Failure to follow safe medication administration procedures puts patients at risk for late medication administration and delayed treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Medication Administration and Documentation," PolicyStat ID# 11762804, last approved 05/22, showed that the licensed nurse shall verify the medication selected based on the seven rights of medication administration. One of those rights is the "Right Time" being sure the medication is administered at the scheduled time.

2. On 5/25/22 at 11:10 AM, Surveyor #3 observed a Registered Nurse (Staff #302) administered ertapenem (an antibiotic) intravenously by piggy-back infusion to Patient #302 during a medication pass. A review of the medication administration record (MAR) showed that the intravenous antibiotic was scheduled to be administered daily at 8:00 AM. The actual time of administration was noted to be three hours past the scheduled time.

3. On 5/25/22 at 1:00 PM, Surveyor #3 interviewed the Registered Nurse (Staff #302) about the observed medication pass for Patient #302. Surveyor #3 asked Staff #302 about the timing of medications and when they are considered a late administration. Staff #302 stated that the hospital policy was that medications may be given one hour prior to or one hour after the scheduled medication time and not be considered late.

When asked about Patient #302's intravenous antibiotic medication administration, Staff #302 acknowledged the medication was given late due to the assigned nurse for that patient being pulled to the emergency room to care for another patient.

4. Review of medical record showed the following:

a. Patient #302 was a 7l year-old admitted to the hospital for a 6-week course of intravenous antibiotics following a post-operative wound infection and subsequent wound dehiscence (unplanned opening of the wound). A provider wrote an order for the patient to receive one gram of the antibiotic ertapenem intravenously every 24 hours for 36 days.

b. Patient #302's MAR showed that the intravenous antibiotic was administered late 3 out of the 5 days reviewed including:

On 05/22/22, the intravenous antibiotic ertapenem was administered at 9:30 AM, 1 hour and 30 minutes past the scheduled time.

On 05/23/22, the intravenous antibiotic ertapenem was administered at 9:57 AM, 1 hour and 56 minutes past the scheduled time.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff develop and keep current an individualized plan of care for 2 of 4 patient care plans reviewed (Patient #303, #304).

Failure to assess the patient's healthcare needs and develop an individualized plan of care can result in the inappropriate, inconsistent, and delayed treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Acute Admission Criteria," PolicyStat ID#11108534, last approved 02/22, showed that a nursing care plan will be initiated at the time of admission and completed within 24 hours of admission. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting those changes in condition.

2. On 05/26/22 at 3:00 PM, Surveyor #3 and the Nurse Manager (Staff #301) reviewed the medical records of 4 patients with recent hospitalization on the inpatient unit. The review showed the following:

a. Patient #303 was a 68-year-old admitted on 02/05/22 with COVID-19 pneumonia and acute respiratory distress. The surveyor found no evidence that the patient's nursing care plan included a patient problem for the admitting diagnosis including respective goals and interventions for the pulmonary illnesses.

b. Patient #304 was a 69-year-old admitted on 01/26/22 with acute respiratory distress, influenza, multiple medical problems including diabetes mellitus, and chronic kidney disease. The surveyor found no evidence that the patient's nursing care plan included a problem for the admitting diagnosis including respective goals and interventions for the pulmonary illnesses.

3. At the time of the review, Surveyor #3 interviewed the Nurse Manager (Staff #301) about the plan of care. Staff #301 confirmed that the care plans were not individualized to the patient's identified problems and should have at a minimum included a problem related to the problems which required their hospitalization.
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Based on record review, document review, and interview, the hospital failed to ensure staff members signatures included their professional credential or title in the patient's medical record.

Failure to include the staff member's professional credential or title in their signature risks misinterpretation of information and potential delays in patient care.

Findings included:

1. On 05/25/22 at 3:05 PM, Surveyor #3 and the Nurse Manager (Staff #301) reviewed the medical record of Patient #303 who was admitted to the observation unit for chest pain and overall body weakness. The surveyor observed that the nursing notes electronically written and signed by the registered nurse (Staff #310) only included their name and did not include their professional credential or title.

2. At the time of the review, Surveyor #3 interviewed the Nurse Manager (Staff #301) about the absence of the professional title or credential in the electronic signature block of the nurse. Staff #301 was not aware that the professional title and credential was not part of the printed electronic medical record. She did not know who was responsible for ensuring that hospital staff member's credential and title was part of their electronic signature.

