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Based on observation, the Critical Access Hopital failed to provide certain items (defibrillator pads/electrodes) on its emergency carts that were not expired for use.

Failure on the part of the facility to provide emergency equipment that has not expired puts patients at risk of injury and/or death.

Findings:

1. On 8/12/2014, at 1:30 PM, Surveyors #1 and #3 noted that two (2) packages of 3M defibrillator pads and two (2) packages of Med Choice Multi-function electrodes onboard the medical unit crash cart had expiration dates of 06-2014, respectively.

2. On 8/13/2014, at 9:30 AM, Surveyors #1 and #3 noted that two (2) packages of 3M defibrillator pads onboard the emergency department crash cart had expiration dates 06-2014.

Based on observation, the Critical Access Hospital failed to maintain air pressure relationships required for the protection of patients in clinical care areas of the facility.

Failure on the part of the facility to maintain proper air pressure relationships in clinical care areas puts patients at risk of infection.

Findings:

1. On 8/12/2014, at 10:30 AM, Surveyors #1 and #3 used a light weight flutter strip (tissue) to evaluate the air relationships between the microbiology lab and the general lab area, and the air relationship between the general lab area and adjoining spaces. It was noted that the microbiology lab was positive to the general lab area while the microbiology lab hood was running. The microbiology lab should be negative to the general lab area. It was further noted that the general lab area was negative to adjoining spaces which is correct.

2. On 8/12/2014, between 2:30 PM and 3:00 PM, Surveyors #1 and #3 used a light weight flutter strip (tissue) to evaluate the air relationships between the special procedure room (Operating Room #1) and Operating Room #2 with their adjoining spaces. It was noted that the special procedure room was negative to the sub-sterile processing room, not positive as is required.

Based on record review, interview, and review of policies and procedures, the Critical Access Hospital failed to follow its policy and procedure for restraining patients for 2 of 3 patient records reviewed (Patients #1, #2).

Failure to follow policies and procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure titled "Restraints" (Procedure Number PR009-006; Effective 10/28/2013) stated that an order for restraints must be obtained within one hour of application. The policy stated that patient assessments and interventions would be documented in the patient's medical record every 15 minutes. The assessment was to include signs of injury associated with the application of the restraints, circulation and range of motion of the patient's extremities, the patient's physical and psychological status and comfort, and the patient's readiness for discontinuation of the restraints.

2. Review of the medical records of three patients who had been restrained while being treated in the emergency department revealed the following:

a. Patient #1 was a 15 year-old patient who was admitted to the emergency department (ED) at 2:15 AM on 6/8/2013. The patient exhibited signs of acute alcohol intoxication and altered mental status following a physical assault. The patient was agitated and combative during examination and was placed on a backboard at 2:20 AM. Nursing documentation indicated that the patient was restrained on the backboard from 2:20 AM until 3:10 AM. There was no order in the patient's record authorizing the use of the backboard as a restraint.

b. Patient #2 was a 51 year-old patient who was admitted to the ED at 2:50 PM on 7/1/2013. The patient was hallucinating and delusional and exhibited "bizarre behavior" on admission. A physician's note indicated the patient was placed in bilateral wrist restraints while in the ED. There was no documentation in the patient's record of the time the restraints were applied. There was no nursing documentation in the patient's record of assessment every 15 minutes of the patient's condition while in restraints.

3. During an interview with Surveyor #2 on 8/13/2014, at 4:15 PM, the hospital's Director of Nursing Services (Staff Member #1) confirmed the findings above.

Item #1 - Controlled Substances Inventory

Based on interview, review of policies and procedures, and review of controlled substance inventory logs, the Critical Access Hospital failed to ensure that hospital staff members inventoried controlled substances according to Washington State pharmacy laws and rules for hospitals.

Failure to inventory and track controlled substances risks diversion of narcotics and unsafe healthcare delivery.

Reference: WAC 246-873-080 Drug procurement, distribution and control.
(7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations ... (h) Controlled substances, Schedule II and III, which are floor stocked, in any hospital patient or nursing service area shall be checked by actual count at the change of each shift by two authorized persons licensed to administer drugs.

Findings:

1. On 8/12/2014, at 11:20 AM, Surveyor #2 interviewed a Certified Registered Nurse Anesthetist (CRNA) (Staff Member #2) regarding Schedule II and III controlled substances stored in the anesthesia supply cart. The CRNA stated he/she counted the controlled substances without another staff member each day that the surgery department was open.

2. The hospital's policy and procedure titled "Anesthesia Narcotic Control" (No Procedure Number; Revised 8/2010) read as follows: "6. At the end of the shift, the anesthetist will return the narcotic box to the narcotic locker in survey. a) Before returning the narcotic box, the anesthetist will double-check the ACSR [Anesthesia Controlled Substance Record] for completeness. b) Any discrepancies or incompleteness will be reconciled."

