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Based on medical record review, the hospital failed to ensure that the provisions of CFR 42.482, regarding the use of physical and chemical restraints, were followed for 4 of 4 records reviewed for restraints (P4-P7).

Failure to follow the established regulations regarding restraints places all patients at risk of harm related to the potentially inappropriate use of restraints.

Findings:

A) Reference: Per CFR 42.482.13(e)(6) it states, "Orders for use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)."

Per record review, Patient #6 was admitted on 9/3/2011. Admitting physician orders included one for restraints. The order states, "restrain pt if needed'.

B) Reference: Per review of policy and procedure titled "Physical and Chemical Restraint Policy", effective 6/27/2011, it states under guidelines at D.1, "Use the appropriate size of restraint & one that is the least restrictive but the most effective".

1. Per record review, Patient #6 was admitted on 9/3/2011. A "Restraint Assessment and Physician Order" form was found dated 9/3/2011. The "type of restraint" section showed the patient was to be restrained in bed with "four side rails", to have wrist restraints placed on both hands, and then be given a chemical restraint, as needed. There was no documentation concerning why the patient needed three different types of restraints at the same time and which one was the least restrictive.

2. Per record review, Patient #4 was a 81 year old placed into restraints on 8/27/2011 at 3:55 PM. A review of the paper Physician Orders form showed a sticker for re-ordering restraints that was completed as a "telephone order" at 7:00 PM on 8/28/2011. The rationale for restraining the patient was listed as "Wife prefers". This indication is not listed as an appropriate reason to restrain a patient in the policy and procedure.

C) Reference: Per review of policy and procedure titled "Physical and Chemical Restraint Policy", effective 6/27/2011, it states under Physician notification for restraint orders at 2., "request a physician order a soon as possible after initiating physical restraints"; and at Para #4 it states, "Medical restraints may be ordered for 24 hours and must be reordered every 24 hours after evaluation of the patient'.

1. Per record review, Patient #5 was a 61 year old placed into restraints on 10/2/2011 at 9:00 PM. A review of the paper Physician Orders form showed a sticker for re-ordering restraints that had been "crossed-out" and uncompleted. The next order for restraints was dated 10/3/2011, but the order was not timed, thus there was no evidence that the restraints had been re-ordered within 24 hours of the previous order.
The next re-order for restraints was dated 10/6/2011 without a time listed (approximately 2 days without an order). Subsequent re-order stickers were noted dated 10/7/2011 and 10/8/2011 without a time for the order. This was repeated on 10/10/2011 and 10/11/2011.

2. Per record review, Patient #6 was a 65 year old placed into restraints on 9/3/2011. A review of the paper "Restraint Assessment and Physician Order" form showed a date the physician signed the order but no time for tracking a re-order time period. The next restraint re-order showed a sticker with the date of 9/5/2011 at 9:45 AM. No re-order for restraints was found for 9/4/2011 even though documentation showed the patient was still restrained. The next restrain order sticker was placed into the record after 6:00 AM on 9/7/2011 but was never completed or signed by the physician. Another sticker was found in the record after 10:00 PM on 9/7/2011 that had been signed by the physician but not dated or timed. A subsequent "Restraint Assessment and Physician Order" form was found dated 9/10/2011 that had no restraining devices checked. Two additional restraint order stickers were found dated 9/12/2011. One of the stickers stated that the order on 9/12/2011 was a "retroactive" order for having the patient in restraints on the previous day (9/11/2011). Thus there was no evidence that the restraints had been ordered as required and the orders properly completed to meet hospital standards.

3. Per record review, Patient #7 was a 84 year old placed into restraints on 7/20/2011. A review of the paper "Restraint Assessment and Physician Order" form showed a date the physician signed the order but did not time the order for tracking a re-order time period.