3. On 05/27/22 at 8:10 AM, Surveyor #3 and the Nurse Manager (Staff #301) reviewed the medical record of Patient #302 who was admitted on 04/20/22 for a 6-week course of intravenous antibiotics following a post-operative wound infection. The surveyor observed that progress notes written by the social worker (Staff #303), physical therapist (Staff #304), registered dietician (Staff #305), two registered nurses (Staff #302 and #306), a licensed practical nurse (Staff #307), and the activity director (Staff #308) only included the hospital staff members' names. The signed electronic signature did not include their professional credential or title.

A review of Patient #301, #304, and #306's medical records showed similar observations in the medical record with no professional credential or title in the staff members' electronic signature.

4. At the time of the 05/27/22 record review, Surveyor #3 requested the hospital policy concerning medical records and use of professional title and credentials in clinical records signature. No policy could be located or provided.
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Item #1 - High Level Disinfection

Based on observation, document review, and interview, the hospital failed to implement high level disinfection (HLD) procedures according to policy and national standards.

Failure to properly implement high level disinfection procedures risks patient infection from improperly reprocessed equipment.

Findings included:

1. Record review of the policy titled, "Cleaning, Disinfection & Sterilization Policy & Procedure," PolicyStat 10144081, approved 07/21, showed that routine testing of high-level disinfectants should be performed to ensure effective concentration of active ingredients. High-level disinfectant temperatures should be monitored and recorded prior to use.

2. Record review of the manufacturer's instructions for use (IFU) for McKesson 28-Day Gluteraldehyde HLD solution showed that temperature must be maintained at 25 degrees Celsius, and temperature should be monitored with a thermometer. Users should also test the solution for proper concentration prior to each use.

3. On 05/25/22 at 3:07 PM, Surveyor #17 toured the reprocessing area of the CAH with the Central Services clerk (Staff #1709). During the tour, the surveyor asked Staff #1709 if there was any high-level disinfection performed. Staff #1709 said that the CAH rarely uses HLD reprocessing but has the capability to perform the procedure. The surveyor asked Staff #1709 to walk them through the process for HLD. During the walkthrough, the surveyor noted that there was no thermometer to measure temperature of the solution and that the CAH did not have test strips to test the efficacy of the solution. No log book was available for staff to record the time, temperature, or test strip results.

Item #2 - Disinfectant Use

Based on observation, document review, and interview, the hospital failed to adequately label disinfectants that were available for use with disinfectant type and expiration date and remove expired disinfectants from use.

Failure to properly label disinfectants and remove expired items places patients, staff, and visitors at risk from inadequately cleaned surfaces or equipment should incorrect or expired disinfectants be used during environmental cleaning.

Findings included:

1. Review of the instructions for use for Kimtech WetTask System (a cleaning wipe and bucket system that allows the facility to add its own chemical solutions) showed that staff should fill out the label information as required prior to use.

2. On 05/25/22 at 10:10 AM, Surveyor #17 inspected the ED overflow room. During the inspection, the surveyor noticed a bucket of Kimtech WetTask System wipes that were available for environmental cleaning. The bucket was filled with solution, but the label had no information on the product type or expiration date of solution. The surveyor also found a container of Medline Micro-Kill Bleach wipes with an expiration date of 04/22.

3. At the time of observation, Surveyor #17 interviewed the Nurse Manager (Staff #1713) about the wipes. Staff #1713 confirmed that the Kimteck wipe label was not filled out with the required product name or expiration date. Staff #1713 also confirmed that the Micro-Kill bleach wipes were expired.

Item #3 - Transmission Based Precautions

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff displayed isolation precaution signage in a clear, visible location to notify staff, visitors, and other patients.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff and visitors at risk from communicable illnesses.

Findings included:

1. Document review of the Critical Access Hospital's contact precautions placard (Washington State Hospital Association form) last revised 01/23/08, showed that contact precautions signage should be displayed outside the door.

Document review of the hospital policy and procedures titled, "Isolation Precautions," PolicyStat ID # 11771487, last approved 05/22, showed that isolation precautions are to maintain employee and patient safety. They are intended to reduce the risk of transmission from both recognized and unrecognized sources of infection.

2. On 05/25/22 between 8:00 AM and 9:00 AM, Surveyor #3 and the Nurse Manager (Staff #301) toured the acute care, observation, and swing bed areas. The surveyor attempted to walked into Room 108 but was stopped by Staff #301 stating that the patient in that room was on contact precautions. The surveyor observed there was no isolation precaution signage on the door or immediately outside the patient's room to alert staff, visitors, or patients. The signage was located on the isolation cart across the hallway from the patient.

