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Based on observation, policy and procedure review, medical record review and staff interview, the Critical Access Hospital (CAH) failed to follow policy and procedure for hand hygiene for 1 of 1 (Patient 41) observed. The CAH also failed to follow policy and procedure for Foley Catheter care for 1 of 1 (Patient 9) records reviewed. This failed practice had the potential to affect all patients of the CAH with a reported a census of 140 patients and 723 emergency room (ED) visits for the fiscal year ending 6/30/24.

Findings are:

A. Observation (6/10/25 at 10:18) RN-G obtained albuterol (medication to improve breathing) to administer to patient 20. Without performing hand hygiene and without putting on gloves, opened nebulizer (dispenses fine mist medication) packaging and placed albuterol in medication cup. RN-G then entered patients 20's room without performing hand hygiene and without wearing gloves, handed the nebulizer with mouthpiece (allows direct delivery of medication to the lungs) to the patient. RN-G attached the tubing to the oxygen flowmeter (measures amount of oxygen), at this time the tubing to the mouthpiece became disconnected. RN-G reattached the nebulizer tubing without wearing gloves. Once the nebulizer treatment was completed, RN-G took used nebulizer tubing and used mouthpiece from patient without using gloves or performing hand hygiene. With bare hands carried used equipment to the sink in patients room. RN-G without performing hand hygiene or without putting on gloves, disassembled nebulizer mouthpiece, medication cup and tubing. RN-G rinsed used equipment in the sink under running water with bare hands. After rinsing RN-G placed items on a paper towel on the edge of the sink to dry. Without washing hands with soap and water, RN-G dried both hands off with a paper towel. RN-G exited patient 20's room without performing hand hygiene and began charting on a computer outside of the room.

- Review of policy and procedure titled Hand Hygiene Policy (Effective 10/5/19) stated ..."staff ...wash their hands during ...before and after any patient contact ...before entering a patients room and exiting a patients room ...any contact with mucus membranes ...any contact with inanimate objects including medical equipment."

B. Review of patient 9's medical record (6/11/25 at 1:50PM) revealed the patient was admitted as an inpatient from the Critical Access Hospital (CAH) swing bed (12/5-12/11/25) with a diagnosis of anemia (low red blood cell count) and leukopenia (low white blood cell count making it difficult to fight infection) secondary to receiving chemotherapy for chronic lymphocytic leukemia (cancer involving white blood cells). The patient had a Foley catheter (flexible tube to help urinate) in place for a history of urine retention (not being able to fully urinate) and chronic kidney failure. On 12/10/25 review of nursing documentation lacks evidence of documentation of cleaning the Foley catheter site on am cares.

-Review of policy and procedure titled Indwelling Urinary Catheter (Effective 4/1/24) stated ..." Catheters will be routinely cleansed ...with soap and water with am and pm cares."

C. Interview (6/10/25 at 10:35) with RN-G confirmed lack of hand hygiene as outlined above. RN-G stated "I should wear gloves", I should "wash hands in the sink or with gel."

-Interview with CNO (6/12/25 at 10:00AM) confirmed lack of documented am catheter care.

Based on observation of emergency medications and supplies, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure outdated emergency medications were not available for patient use on 2 of 2 crash carts. The CAH also failed to ensure outdated supplies were not available for patient use in 3 of 3 patient rooms (Patient Rooms 7, 8 and 9) observed, and for 5 of 5 of random sample supplies in the central supply room. These failed practices had the potential to affect all patients of the CAH. The CAH reported a census of 140 patients, 223 Surgical patients, 71 procedural patients and 723 emergency room (ED) visits for the fiscal year ending 6/30/24.

Findings are:

A. Observation of emergency medications located in the ED crash cart (6/10/25 at 11:55PM) revealed the following expired medications:

-Norepinephrine (medication used to increase blood pressure) 4 milligrams (mg) in 4 milliliter (ml) vial, 1 of 1 vial expired 4/25.

-Amiodarone (medication used to return the heart to a normal rhythm) 450 mg in 9 ml vial, 2 of 2 vials expired 5/25.

B. Observation of emergency medications located in the patient floor crash cart (6/10/25 at 12:00PM) revealed the following expired medications:

-Norepinephrine 4mg mixed in 250 ml IV bag expired 5/21/25

C. Observation of facility central supply room (6/11/25 at 8:50 AM) revealed the following expired medications:

-5 IV Dextrose (energy for body cells) 10% concentration 500 ml volume bags expired 1/25.

D. Random observation of patient rooms revealed the following expired supplies in 3 patient rooms available for use:

-Room 7 (6/10/25 at 9:08 AM) adult aerosol (fine medication mist) mask expired 5/6/24, adult aerosol mask with opened packaging and exposed mask.