4. Per record review, Patient #4 was a 81 year old placed into restraints on 8/27/2011 at 3:55 PM. A review of the paper Physician Orders form showed a sticker for re-ordering restraints that was completed as a "telephone order" at 7:00 PM (3 hours after the previous order expired).
An additional restraint re-order sticker was found dated 8/29/2011 at 1:00 PM. There was no evidence in the record that the patient was not restrained on 8/28/2011, but there was no order from 8/27/2011 to 8/29/2011.

D) Reference: Per review of policy and procedure titled "Physical and Chemical Restraint Policy", effective 6/27/2011, it states under guidelines at E.1.g., "The patient's response to chemical or physical restraint is documented at least every one hour".

1. Per record review, Patient #4 was a 81 year old placed into restraints on 8/6/2011 at 4:59 AM. A review of the "Restraints-Med/Surg" documentation in the electronic record, as provided by hospital staff, showed no documentation of restraint monitoring from 4:59 AM on 8/6/2011 to 8:00 AM on 8/7/2011 (14 missing assessments). The record also showed the next documented monitoring was at 3:56 PM (8 missing assessments). Further review of the record showed that the patient was in a restraint device from 8/17/2011 to 8/31/2011. During this time period, approximately three-hundred and twenty (320) hourly assessment documentation's were not found. Thus, the record did not contain evidence that restraint monitoring documentation was accomplished every hour, as required in the policy and procedure.

2. Per record review, Patient #5 was a 61 year old placed into restraints on 10/2/2011 at 9:00 PM. A review of the "Restraints-Med/Surg" documentation in the electronic record, as provided by hospital staff, showed no documentation of restraint monitoring from 10:00 PM to midnight (1 missing assessment). The record showed that between 10:00 PM on 10/2/2011 to 7:45 AM on 10/12/2011 documentation of restraint monitoring was missing for a total of eighty-one (81) hourly assessments. Thus, the record did not contain evidence that restraint monitoring documentation was accomplished every hour, as required in the policy and procedure.

3. Per record review, Patient #6 was a 65 year old placed into restraints on 5/24/2011 at 8:30 AM. A review of the electronic record documentation, as provided by hospital staff, showed that between 8:30 AM on 5/24/2011 to 11:30 AM on 5/25/2011 documentation of restraint monitoring was missing for a total of fourteen (14) hourly assessments. Thus, the record did not contain evidence that restraint monitoring documentation was accomplished every hour, as required in the policy and procedure.
The patient was re-admitted on 9/3/2011 and a review of the electronic record documentation, as provided by hospital staff, showed that between 5:20 AM on 9/4/2011 to 9:00 AM on 9/9/2011 documentation of restraint monitoring was missing for a total of fifty-one (51) hourly assessments.

4. Per record review, Patient #7 was a 85 year old placed into restraints on 7/20/2011 at 12:30 PM. A review of the electronic record documentation, as provided by hospital staff, showed that between 12:30 PM on 7/20/2011 to 8:00 AM on 7/23/2011 documentation of restraint monitoring was missing for a total of twenty-six (26) hourly assessments. Thus, the record did not contain evidence that restraint monitoring documentation was accomplished every hour, as required in the policy and procedure.
A subsequent admission showed the patient was restrained on 10/11/2011 at 1:00 PM. A review of the electronic record documentation, as provided by hospital staff, showed that between 1:00 PM on 10/11/2011 to 7:45 AM on 10/13/2011 documentation of restraint monitoring was missing for a total of twenty-four (24) hourly assessments. Thus, the record did not contain evidence that restraint monitoring documentation was accomplished every hour, as required in the policy and procedure.

Based on observations and administrative staff interview, the hospital failed to ensure that emergency supplies were monitored to prevent the use of supplies that were stored beyond the manufacturer's expiration date.

Failure to not ensure monitoring activities prevent the use of patient care supplies outside of the manufacturer's stated parameters places all patients at risk of harm related to the use of these supplies.

Findings:

During observational rounds on 11/1/2011 the following was noted in the Pre-Operative area: a) two (2) Epi-pen cartridges, used for life-saving emergencies, were found with an expiration date of February 2011; and b) a container of injectable epinephrine (1:10,000 units) with an expiration date of July 2011. These observations were verified by Staff #7.