3. At the time of the observation, the Nurse Manager (Staff #301) acknowledged that the isolation precaution signage should be displayed on the door or be located near the door frame. She stated that it would have it corrected immediately.
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Based on observation, document review, and interview, the hospital failed to ensure that environmental surfaces and equipment were maintained to ensure they are easily cleanable.

Failure to maintain environmental surfaces so that they are easily cleanable risks patient, staff, and visitor infection by allowing sources for transmission of infection due to surfaces being unable to be adequately cleaned.

Findings included:

1. On 05/25/22 at 9:08 AM, Surveyor #17 toured the inpatient area of the CAH. During the tour, the surveyor inspected a clean equipment storage room in the "long hall" area of the inpatient unit. During the inspection, the surveyor noticed a floor fall mat with torn seams along the exterior surface which resulted in frayed material and exposure of the internal foam.

2. At the time of observation, Surveyor #17 interviewed the Co-CEO (Staff #1714) about the damaged item. Staff #1714 confirmed the item was damaged and removed it from the storage area.

3. On 05/25/22 at 9:28 AM, Surveyor #17 toured the emergency department (ED). During the tour, Surveyor #17 noted that a significant portion (approximately a 2 by 2 feet square area) of the countertop adjacent to a hand washing sink in Bay 2 was missing, exposing porous wood surface. Items for patient care were being stored on this exposed surface.

4. On 05/26/22 at 3:25 PM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the ED countertops. Staff #1701 stated that the ED was being remodeled to add an additional bay and update the space. The CAH had cabinets and panels on order, so staff started some demolition to prepare for the arrival. Items arrived missing or broken, so the CAH could not complete the work as they had planned. Supply chain issues caused delays in shipping of new items. Staff #1701 provided emails dated 05/04/22, 05/16/22, and 05/19/22 showing that the items were damaged and reordered.
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Based on document review and interview, the hospital failed to ensure that staff completed annual infection control training specific to the work area for 1 of 10 staff reviewed (Staff #1703).

Failure to provide annual infection control training risks infection for patients or staff due to untrained staff working in the CAH.

Findings included:

1. Record review of the hospital policy titled, "Infection Prevention and Control Program," PolicyStat 11555302, approved 04/22, showed that all staff will receive annual infection control education.

2. On 05/27/22 at 8:45 AM, Surveyor #17 reviewed personnel files and training records with the Human Resources Director (Staff #1702). The review showed that a social worker (Staff #1703) last completed infection control training to the specific work area on 12/15/20.

3. At the time of the record review, the Human Resources Director stated that there was an error with the training system and the annual training was not assigned to the individual.
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Based on document review and interview, the hospital failed to ensure that staff completed annual multidrug resistant organism (MDRO) training for 2 of 10 staff reviewed (Staff #1703 and #1709).

Failure to provide annual MDRO training risks infection for patients or staff due to untrained staff working in the CAH.

Findings included:

1. Record review of the hospital policy titled, "Infection Prevention and Control Program," PolicyStat 11555302, approved 04/22, showed that all staff will receive annual infection control education.

2. On 05/27/22 at 8:45 AM, Surveyor #17 reviewed personnel files and training records with the Human Resources Director (Staff #1702). The review showed that a social worker (Staff #1703) last completed MDRO training on 12/15/20. A central services clerk (Staff #1709) had no documented MDRO training in their personnel file.

3. At the time of the record review, the Human Resources Director stated that there was an error with the training system and the annual training was not assigned to Staff #1703. The director stated that Staff #1709 was not assigned MDRO training as they were not given the clinical core annual training, which includes MDRO training.
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Based on document review and interview, the Critical Access Hospital failed to fully implement policies and procedures for COVID-19 vaccination of the hospital staff.

Failure to fully implement COVID-19 vaccination processes and procedures for the healthcare staff risks transmission of COVID-19 to patients, staff, and visitors.

Findings included:

1. Record review of the hospital policy titled, "COVID-19 Vaccine Requirements for Employees, Contractors, Vendors, and Volunteers," PolicyStat ID: 11210378; approved 02/22; showed that the CAH will notify contract agencies of requirements prior to a new contractor providing on site services. All contracted agencies will provide proof of vaccination or exemption to the CAH. Any contractors who do not have documentation on file will not be allowed to work.

