The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EDWARDS COUNTY HOSPITAL 620 WEST EIGHTH STREET KINSLEY, KS 67547 Sept. 19, 2013
VIOLATION: CONSTRUCTION Tag No: C0912
The Critical Access Hospital (CAH) reported a census of six patients. Based on observation, staff interview and the lack of documents for review, the CAH failed to maintain the construction of the hospital in a manner to ensure the safety of patients.

Findings include:

- Observation of the west wing of the hospital building on 9/17/13 at 10:45am, revealed closed to patient rooms and used for storage of items including patient beds, medical records and other items. The rooms and the hallway lacked ceiling tiles, exposing the roofing materials, pipes and electrical wires. The walls in the hallway do not extend to the ceiling.

- Emergency Medical Services staff G, interviewed on 9/20/13 at 8:10am, revealed patients are transported down the west hallway to the helipad.

- Administrator A, interviewed on 9/20/13 at 8:20am confirmed patients are transported through the west hall to the helipad. Administrator A confirmed the lack of ceiling tiles in the west wing of the hospital. On 9/20/13 at 11:00am, staff A confirmed the CAH lacked policies and procedures directing staff on the maintenance of the west hall of the hospital since it is not a patient care area, but confirmed patients are transported through the hall of the west wing.
VIOLATION: MAINTENANCE Tag No: C0914
The Critical Access Hospital (CAH) reported a census of six patients. Based on observation, staff interview and the lack of documents for review, the CAH failed to provide maintenance services to the hospital in a manner to ensure the safety of patients.

Findings include:

- Observation of the west wing of the hospital building on 9/17/13 at 10:45am, revealed closed for patient rooms and currently used for storage of items including patient beds, medical records and other items. The rooms and the hallway lacked ceiling tiles, exposing the roofing materials, pipes and electrical wires. The walls in the hallway do not extend to the ceiling.

- Emergency Medical Services staff G, interviewed on 9/20/13 at 8:10am, revealed patients are transported down the west hallway to the helipad.

- Administrator A, interviewed on 9/20/13 at 8:20am confirmed patients are transported through the west hall to the helipad. Administrator A confirmed the lack of ceiling tiles in the west wing of the hospital. On 9/20/13 at 11:00am, staff A confirmed the CAH lacked policies and procedures directing staff on the maintenance of the west hall of the hospital since it is not a patient care area, but confirmed patients are transported through the hall of the west wing.
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
Based on observation, staff interview and review of records the Critical Access Hospital (CAH) failed to maintain the construction of the hospital in a manner to ensure the safety of patients (G221), to provide maintenance services to the hospital in a manner to ensure the safety of patients (G222), and failed to meet the applicable provisions of the current Life Safety Codes (G231).

The cumulative effect of these systemic problems resulted in the CAH's inability to assure the provision of care in a safe environment.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
Based on observation, records reviewed and staff interview, the Critical Access Hospital (CAH) failed to meet the applicable provisions of the current Life Safety Codes and failed to assure that the fire alarm is continuously maintained in accordance with NFPA (National Fire Protection Association) 70. The deficient practice could result in insufficient warning of a fire or other emergency for occupants of the building, affecting all residents, staff and visitors in 5 of 5 smoke zones. The CAH has a capacity of 12 with a census of 9 on 9/20/13.


Findings include:

- Tour of the CAH conducted by the fire marshal on 09/20/2013, between 12:30 p.m. and 3:30 p.m., revealed that the old CAH building did not have ceiling tiles in place, exposing wires, pipes, and conduit and the roof deck of the building. The old CAH building is used for administrative purposes and storage of medical records and hospital equipment, including beds and other combustible items. The old CAH is occasionally used to move patients from/to the new CAH and to/from the heli-pad located west of the old CAH. Lack of ceiling tiles in the old CAH could affect the functionality of smoke detectors.