Based on observation and interview, the hospital failed to provide plumbing with cross connection controls as required by code. Failure to provide cross connection controls threatens the domestic water supply and puts patients, staff and visitors of the facility at risk from contaminates introduced into the water supply as a result of back-pressure or back-siphonage.

Findings:

1. During rounds of the facility on 11/2/2011 the surveyor observed that the water supply serving the Neptune waste management system in the Surgery dirty processing room didn't not have a Reduce Pressure Backflow Assembly (RPBA) installed. At the time of the observation the surveyor was informed that the Neptune unit was not protected by a RPBA.

Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 11/1/2011 - 11/3//2011.

Based on interview, observation and document review the facility failed to implement policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC). Failure on the part of the facility to comply with the food service codes puts patients, staff and visitors of the facility at risk of food borne illness.

Specific references made in the findings below are found in the Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code.

Findings include:

1. On 11/2/2011 the surveyor noted a food service worker handling ready to eat (RTE) foods such as sandwich buns and bacon while wearing gloves that had been potentially contaminated by contact with dirty surfaces, i.e. refrigerator handles.

Based on medical record review, hospital nursing services failed to complete and document ongoing specialized assessments depending on the patient's condition or needs regarding skin wounds for 1 of 1 record reviewed for skin problems (P8).

Failure to follow policy and procedure regarding skin integrity places patients at risk of harm related to the potential that appropriate care and monitoring is not being accomplished to prevent further skin problems.

Reference; per review of the "Skin Integrity Policy and Procedure/Guidelines", effective 5/5/2008, it states at paragraph III under Clinical Objectives" "Reassessment and complete documentation of ulcers will occur at least daily or with each dressing change"; under "Assessment A.2. it states "Comprehensive assessment and documentation of pressure ulcers using the Skin Integrity Flow Record should include-"... and then lists ten (10) specific documentation items to be accomplished.

Findings:

(Access to the electronic record and copies made were provided by hospital staff)

Per record review, Patient #8 was admitted on 10/29/2011 with a diagnosis of pneumonia. The "Patient Status Report" indicated the patient was seen in the Emergency Department which noted "Bed sores on bottom, pictures taken". The "Wound Assessment" section, of the status report, documents the patient had a "Buttock/Coccyx" wound.
The patient's care plan, for this wound, stated "Monitor coccyx ulcer (each) shift and (as needed). A review of a print-out from the electronic record showed the patient was assessed with a Braden Score of "11" on 10/30/2011 at 8:22 PM. and that the "Skin Integrity Risk Protocol" had been initiated.
Nursing notes on 10/29/2011 at 8:00 PM state, "Pt also has beginnings of pressure ulcer bed sores on buttocks... area covered with protective dressing". The next nursing note regarding the patient's skin problems was on 10/31/2011 at 8:15 AM (36 hours later). This note states "Transparent dressing C/D/I no redness/edema/pain noted". Another note on 10/31/2011 at 3:56 PM stated the skin problem assessment was "Coccyx Dressing CDI".
There was no documentation in the electronic record that: a) daily assessments and documentation were accomplished, per policy and procedure; and b) the Comprehensive Assessment and documentation of pressure ulcers was accomplished, at any time, using the ten (10) specific assessment/documentation points.

Based on record review and review of policy and procedure, the hospital failed to ensure that physician orders were written in print for 4 of 4 records reviewed (P1, P4, P6, P7).

Failure to write orders in print places all patients at risk of receiving or not receiving prescribed care and services because of a misinterpretation of the physician order caused by handwriting styles.

Reference: Per review of policy and procedure titled "Prescribing/Ordering General Practices", effective 2/2010, it states, "All orders are to be printed in a clear, legible, and complete manner".

Findings:

1. Per record review, Patient #1 was admitted on 10/31/2011. Handwritten orders were reviewed from 10/31/2011 to 11/1/2011. Of the 3 orders reviewed, all 3 were in "script" and not printed. Some of the orders were written as a telephone order by nursing staff.
In addition, the patient's discharge medication prescription was written in script.