2. On 05/27/22 at 8:45 AM, Surveyor #17 reviewed COVID-19 vaccine documentation with the Manager of Human Resources (Staff #1702). Review showed that a contracted staff member (Staff #1706) had submitted a request to the contract agency. The document in the personnel file did not have an approval from the hospital or agency. Staff #1702 stated that Staff #1706 had worked at the CAH since 03/07/22 and that he would try to find the approved request.

3. On 05/27/22 at 10:15 AM, Staff #1702 brought an approved exemption request from the contract agency for Staff #1706. The approval date for the request was 05/24/22. Staff #1702 acknowledged that the contracted staff person had worked at the facility for almost two months without documentation of the approved exemption request and the process needs work to ensure that agencies or contracted staff provide documentation of exemptions.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to establish and maintain a comprehensive emergency preparedness program.

Failure to establish and maintain a comprehensive emergency preparedness program places patients, staff, and visitors at risk for delayed or compromised care, injury, or death in the event of an emergency.

Findings included:

1. Failure to develop an emergency preparedness plan that includes all required elements.

Cross Reference: Tag E-0004

2. Failure to develop an emergency preparedness plan based on a risk assessment using an all-hazards approach and developing strategies to address areas identified in the risk assessment.

Cross Reference: Tag E-0006

3. Failure to develop policies and procedures based on a risk assessment.

Cross Reference: Tag E-0013

4. Failure to develop a policy for using alternate care sites during an 1135 waiver

Cross Reference: Tag E-0026

5. Failure to develop a training and testing program based on a risk assessment.

Cross Reference: Tag E-0036

6. Failure to implement a training program based on a facility or community specific risk assessment and conduct trainings at timelines specified by policy.

Cross Reference: Tag E-0037

7. Failure to develop a process for testing the emergency plan and conducting testing according to require intervals.

Cross Reference: Tag E-0039

Due to the scope of these findings, the Condition of Participation 42 CFR 485.625: Emergency Preparedness was NOT MET.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness program based on an all-hazards risk assessment that was specific to the facility.

Failure to develop and maintain an emergency preparedness program based on an all-hazards risk assessment specific for the facility risks an inadequately developed emergency preparedness plan and the inability of the facility to properly respond to an emergency.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that the plan did not contain all of the required elements. The plan was missing the following elements:

a. The plan was not based on an all-hazards risk assessment.

b. The policies and procedures were not developed based on identified risks from an all-hazards risk assessment.

c. The plan did not contain a policy or procedure for providing alternate care sites during an 1135 waiver

2. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the CAH's emergency preparedness program and an all-hazards risk assessment. Staff #1701 stated that the CAH did not have an all-hazards risk assessment. Staff #1701 stated that he had recently taken over the position and was unable to locate an assessment.
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Based on document review and interview, the CAH failed to develop an emergency preparedness plan based on a documented facility or community-based risk assessment utilizing an all-hazards approach and include strategies for addressing emergencies identified in that assessment.

Failure to develop an emergency preparedness plan based on a risk assessment using an all-hazards approach and failure to include strategies addressing emergencies identified in that risk assessment places patients, staff, and visitors at risk of injury or death during an emergency due to inadequate preparation.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that no all-hazards risk assessment was present in the documents and the plan was not based on an all-hazards assessment.

2. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the CAH's emergency preparedness program and an all-hazards risk assessment. Staff #1701 stated that the CAH did not have an all-hazards risk assessment. Staff #1701 stated that he had recently taken over the position and was unable to locate an assessment.
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Based on document review and interview, the CAH failed to implement emergency preparedness policies and procedures based on a community or facility risk assessment.

Failure to develop policies and procedures based on the risk assessment risks implementation of processes that are inadequate for the risks at the facility.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that no all-hazards risk assessment was present in the documents. Since there was no all-hazards risk assessment, the policies and procedures could not be based on a facility or community specific risk assessment.

2. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the CAH's emergency preparedness program and an all-hazards risk assessment. Staff #1701 stated that the CAH did not have an all-hazards risk assessment. Staff #1701 stated that he had recently taken over the position and was unable to locate an assessment.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop a policy for the CAH's role during an 1135 waiver for providing care at an alternate care site.

Failure to develop a policy for providing care at an alternate care site during an 1135 waiver risks the inability of the CAH to provide adequate care should they need to relocate patients during the activation of the emergency preparedness plan.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that no policy specifying the CAH's role for providing care at alternate care sites under an 1135 waiver was present.

2. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the CAH's emergency preparedness program and the CAH's policy for providing care at alternate care sites. Staff #1701 stated that there were policies for providing care at other areas in the community if needed but the policies were not specific to providing care under an 1135 waiver.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop and implement a policy for testing the emergency preparedness program and train staff to the program based on an all-hazards risk assessment.

Failure to develop and implement a policy for testing the program and providing training based on a risk assessment places patients, staff, and visitors at risk from inadequate implementation of the program should it need to be activated.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that the CAH had not developed a policy on testing the emergency preparedness program and had not developed an all-hazards risk assessment to guide the implementation of a testing program.

2. Record review of the hospital policy titled, "Preparedness Training Policy," PolicyStat ID: 11765002, approved 05/22, showed that all staff will receive mandatory annual preparedness training. The policy did not specify that the training would be based on an all-hazards risk assessment.

Record review of the annual emergency preparedness training, "Regulation Express: Emergency Preparedness and Response," dated 2021, showed that the training was standard training developed by the company Relias. The training was not specific to the facility or any risks identified by the CAH.

3. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the testing and training components of the CAH's emergency preparedness program. Staff #1701 stated that the last testing exercise of the program occurred in 2020 and that there was not policy or documentation regarding that event.

4. On 06/01/22 at 12:00 PM, Surveyor #17 interviewed the Human Resources Manager (Staff #1702) about the emergency preparedness testing program. Staff #1702 stated that staff complete training annually through the Relias platform and provided the Surveyor with the training materials.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to train staff to the program based on an all-hazards risk assessment and at intervals specified in hospital policy.

Failure to providing training based on a risk assessment places patients, staff, and visitors at risk from inadequate implementation of the program should it need to be activated.

Findings included:

1. Record review of the hospital policy titled, "Preparedness Training Policy," PolicyStat ID: 11765002, approved 05/22, showed that all staff will receive mandatory annual preparedness training. The policy did not specify that the training would be based on an all-hazards risk assessment.

Record review of the annual emergency preparedness training, "Regulation Express: Emergency Preparedness and Response," dated 2021, showed that the training was standard training developed by the company Relias. The training was not specific to the facility or any risks identified by the CAH.

2. Record review of the personnel files for 10 staff members showed the following:

a. A social worker (Staff #1703) last completed annual emergency preparedness training on 12/16/20.

b. A registered nurse (Staff #1704) last completed annual emergency preparedness training on 07/06/20.

c. A contracted certified nursing assistant (Staff #1705) had completed a Relias training titled, "Core Mandatory Part I," which included an emergency preparedness component. This training was not reflective of a CAH specific program or risk assessment.

d. A contracted registered nurse (Staff #7106) had completed a Relias training titled, "Core Mandatory Part I," which included an emergency preparedness component. This training was not reflective of a CAH specific program or risk assessment.

e. All other staff reviewed (Staff #1707, #1708, #1709, #1710, #1711, and #1712) had completed training but had not taken a training specific to the CAH or based on a CAH specific risk assessment.

3. On 06/01/22 at 12:00 PM, Surveyor #17 interviewed the Human Resources Manager (Staff #1702) about the emergency preparedness testing program. Staff #1702 stated that staff complete training annually through the Relias platform and provided the Surveyor with the training materials. Staff #1702 confirmed the missing annual trainings for the two employed staff members and that the contracted staff members complete emergency preparedness training through the Relias platform.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop and implement a policy for testing the emergency preparedness program and did not conduct the required testing exercises of the program.

Failure to develop and implement a policy for testing the program based on a risk assessment places patients, staff, and visitors at risk from inadequate implementation of the program should it need to be activated.

Findings included:

1. Record review of the emergency preparedness program and policies, reviewed 05/20/22, showed that the CAH had not developed a policy on testing the emergency preparedness program and had not developed an all-hazards risk assessment to guide the implementation of a testing program. No documentation of any testing of the program was found in the emergency preparedness documents provided by the CAH to the surveyor.

2. On 06/01/22 at 9:42 AM, Surveyor #17 interviewed the Facilities Manager (Staff #1701) about the testing and training components of the CAH's emergency preparedness program. Staff #1701 stated that the last testing exercise of the program occurred in early 2020. The training was multi-agency training. Staff #1702 stated that here was not policy for testing the program and that they could not find documentation regarding the event. The surveyor could find no documentation of the event or any after action review.
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