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Based on observation, staff interview and review of the hospital emergency room crash cart logs it was determined that the hospital failed to ensure that emergency life saving equipment was maintained.

Findings include:

Observation of the emergency room crash cart with the cardiac defibrillator and monitor on 1/14/10 with Staff C (Registered Nurse) and Staff D (Registered Nurse) revealed a monthly/daily "CODE CART CHECK" log. This emergency room monthly/daily log revealed that the crash cart lock number is secure and intact and that the cardiac defibrillator function testing is checked twice a day, once "7 AM TO 7 PM" and once "7 PM TO 7 AM".

Further review of the emergency room crash cart logs revealed the following:
- October 2009 "CODE CART CHECK" showed no documentation of the crash cart check done on 10/8, 10/13, 10/16, 10/21 and 10/24 for a total of 5 times for the 1st shift and no documentation on 9/30/09, 10/5, 10/11 and 10/24 for 4 times on the 2nd shift. There was also no documentation of the monitor check done on 10/11, 10/20 and 10/29 for 3 times on the 2nd shift.

- November 2009 "CODE CART CHECK" showed no documentation of the crash cart check done on 11/6 one time on the 1st shift and on 11/13 one time on the 2nd shift.

- December 2009 "CODE CART CHECK" showed no documentation of the crash cart check done on 12/7, 12/9 and 12/17 for three times on the 1st shift and no documentation of the crash cart check done on 12/7, 12/19 two times on the 2nd shift. There was also no documentation of the monitor check done on 12/2, 12/3, 12/4, 12/14 and 12/21 for a total of five times on the 1st shift and no documentation of the monitor check done on 12/22 on the 2nd shift.

- January 2010 "CODE CART CHECK" showed no documentation of the crash cart check done on 1/5 for the 1st shift . There was also no documentation of the monitor check done on 1/1,1/2,1/3 and 1/6 on the 1st shift and no documentation of the monitor check done on 1/1 once on the 2nd shift.

During interview with Staff C (Registered Nurse) and Staff D (Registered Nurse) on 1/14/10 at approximately 9:15 a.m. Staff C and D confirmed that the emergency room crash cart defibrillator and lock number check was to be performed twice a day with documentation on the above listed "CODE CART CHECK" monthly/daily form.

The hospital failed to show documented evidence that the twice a day emergency room crash cart cardiac monitor, defibrillator and security lock were maintained as evidenced by the above listed logs.

AIA, (American institute of Architects) Guidelines for Design and Construction of Health Care Facilities Under the 2006 edition, section 2.1, 8.2.3.4 it states in part:

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, nonperforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plan into the semirestricted environment. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.

(4) Restricted areas. Ceiling finishes in restricted areas such as operating rooms shall be monolithic, scrubbable, and capable of withstanding chemicals. Cracks or perforations in these ceilings are not allowed."

Based on tour of the surgical suite on 1/12/10 and 1/14/10 with Staff A (Manager of Surgical Services) it was observed that the facility failed to have the proper ceiling tiles in several areas.

Findings include:

During tour of the surgical suite with Staff A on 1/12/10 and again on 1/14/10 it was observed and shown to Staff A that all ceiling tiles throughout the surgical area were perforated and failed to be clipped down.

ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa).


ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:


*A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.


Based on observation and interview it was found that the facility failed to properly monitor the pressurization of the surgical suite and supply areas.

Findings include:

During tour on 1/12/10 at 1:30 p.m. it was observed and shown to Staff A (Manager of Surgical Services) that both operating rooms #1 and #2 along with the minor procedure room failed to have pressurization monitoring devices. Also it was observed that the sterilizer equipment rooms, clean workroom/central supply and decontamination room failed to have air pressurization monitoring devices to show the appropriate air pressurization. All findings were confirmed by Staff A at time of observation.

Based on tour of the radiology department it was found that the facility failed to secure the department to provide the safety and security of patients, staff, and supplies within this unit.

Findings include:

During tour of the facility's radiology department it was observed and shown to Staff E (Manager of Radiology) that multiple pre filled syringes and bottles of contrast media were unsecured and unlocked within the Cat Scan room. Also while touring the radiology department it was observed that the public was able to walk through the department several times while touring with Staff E. Staff E was asked by surveyor if the department can be secured, to prevent public traffic through the department. Staff E stated that the unit can not be locked down due to the location of the unit and the multiple means of entry into the unit. Based on information found during tour of the radiology department the facility failed to protect and secure the integrity of the department, providing a safe environment for patients and staff.

Based on review of hospital documents and interview the hospital failed to designate in their governing body documentation that the governing body assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's (Critical Access Hospitals) total operation.

Findings include:

Review of the corporate By Laws related to the Governing Body on 1/13/10 at 1 p.m. revealed that the document does not designate the governing body as the corporate body that assumes full legal responsibility for the CAH's total operation.

Interview of Staff A (Vice President Patient Care and Laboratory Services) and Staff B (Director Quality Management) on 1/13/10 at 2 p.m. and on 1/14/10 at 10 a.m. confirms the hospital documents relevant to the CAH's operations fail to identify the governing body as the corporate body that assumes full legal responsibility for the CAH.

Based on record review and staff interview it was determined that the hospital failed to assure that the patient rights and responsibilities were provided to 3 patients in a standard survey sample of 35. (Patient identifiers are #7, #8 and #10.)

Findings include:

Review of the hospital policy and procedure titled "Advance Directives, Patient Rights and Organizational Ethics Chapter" dated "5/09" revealed the following:
- "Policy: ... 5. Written information concerning patient's rights under State law to make decisions concerning their health care and statements of Hospital policy developed to honor these rights shall be made available to all patients.
- Procedure: 1. The Patient's Bill of Rights, a statement of the individual's rights under New Hampshire State Law to make decisions about medical care including the right to accept or refuse medical and surgical treatments and information describing an individual's right to formulate Advance Directives shall be given to all patients."

Record review on 1/13/10 and 1/14/10 of the hospital "Patient Consent, Authorization and Payment Guarantee" for Patient #7, Patient #8 (two individual forms) and Patient #10 revealed no documented evidence on these forms in the section indicating "Received Patient Bill of Rights" that Patient #7, #8 and #10 were given the Patient Bill of Rights on admission to the hospital.

During interview with Staff C (Registered Nurse) and Staff D (Registered Nurse) on 1/14/10 at approximately 9:30 a.m., after Staff C and D reviewed the "Patient Consent, Authorization and Payment Guarantee" forms listed above, Staff C and D confirmed that there was no documented evidence that the Patient Bill of Rights were given to Patient #7, #8 (two individual forms) and #10.