CEO (Chief Executive Officer) and Maintenance Staff A were present and acknowledged the findings. CEO stated they would contact the service vendor and take whatever measures necessary to assure that the alarm system is functioning properly. The CEO stated the CAH would immediately discontinue use of the old CAH building that facilitated moving patients from/to the heli-pad.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

NFPA Standard: Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational. 2000 NFPA 101, 4.2.3

See the results of the Life Safety Code survey completed on 9/30/13.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
The Critical Access Hospital (CAH) reported a census of six patients. Based on document review, observation and staff interview, the CAH staff failed to perform hand hygiene in accordance with recognized standards of care. The CAH failed to develop and implement a method for staff to perform hand hygiene in accordance with the CAH ' s policies and accepted standards of practice. The deficient practice places patients at risk for potential exposure to infections.


Findings include:

- Infection Control officer E, interviewed on 9/19/13 at 10:10am, revealed the CAH uses CDC (Centers for Disease Control) and APIC (Association of Professionals in Infection Control and Epidemiology) as standards for the CAH ' s infection control program.

- The CAH's policy titled "Hand Hygiene", reviewed on 9/17/13, revealed "Hospital staff shall wash their hands or utilize alcohol based hand sanitizer .... ", " before applying gloves and after removing gloves " .

- Observation of the cleaning of a patient room in preparation for another patient revealed housekeeping staff F cleaning the room. Staff F applied protective gloves and disinfected the silver colored cart, sink, paper towel dispenser, and patient cart. Staff F performed hand hygiene with the alcohol based disinfectant to the gloves still being worn, reached into their uniform pocket to obtain keys to the locked housekeeping cart. Staff F disinfected the counters and cupboard doors, removed the gloves and performed hand hygiene.

- Observations of nursing staff J on 9/17/13 at 1:50pm, revealed staff J preparing to perform a finger-stick blood glucose (blood sugar) check. Staff J applied protective gloves, and wiped the blood glucose machine with a disinfectant wipe. Staff J removed the glove from their right hand, and applied another protective glove. Staff J determined the patient lacked a name band, removed both protective gloves and left the patient ' s room. Staff J returned to the patient ' s room, applied protective gloves, wiped the blood glucose machine again and removed the gloves. Staff J applied another pair of gloves, and obtained the patient ' s blood for glucose testing. Staff J removed the gloves and wiped the machine with the disinfectant wipe, returned the blood glucose meter to it ' s case and prepared to perform blood glucose testing on the other patient in the room. Staff J failed to perform hand hygiene after removing protective gloves.

- Observation of laboratory technician H on 9/17/13 at 2:10pm, revealed the patient's skin preparation of the needle stick for the lab draw. Staff H fanned the patient's skin at the lab draw site to dry the skin at the preparation site. After obtaining the lab samples, staff H removed the protective gloves and left the patient's room. Staff H failed to perform hand hygiene after removing protective gloves.

- Infection control registered nurse E, interviewed on 9/19/13 at 10:10am confirmed the CAH uses APIC and CDC guidelines for their infection control program. Staff E confirmed staff are to perform hand hygiene prior to applying protective gloves and upon removal of the gloves. Employee education regarding hand hygiene is provided upon hire and annual as part of the CAH's continuing education program. Staff E acknowledged the CAH lacked a surveillance program including observation of staff and their hand hygiene practices.
VIOLATION: NURSING DIRECTOR (412.27(D)(3)) Tag No: C0583
The Psychiatric Unit reported a census of nine patients. Based on the Job Description for the Program Director and staff interview the Psychiatric Unit failed to employee a qualified nursing service director.

Findings include:

- The Job Description for the Program Director reviewed on 9/17/13 at 9:00am directed, "Minimum Experience Requirements: Three years of full-time paid professional experience in a treatment setting, one of which is in a supervisory or administrative position..."Minimum Educational Requirements: Prefer Master's degree in the behavioral sciences, or health administration. Bachelor's degree in nursing or Diploma in Nursing acceptable with appropriate experience."

- Staff B Program Director, Registered Nurse, interviewed on 9/16/13 at 3:15pm acknowledged they did not have a Master's degree in Psychiatric and Mental Health nursing, or it's equivalent, nor did they have education or experience in the care of the mentally ill. Staff B confirmed they started working as a Program Director for the psychiatric unit about one year ago.