3. During an interview with Surveyor #2 on 8/12/2014, at 1:00 PM, the hospital's pharmacy director (Staff Member #3) confirmed that the narcotics stored in the anesthesia cart were not counted by two hospital staff members licensed to administer drugs.

Item #2 - Protection of Clean/Sterile Items

Based on observation the facility failed to adequately protect clean/sterile medical items by maintaining adequate separation of those items from dirty processes.

Failure on the part of the facility to protect clean/sterile medical items from potential contamination by dirty processes puts patients at risk of infection.

Findings:

On 8/19/2014, at 3:12 PM, Surveyors #1 and #3 toured the Central Sterile processing area. At that time it was noted that an open wire shelf storage rack containing clean/sterile medical supplies (sterile saline, Kittner sponges, oxygen masks, syringes and electrodes) was located in an area used to clean dirty instruments (dirty work area).

Based on observation and staff interview, the Critical Access Hospital 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.

References:

Washington State Retail Food Code Working Document; Part 5: Water, Plumbing and Waste; Subpart B - Plumbing; 05230 Numbers and capacities - - Handwashing sinks (2009 FDA Food Code 5-203.11) etal

Findings:

1. On 8/13/2014, at 11:30 AM, Surveyors #1 and #3 noted that staff at the grill/serving line did not have a conveniently located handwash sink. A utility sink was located at or adjacent to the serving line but the nearest sink dedicated for handwashing purposes was located around the corner in the kitchen. A member of the kitchen staff (Staff Member #4) indicated that the handwash sink in the kitchen is not always convenient to use. And, during rush service times its use is especially inconvenient. Because of this the kitchen staff indicated that hand gel is often substituted for handwashing. During the course of food service activities Surveyor #3 noted that a member of the kitchen staff (Staff Member #4) had made several glove changes without the benefit of hand hygiene (handwashing or use of gel) being performed.

Based on interview and review of facility policies and procedures, the Critical Access Hospital failed to ensure that patient care policies and procedures were reviewed on an annual basis.

Failure to systematically review policies and procedures risk delivery of inappropriate or ineffective patient care.

Findings:

1. Review of the hospital's policies and procedures on 8/14/2014, revealed the following:
a. The hospital's pharmacy policies and procedures had not been reviewed since 2010;
b. The hospital's pediatric patient policies and procedures had not been reviewed since 2010;
c. The hospital's dietary policies and procedures had not been reviewed since 2011;
d. The hospital's infection prevention and control policies and procedures had not been reviewed since 2012; and
e. The hospital's swing bed program policies and procedures had not been reviewed since 2012.

2. The hospital's policy titled "Policies, Procedures, Bylaws Medical Staff Rules and Regulations, and Allied Health Professional Manual" (Procedure Number PR060-106; Effective 4/29/2009) stated that procedures would be reviewed periodically. The policy did not comply with the requirement for annual review of patient care policies and procedures.

3. During an interview with Surveyor #2 on 8/14/2014, at 10:20 AM, the hospital's quality program coordinator (Staff Member #1) confirmed the findings above.

Based on interview the Critical Access Hospital failed to provide evidence that it had policies and procedures for the collection, preservation, transportation, receipt, and reporting of tissue specimen results.

Failure on the part of the facility to have policies and procedures for the collection, preservation, transportation, receipt, and reporting of tissue specimen results puts patients at risk from what are potentially compromised laboratory practices.

Findings:

On 8/12/2014, Surveyors #1 and #3 interviewed the laboratory manager (Staff Member #5) and asked that policies and procedures for the collection, preservation, transportation, receipt, and reporting of tissue specimens be presented for review. Said policies and procedures were not made available during the course of the survey.

Based on record review the Critical Access Hospital failed to assure that a member of the nursing staff was evaluated in the performance of her/his duties (Staff Member #6).

Failure on the part of the facility to evaluate nursing staff in the performance of their duties puts patients at risk from the care provided by individuals who may not be adequately trained to perform assigned duties.

Findings:

1. On 8/13/2014, at 1:30 PM, Surveyors #1 and #3 performed a review of human resource files and found that 1 of 2 nursing staff records reviewed (Staff Member #6) failed to include a current performance evaluation. The file in question contained a performance evaluation performed in 2011.

Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop an individualized plan for patient care according to facility policy for 5 of 6 patients reviewed (Patients #3, #4, #5, #6, #7).

Failure to develop an individualized plan of care that includes care interventions can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. The hospital's policy and procedure titled "Care Planning" (Policy Number PR008-423; Revised 4/26/2010), read as follows: "Procedure: All patients admitted to the Acute Care floor will have an individualized plan of care initiated as part of the admission process. The registered nurse will formulate nursing diagnoses for at least 3 problems on admit. The care plans are individualized to reflect identification of goals, appropriate interventions, and expected outcomes."

