HospitalInspections.org

ITEM #1 - NOTICE OF DISCHARGE RIGHTS

Based on interview and medical record review, the Critical Access Hospital failed to provide Medicare patients with a notice regarding their right to appeal their discharge from the hospital as required by federal regulations for 3 of 3 patients reviewed (Patients #1, #2, #3).

Failure to provide such notice limits the patient's ability to contest their discharge and appeal to a Quality Improvement Organization for review of their case.

Reference: 42 CFR 405.1205 - Notifying beneficiaries of hospital discharge appeal rights.
(b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital...

(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge.

Findings included:

1. Review of the medical records of 3 Medicare patients admitted to the hospital between 08/15/17 and 09/10/17 showed the following:

a. Review of the records of Patient #1 showed that the patient had been admitted on 08/15/17 and discharged on 08/19/17. The patient's records included an "Important Message from Medicare" information form. The form included the patient's signature, the date 08/15/17, and the time 11:32 AM. There was no evidence in the patient's record that the patient had received a second notice of their discharge rights within two calendar days of discharge.

b. Review of the records of Patient #2 showed that the patient had been admitted on 09/10/17 and discharged on 09/14/17. The patient's records included an "Important Message from Medicare" information form. The form included the patient's signature, the date 09/11/17, and the time 11:17 AM. There was no evidence in the patient's record that the patient had received a second notice of their discharge rights within two calendar days of discharge.

c. Review of the records of Patient #3 showed that the patient had been admitted on 09/06/17 and discharged on 09/10/17. The patient's records included an 'Important Message from Medicare" information form. The form did not include a date or time. There was no evidence that the patient had received the notice of their discharge rights within two calendar days of admission to the hospital and within two calendar days of discharge from the hospital.

2. On 10/04/17 at 10:10 AM during an interview with Surveyor #1, the hospital's medical/surgical unit nurse manager (Staff #1) and discharge planning nurse (Staff #2) stated that ward clerks who worked in the inpatient unit provided the "Important Message from Medicare" information forms to patients on admission. They stated there was no process for providing a second notice if the patient was hospitalized longer than two calendar days.


ITEM #2 - NOTIFICATION OF PHYSICIAN (MD/DO) ON-SITE PRESENCE

Based on interview and review of patient rights information, the Critical Access Hospital failed to provide written notice to patients that a doctor of medicine (MD) or doctor of osteopathy (DO) was not present in the hospital 24 hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. On 10/03/17 at 9:15 AM, Surveyor #1 interviewed the hospital's Chief Nursing Officer (CNO) (Staff #3). During the interview, the CNO stated that an MD or DO was not on site 24 hours per day 7 days per week.

2. During the interview, the CNO stated that all patients were given a handout to read entitled "Patient Rights and Responsibilities" (Revised 04/17) when admitted to the hospital for inpatient and outpatient care. Review of the contents of this handout revealed that it did not include written notice to patients that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week. The hospital did not have a process for informing patients how the hospital would meet the medical needs of any patient who develops an emergency medical condition when a physician is not present.
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Based on observation, interview, and document review, the Critical Access Hospital failed to 1) compile a complete inventory of all facility and medical equipment; 2) ensure that such equipment was included in the hospital's preventive maintenance program; and 3) maintain the equipment according to the manufacturer's directions for use.

Failure to include all hospital equipment in the hospital's preventive maintenance program and maintain that equipment according to the manufacturer's directions for use risk patient injury related to malfunctioning equipment.

Findings included:

1. On 10/04/17 between the hours of 9:00 AM and 11:30 AM, Surveyor #2 interviewed the hospital's maintenance department manager (Staff #13) about the hospital's preventive maintenance program. The surveyor asked to see the preventive maintenance history for the following equipment:

Laminar flow hood in the laboratory
Hydrocollator (Chattanoga) in the physical therapy clinic
Paraffin wax bath (Therabath) in the physical therapy clinic
Commercial washing machine in the hospital's laundry room
Biological incubator (Steris Verify) in the central sterile processing room
Ice machines (Hoshizaki)

The manager indicated that the maintenance department was only in charge of facility equipment and that all patient care equipment was maintained by a contractor through the central supply department.