2. Per record review, Patient #6 was admitted on 9/30/2011. Handwritten orders were reviewed from 9/3/2011 to 9/12/2011. Of the seventeen (17) orders reviewed, fifteen (15) were in "script" and not printed. Some of the orders were written as a telephone order by nursing staff.

3. Per record review, Patient #4 was admitted on 8/26/2011. Handwritten orders were reviewed from 8/26/2011 to 8/29/2011. Of the fourteen (14) orders reviewed, thirteen (13) were in "script" and not printed. Some of the orders were written as a telephone order by nursing staff.

4. Per record review, Patient #7 was admitted on 7/20/2011. Handwritten orders were reviewed from 7/20/2011 to 7/23/2011. Of the twelve (12) orders reviewed, five (5) were in "script" and not printed by the physician; five (5) were written as a telephone order by nursing staff; and two (2) orders were written by a "Pharmacist".

Based on medical record review and review of policy and procedure, the facility failed to ensure that the medical record was completed to show practitioner orders for medications and other therapeutic interventions for of records reviewed for orders (P1, P4, P6, P7 ).

Failure to do so places patients at risk for medication errors, or other errors in care, and impairs the ability to determine the timeline and course of the patient's care and response to interventions.

Reference: Per policy and procedure titled "Prescribing/Ordering General practices, revised 10/02, it states, "the prescriber must verify and sign order within 24 hours".

Findings include:

1. Per record review, Patient #1 was admitted on 10/31/2011. The record contained a medication telephone order on 10/31/2011 at 10:00 AM. The order had not been authenticated by the physician, as of 11/2/2011. The record contained a medication telephone order on 10/31/2011 at 12:15 PM. The order had been "initialed" by the physician, but no date or time of the authentication was present in the record, as of 11/2/2011.

2. Per record review, Patient #6 was admitted on 9/30/2011. The record contained a medication telephone order on 9/3/2011 at 11:50 PM. The order had been "signed" by the physician, but no date or time of the authentication was present in the record, as of 11/2/2011. Other telephone orders were dated 9/7/2011 and 9/11/2011 that had been "signed" by the physician, but no date or time of the authentication was present in the record, as of 11/2/2011.

3. Per record review, Patient #7 was admitted on 7/20/2011. The record contained medication five (5) telephone orders on 7/20/2011 from 12:45 AM to 4:00 AM that had been "signed" by the physician, but no date or time of the authentication was present in the record, as of 11/2/2011.

4. Per record review, Patient #4 was admitted on 8/26/2011. The record contained medication nine (9) telephone orders from 8/26/2011 to 8/29/2011 that had been "signed" by the physician, but no date or time of the authentication was present in the record, as of 11/2/2011.

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information showing an evaluation of its total program.

Failure to document an evaluation of the total program places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

1. Per review of the 2010 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation identified program services being offered to patients, such as: Diagnostic Imaging; Emergency Department; Family Birth Center; Medical/Surgical and Intensive Care Services; Cardiopulmonary ; Laboratory; Pharmacy; Surgery; Food and Nutrition; and the Specialty Center Surgical Group.
The evaluation pamphlet described the services provided by each listed entity, but did not provide evidence that these services had been analyzed, at a minimum, for the number of patients served and the volume of services provided.

2. Per review of the 2009 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation identified program services being offered to patients, such as: Diagnostic Imaging; Emergency Department; Family Birth Center; Medical/Surgical and Intensive Care Services; Cardiopulmonary ; Laboratory; Pharmacy; and Surgery.
The evaluation pamphlet described the services provided by each listed entity, but did not provide evidence that these services had been analyzed, at a minimum, for the number of patients served and the volume of services provided.

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information from a representative sample of "open" patient records.

Failure to document the inclusion of open records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

1. Per review of the 2010 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that open records were included in the sample. No evidence could be provided by the hospital that anything but "closed" records were reviewed.