-Room 8 (6/10/25 at 9:10 AM) adult oxygen mask (used to deliver oxygen over nose and mouth) expired 5/6/24 for 2 of 2 masks.

-Room 9 (6/10/25 at 9:15 AM) adult oxygen mask expired 5/6/24.
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E. Review of policy and procedure titled Medication Carts-Monitoring (Revision 5/25/25) stated " ...all crash carts/medication carts shall be checked by a licensed nurse on a routine basis ...any outdated items should be removed."

-Review of policy and procedure titled Medications-Management of Expired Drugs (last review 3/17/25) ..."Outdated medications shall be managed by ...qualified individuals within the departments. Outdates shall be checked on at least a monthly basis."

F. Interview with the CNO (6/11/25 at 12:30 PM) confirmed the above medications and supplies were expired and available for patient use.

Based on medical record review, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a discharge summary that included a recapitulation of the patients stay for 5 of 5 swing bed patients (Patients 32, 33, 34, 35 and 36). This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 24 was 47 swing bed patients.

Findings are:

A. Review of Patient 32's medical record (6/11/25 at 4:00PM) revealed a swing bed admission of 11/22/24 - 12/18/24 for a left hip joint replacement. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay.
- Review of Patient 33's medical record (6/11/25 at 4:30PM) revealed a swing bed admission of 1/13/25 -2/3/25 for pinning of a right hip fracture. Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay.
- Review of Patient 34's medical record (6/12/25 at 8:30AM) revealed a swing bed admission of 1/8/25 - 2/6/25 for osteomyelitis (an infection of the bone). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay.
- Review of Patient 35's medical record (6/12/25 at 8:55AM) revealed a swing bed admission of 2/27/25 - 3/3/25 for congestive heart failure (CHF - the heart is unable to pump enough blood to meet the body's needs). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay
- Review of Patient 36's medical record (6/12/25 at 9:15AM) revealed a swing bed admission of 4/19/25-4/28/25 for encephalopathy (a brain disorder that affects the function). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay.

B. The facility lacked evidence of a policy for the discharge summary with recapitulation of the patients stay.

C. Interview with Chief Nursing Officer (CNO) (6/12/25 at 10:00AM) confirmed, 5 of 5 swing bed records lacked the document type discharge summary with recapitulation.

Based on review of emergency medication count log, review of crash cart checklists, policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to ensure the emergency department (ED) count of controlled substances were completed on 1 of 1 ED crash carts. The CAH failed to ensure the crash cart defibrillator log was completed on 1 of 1 (ED) crash carts and 1 of 1 nursing unit crash carts. The CAH also failed to ensure the pediatric crash cart log was completed on 1 of 1 pediatric crash carts. This failed practice had the potential to affect all patients of the CAH. The CAH reported a census of 140 patients, 223 Surgical patients, 71 procedural patients and 723 ED visits for the fiscal year ending 6/30/24.

Findings are:

A. Review of (ED) crash cart count of controlled substances (medications used for pain and relaxation) on (6/11/25 at 10:00 AM) dated (1/1/-6/10/25) revealed lack of documentation of crash cart count of controlled substances being completed on the following dates: 1/12/25, 1/18/25, 1/19/25, 1/31/25, 2/15/25, 3/25/25, 4/23/25, 4/29/25, and 5/4/25.

B. Review of the (ED) defibrillator log (6/11/25 at 10:00 AM) dated (1/1/-6/10/25) revealed lack of documentation of defibrillator log being completed on the following dates: 1/8/25, 1/16/25, 1/17/25, 1/18/25, 1/27/25, 1/31/25, 3/1/25, 3/25/25, 4/23/25, 4/29/25, 4/31/25, 5/3/25, 5/3/25, 5/4/25, 6/1/25, and 6/7/25.

-Review of nursing unit defibrillator log (6/11/25 at 10:30AM) dated (1/1/-6/9/25) revealed lack of documentation of defibrillator log being completed on the following dates:1/25/25, 1/26/25, 2/2/25, 2/3/25, 2/7/25, 3/19/25, 4/4/25, and 5/4/25.

C. Review of pediatric crash cart log (6/11/25 at 10:00 AM) dated (12/24-5/25) revealed a lack of documentation of being completed for April 2025.

E. Policy and procedure titled Medication Carts-Monitoring (last revision 5/5/25) stated "...All crash carts shall be checked by a licensed nurse on routine schedule."

F. Interview with CNO (6/11/25 at 11:00 AM) confirmed the above crash cart count of controlled substances, (ED) crash cart log, nursing unit crash cart log, and pediatric crash cart log lacked doumentation of being completed.