2. Review of the medical records of six patients hospitalized between 3/30/2014, and 8/12/2014, revealed the following:

a. Patient #3 was a 58 year-old patient who had been admitted on 8/11/2014, for surgical treatment of a diabetic foot ulcer. The patient also had chronic mental illness. Problems on the patient's plan of care included anxiety, infection (actual), impaired mobility, pain, and impaired skin integrity. The patient's plan for care did not include care interventions that addressed all of these problems.

b. Patient #4 was a 72 year-old patient who had been admitted to the hospital's long-term care ("Swing Bed") program for rehabilitation following leg surgery. Problems on the patient's plan of care included pain, risk for falling, and constipation. The patient's plan for care did not include care interventions that addressed all of these problems.

c. Similar findings were found in the records of Patients #5, #6, and #7.

3. During an interview with Surveyor #2 on 8/13/2014, at 11:00 AM, the Director of Nursing Services (Staff Member #1) confirmed findings above.

Based on interview, the Critical Access Hospital (CAH) failed to aggregate and analyze data regarding CAH services as part of the annual program evaluation.

The purpose of the program evaluation is to determine whether the utilization of services was appropriate, that established policies were followed, and if any changes to the CAH program are needed. Failure to perform such an evaluation impairs the facility's ability to improve the quality of healthcare it provides to patients.


Reference: 42 CFR 485.641(a)
[The evaluation includes review of] (1)(i)The utilization of CAH services, including at least the number of patients served and the volume of services; (ii) A representative sample of both active and closed clinical records; and (iii) The CAH's health care policies.

Findings:

During an interview on 8/14/2014, at 9:00 AM, the hospital's compliance coordinator (Staff Member #7) gave Surveyor #2 PowerPoint presentations from March 2013, and March 2014. The compliance coordinator stated these presentations represented the hospital's annual CAH program evaluations for 2012 and 2013 and had been presented at hospital board meetings.

The presentations included graphs of the number of patients and volume of services and a list of items reviewed during clinical record audits. There was no evidence in the presentation that these items had been analyzed to determine whether utilization and delivery of CAH services was appropriate, that established policies and procedures had been followed, and whether changes to the CAH program were needed.

Based on interview and review of the patient care contractors evaluation process, the Critical Access Hospital failed to evaluate the performance of contractors who provided clinical care and services to hospital patients for 3 of 3 contractors reviewed.

Failure to determine whether contractors meet all Medicare Conditions of Participation and standards risks provision of ineffective and unsafe healthcare to patients.

Findings:

1. On 8/14/2014, at 9:00 AM, Surveyor #2 interviewed the hospital's quality program coordinator (Staff Member #1) and compliance coordinator (Staff Member #7) regarding the hospital's process for evaluation of contracted patient care services. The compliance coordinator stated these contractors were evaluated annually.

2. Review of the contract files for telepharmacy services, teleradiology services, and physical therapy services revealed the files lacked evidence that the quality of care and services provided by the contractors had been evaluated by the hospital.

Based on interview, record review, review of hospital policies and procedures, the Critical Access Hospital failed to implement its policy and procedure for notifying long-term care ("Swing Bed") patients of the reason for their discharge or transfer for 3 of 4 patients reviewed (Patients #4, #6, #8).

Failure to notify long-term care patients of the reason for discharge impedes their right to appeal this discharge to the state's long-term care ombudsman.

Findings:

1. The hospital's policy and procedure titled "Transfer and Discharge - Swing Bed" (Procedure Number PR008-301; Effective 2/2/2011), under "Procedure", read as follows: "Before a transfer or discharge of an Extended Swing Bed patient is made, notice will be given in writing to the resident and, if known, a family member or legal representative 30 days prior to discharge/transfer."

2. Review of the records of four long-term care patients who had been hospitalized between 6/27/2014, and 7/29/2014, revealed that the records of Patients #4, #6 and #8 did not include a written notification of discharge.

3. During an interview on 8/13/2014, at 10:00 AM with Surveyor #2, the Director of Nursing Services (Staff Member #1) stated that the hospital did not provide a written notification of discharge to all long-term care patients.

Based on interview, review of the hospital's patient rights information, and review of the hospital's visitation policy, the Critical Access Hospital failed to develop a policy and procedure for informing patients of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f)(1) and (2).

Failure to inform patients of their rights and to incorporate those rights into visitation policies and procedures limits the patient's ability to exercise those rights.

Findings:

1. During an interview with Surveyor #2 on 8/12/2014, at 9:10 AM, a patient admissions clerk (Staff Member #8) stated that patients were given a handout to read titled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient and outpatient care.

2. Review of the contents of this handout revealed it did not include the patient's visitation rights identified under 42 CFR 485.635(f)(1) and (f)(2).

3. Review of the hospital's policy and procedure titled "Patient Nondiscrimination Policy" (No Policy Number; Effective 3/18/2014) revealed that the policy did not identify how patients would be notified of their visitation rights. The policy also did not identify clinically necessary or other reasonable restrictions that would limit the patient's visitation rights.

4. During an interview with Surveyor #2 on 8/13/2014, at 8:40 AM, the hospital's Director of Nursing Services (Staff Member #1) confirmed the findings above.