2. Per review of the 2009 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that open records were included in the sample. No evidence could be provided by the hospital that anything but "closed" records were reviewed.

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that health care policies had been reviewed, as a result of annual program evaluation findings.

Failure to document the review of policies that were found to need updating, as a result of the program evaluation, places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

1. Per review of the 2010 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies had been reviewed, as a result of program evaluation identified issues that had a concurrent policy relation.

2. Per review of the 2009 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies had been reviewed, as a result of program evaluation identified issues that had a concurrent policy relation.

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that utilization of services were appropriate, established policies were followed, and any changes were needed.

Failure to document the review of comprehensive evaluation for services used and any identified changes to policies, procedures or facility practices places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

1. Per review of the 2010 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies, procedures and /or facility practices were added, deleted or revised as a result of the yearly program evaluation, as needed.

2. Per review of the 2009 Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies, procedures and /or facility practices were added, deleted or revised as a result of the yearly program evaluation, as needed.

Based on review of policy and procedures and administrative staff interview, the hospital failed to develop and implement written policies and procedures regarding the newly adopted patient visitation rights requirements.

Failure to develop and implement policies and procedures including: a) clinical necessity for any restriction/limitation on visits; b) any limitations or restrictions when visitation would interfere with the care of the patient and/or the care of other patients; and c) addressing how CAH staff who play a role in facilitating or controlling visitor access to patients will be trained so as to assure appropriate implementation of the visitation policies and procedures and avoidance of unnecessary restrictions or limitations on patients' visitation rights places all patients at risk of not having visitors to meet their therapeutic care needs.

Findings:

Per review of the patient rights and responsibilities handout given to all patient upon admission, the only statement regarding visitation states the patient is entitled , "to visits within the Hospital established visiting hours and guidelines. You have the right to refuse visitors.".
Per interview with Staff #7 on 11/2/2011, the newly adopted Federal Regulations at CFR 42 485.635(f)(1) had not been implemented to date.

Based on review of policy and procedures and administrative staff interview, the hospital failed to develop and implement written policies and procedures regarding the newly adopted patient visitation rights requirements.

Failure to develop and implement policies and procedures including: a) informing each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, in advance of furnishing patient care whenever possible; and b) informing each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time places all patients at risk of not having visitors to meet their therapeutic care needs.

Findings:

Per review of the patient rights and responsibilities handout given to all patient upon admission, the only statement regarding visitation states the patient is entitled , "to visits within the Hospital established visiting hours and guidelines. You have the right to refuse visitors.".
Per interview with Staff #7 on 11/2/2011, the newly adopted Federal Regulations at CFR 42 485.635(f)(2) had not been implemented to date.

Based on review of policy and procedures and administrative staff interview, the hospital failed to develop and implement written policies and procedures regarding the newly adopted patient visitation rights requirements.

Failure to develop and implement policies and procedures including: a) ensuring all visitors (including individuals seeking to visit the patient) enjoy full and equal visitation privileges, consistent with the preferences the patient (or, where appropriate, the patient's support person) has expressed concerning visitors; b) ensuring that hospital staff treat all individuals seeking to visit patients equally, consistent with the preferences of the patient (or, where appropriate, the patient's support person) and do not use the race, color, national origin, religion, sex, gender identity, sexual orientation, or disability of either the patient (or the patient's support person, where appropriate) or the patient's visitors (including individuals seeking to visit the patient)as a basis for limiting, restricting, or otherwise denying visitation privileges; and c) the hospital is expected to educate all staff who play a role in facilitating or controlling visitors on the hospital's visitation policies and procedures, and are responsible for ensuring that staff implement the policies correctly.

Findings:

Per review of the patient rights and responsibilities handout given to all patient upon admission, the only statement regarding visitation states the patient is entitled , "to visits within the Hospital established visiting hours and guidelines. You have the right to refuse visitors.".
Per interview with Staff #7 on 11/2/2011, the newly adopted Federal Regulations at CFR 42 485.635(f)(3) had not been implemented to date.