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A. Based on document review, observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure crash carts were checked on a daily basis to assure safe functioning, per policy. This has the potential to affect all inpatients and outpatients who receive care by the CAH.

Findings include:

1. The Patient Care Policy 210 titled, "Code Blue Medical Emergency" (reviewed 4/2020 by CAH) was reviewed on 10/21/2020 at approximately 10:15 AM. The policy noted, "Guidelines: Crash Cart locks will be checked and documented on once daily..."

2. During a tour of the Emergency Department (ED) on 10/20/2020 at approximately 10:30 AM, the following October 2020 logs were observed and lacked documentation of the required daily check:
a) AED (Automatic External Defibrillator) Log Sheet, 5 out of 20 days;
b) Defibrillator Crash Cart Log Sheet "peds (pediatric) 4", 5 out of 20 days;
c) Defibrillator Crash Cart Log Sheet "Adult 7", 8 out of 20 days;
d) Defibrillator Crash Cart Log Sheet "Adult 4", 5 out of 20 days.

3. During a tour of the Family Acute Care Unit (FACU) on 10/20/2020 at approximately 11:00 AM with E#4 (Director of Family Acute Care), the "Defibrillator-crash cart log sheet" for October 2020 was observed on the emergency cart in the hallway. The log lacked signatures and checks for 4 out of 19 days. E#4 also observed the log and lack of documentation. The "Defibrillator- crash cart log sheet" for September 2020 was reviewed on 10/20/20 at approximately 1:00 PM, on the same emergency cart. The log included signatures for the crash cart log; however the log was blank, as to what was checked in 5 out of 30 days.

4. During an interview, conducted during the FACU tour, E#4 verbally agreed the FACU crash cart check had not been conducted 4 of 19 days and should have been.

5. During an interview on 10/20/2020 at approximately 2:30 PM, E#2 (Director of Care Management) reviewed the September 2020 FACU log and verbally agreed the FACU crash cart check had not been conducted 5 of 30 days and should have been.

6. During an interview on 10/20/20 at approximately 1:00 PM, E#2 reviewed the ED logs sheets and verbally agreed the AED and defibrillators were to be checked daily and had not been.




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B. Based on document review and interview, it was determined in 1 of 3 Automated External Defibrillator (AED) Log Sheets reviewed, the Critical Access Hospital (CAH) failed to ensure documentation was accurately completed and legible. This has the potential to affect all patients who receive care by the CAH's Emergency Department, approximately 544 patients per month.

Findings include:

1. The policy titled "Documentation Error Correction" (revised 3/20) was reviewed on 10/23/2020. The policy noted "B. If the mistaken entry is in paper form it needs to be marked with a single line... Make a LATE ENTRY.. documenting the correct information, Write your initials, date and time next to both entries."

2. The AED Log Sheet dated August 2020 were reviewed on 10/20/2020 at approximately 3:00 PM. The logs noted 7 of 31 adult pad expiration dates and 5 of 31 pediatric pad expiration dates were illegible. The expiration dates of the adult and pediatric pads documented varied throughout the month and it was unable to be determined when the pads expired.

3. During an interview on 10/20/2020 at approximately 1:00 PM, E#2 (Director of Care Management) reviewed the AED Log Sheet and verbally agreed 12 of the entries had been altered and were illegible. E#2 verbally agreed it was unable to be determined when the adult and pediatric pads expired. E#2 verbally agreed the documentation of the edits were not conducted per policy and should have been.

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 October 21-22, 2020, 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 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 October 21-22, 2020, 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 October 22, 2020.

Based on document review and interview, it was determined for 3 of 6 (E#6, E#7, E#8) personnel files reviewed, the Hospital failed to ensure staff who provided direct patient care, demonstrated competencies for the application of restraints and care of a patient in restraints or seclusion, per policy. This has the potential to affect all inpatients and outpatients who require the use of restraints by the CAH.

Findings include:

1. The policy titled, "Restraints/and or Seclusion- Acute Care Setting" (reviewed by Hospital 02/2019) was reviewed on 10/21/2020 at approximately 3:20 PM. The policy noted, "A trained and competent staff member will assess the patient every 15-30 minutes... Reference:... Center for Medicare and Medicaid (CMS) Hospital Conditions of Participation for Patient's Rights... Title 77 Public Health... Part 250 Hospital Licensing Requirements Section 250.1075 Use of Restraints and Seclusion..."
a. 482.13(f)(1) required, "Training Intervals - Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion - (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy."
b. Section 250.1075 required, "Use of Restraints and Seclusion... b) The hospital's policy governing the use of restraints and seclusion shall be consistent with 42 CFR 482.213(e) and (f)."

2. The personnel files were reviewed on 10/21/2020 at approximately 9:30 AM. The following personnel files lacked documentation of restraint and seclusion training or demonstrated competencies:
a) E#6 (Emergency Department Registered Nurse), Date of Hire (DOH): 10/5/20
b) E#7 (Physical Therapist), DOH: 1/6/2020
c) E#8 (Emergency Department Patient Care Technician), DOH: 8/3/20

3. During an interview on 10/23/2020 at approximately 12:00 PM, E#2 (Director of Care Management) stated upon hire employees do restraint training on-line, although the demonstrated competency is only done annually in July at "Skill Days". E#2 verbally agreed E#6, E#7, and E#8 had provided patient care and had not demonstrated restraint competency. E#2 stated "We don't have a specific policy for restraint training but the policy does reference the CMS Condition of Participation Patient's Rights and the state law."

Based on document review and interview, it was determined in 1 of 2 (Pt #15) medical records reviewed, of patients with Intravenous (IV) sedation given by a Registered Nurse (RN) during an endoscopic procedure, the Critical Access Hospital (CAH) failed to ensure the nursing staff provided care to meet the patient needs, as per policy. This has the potential to affect all patients receiving endoscopic services by the CAH.

Findings include:

1. The Patient Care Policy 109 titled, "Sedation Patients" (revised by the CAH 01/2020)" was reviewed on 10/21/2020 at approximately 12:45 PM. The policy noted, "Definitions: Medications-...Versed (Midazolam)...and Demerol (Meperidine) are examples of light, moderate and deep sedation medications...Competencies: RN's giving or monitoring IV... sedation to patients are responsible for maintaining proficient skills necessary to provide quality patient care, prior to administering and monitoring IV conscious sedation..."

2. Pt. #15 Diagnoses: Dysphasia and Hemorrhoid.
The clinical record was reviewed on 10/21/2020 at approximately 10:15 AM. The record noted the patient had a Colonoscopy on 9/14/2020. The record noted on 9/14/2020 the patient was given Meperidine 100 mg (milligrams) IV push and Midazolam 3 mg IV push by Registered Nurse (E#5). The competencies of E#5, Date of Hire 5/2019, were reviewed on 10/21/2020 at approximately 12:00 PM and lacked any competencies/ training to conduct the IV sedation.

3. During an interview with the Director of Ambulatory Surgery and Special Procedures (E#5) on 10/21/2020 at approximately 2:30 PM. E#5 verbally confirmed E#5 was an RN and doesn't have competencies for the IV sedation but should have.