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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on March 10, 2025, the surveyor finds 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 C930.

Based on observation, and interview, it was determined that the Facility failed to ensure all patient care supplies was not discarded when they expired.

Findings include:

1. A tour of the treatment and storage areas was completed on 2//24/25 between 1:00 PM and 4:00 PM. During the tour, the following supplies were found outdated and were available for patient use.

a. Nine 22 Gauge x 3.50-inch Spinal Needles. The manufacturer's expiration date was 10/2024.
b. Two 1.5-liter Jevity Complete Balanced Nutrition with Fiber. The manufacturer's expiration date was 12/2024.
c. Twenty packets of Sterile Aquasonic ultrasound transmission gel 20 grams. The manufacturer's expiration date was 11/2023.

2. On 2/24/25 at approximately 2:00 PM, an interview was conducted with the Quality and Safety Coordinator (E #2). E #2 verbally agreed the supplies were expired and the expired supplies were removed from the treatment area.


3. On 2/24/25 at approximately 3:00 PM an interview was conducted with the Chef manager (E #9). E #9 verbally agreed the supplies were expired and the expired supplies were removed from the kitchen/dietary area.

Based on observation, document review and interview, it was determined for 1 of 1 Radiology Temperature log, the Hospital failed to ensure that all mechanical, electrical, and patient-care equipment was maintained in safe operating condition.

Findings include:

1. During an observational tour of the CAH on 2/24/25 at approximately 2:30 PM, the "Radiology Temperature Log" was observed to have checklists to monitor the temperature of the CT (Computed Tomography) Refrigerator Contrast, CT Refrigerator Water, and Blanket Warmer each day. The following checklists were not completed:

a) For the month of December 2024, 20 days (12/11, 12/12, and 12/14-12/31/24) lacked documentation of the temperatures being checked.
b) For the month of January 2025, 31 days (1/1-1/31/25) lacked documentation of the temperatures being checked.
c) No log observed for the month of February 2025.

2. An interview was conducted during the observational tour with Radiology Manager (E #15) on 2/24/25 at approximately 2:45 PM. E #15 reviewed the Radiology Temperature Log and verbally agreed the daily checklist had not been completed and should have been.

3. An interview was conducted on 2/27/25 at approximately 10:15 AM with the Quality and Safety Coordinator (E #2). E #2 stated, "Although we do not have a policy regarding monitoring the temperatures of the blanket warmers and refrigerators, the logs should have been completed."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on March 10, 2025, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 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 10, 2025.

Based on document review and interview, it was determined for 1 of 2 (E#13 Employee) Physician files reviewed, the hospital failed to ensure the Physician's ordering non-violent and violent restraints had a working knowledge of the hospital's policy.

Findings include:

1. The policy titled "Restraint and Seclusion Management" was reviewed on 2/26/25. The policy noted "9. Training: a. Physicians... that order and or evaluate for restraints, have working knowledge about the hospital policy for restraint use. Training occurs during orientation and as deemed necessary..."

2. The Physician files were reviewed on 2/26/25 at approximately 10:30 AM. E#13 (Employee-Medical Doctor) file lacked documentation the Physician had working knowledge of the hospital's restraint/seclusion policy and competence in ordering restraints:

3. During an interview on 2/26/25 at approximately 11:40 AM, the Director of Quality and Safety (E#14) verbally agreed that E#13 personnel file lacked any documentation of violent and/or non violent restraint training and competence.