The manager provided documentation for preventive maintenance of the ice machines. The log indicated the last preventive maintenance occurred on 01/18/16, 04/20/16, and 07/12/16. The manager stated that preventive maintenance on the ice machines was done yearly. Review of the facility's ice machine service manual (Hoshizaki Service Manual; Issued 2004; Chapter "V" page 3), showed preventive maintenance should be performed twice a year.

During the interview, Surveyor #2 inquired about the commercial washing machine in the laundry room. The facility manager indicated that the environmental service department was in charge of the commercial washing machine.

2. On 10/04/17 at 2:00 PM Surveyor #2 interviewed the environmental services manager (Staff #17) regarding preventive maintenance schedule for the commercial washing machine. The manager was unable to provide documentation for preventive maintenance schedule.

3. On 10/04/17 at 2:30 PM Surveyor #2 interviewed the central supply manager (Staff #18). During the interview, the manager indicated that preventive maintenance of patient care equipment was performed by a contractor (Kadlec Hospital).

4. On 10/04/17 at 3:00 PM Surveyor #2 received an equipment inventory list from the contracted preventive maintenance service provider. Review of the list showed the paraffin wax bath and hydrocollator were not on the list. The surveyor was unable to verify initial checks or preventive maintenance activities for this equipment.

5. On 10/03/17 at 9:30 AM during a tour of the laboratory, Surveyor #2 observed that the preventive maintenance sticker on the Laminar Flow Hood in the laboratory indicated that maintenance was due on 02/16.

On 10/04/17 at 3:30 PM, Surveyor #2 received documentation from the contracted preventive maintenance vendor (Asepsis Air Control), that the last preventive maintenance of the Laminar Flow Hood in the laboratory had occurred on 08/25/15 and that the vendor had discontinued the service. The hospital was not aware the service had been discontinued.

6. On 10/05/17 at 9:45 AM during a tour of the central sterile processing room, Surveyor #2 observed that the lights on the biological incubator were flashing red. A sticker on the incubator included the letters "UHC" and an illegible date. Surveyor #2 asked the surgical technician responsible for sterilization of medical instruments (Staff #16) if the biological incubator was malfunctioning. The technician stated that the lights had always flashed like that.

On 10/05/17 at 2:00 PM Surveyor #2 reviewed the medical equipment list and interviewed the central supply manager (Staff #18) regarding the biological incubator. The supply manager stated that "UHC" (Universal Health Center) was the hospital's previous preventive maintenance contractor. Review of the current inventory list provided by the hospital's current contractor (Kadlec) showed that the biological incubator was not on the list. The unit had not been scheduled for routine preventive maintenance.
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Based on observation, interview, and review of hospital policies, procedures, and documents, the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements and responsibilities impaired the hospital's ability to provide quality care in a safe environment.

Reference: CFR 485.627(a) "The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment."

Findings included:

1. The hospital failed to ensure that the hospital's infection control program provided oversight of procedures relating to infection prevention in all hospital departments as directed by the hospital's infection control plan.

2. The hospital failed to evaluate the quality of services provided in all hospital departments as directed by the hospital's quality plan

Due to these findings and the scope and severity of deficiencies detailed under the Conditions of Participation at 42 CFR 485.635 Provision of Services and 42 CFR 485.641 Periodic Evaluation and Quality Monitoring, the Condition of Participation for Organizational Structure was NOT MET.

Cross-reference: Tags C0270, C0330
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Based on observation, interview, and review of hospital policies, procedures, and documents, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services. The hospital failed to ensure that the hospital's infection control program provided oversight of procedures relating to infection prevention in all hospital departments as directed by the hospital's infection control plan.

Failure to provide such oversight risks transmission of communicable diseases to patients, staff, and visitors.

Findings included:

The hospital failed to ensure that the infection control program included oversight of procedures relating to infection prevention in central processing, maintenance, physical therapy, dietary services, and surgery,

Due to the cummulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.

Cross-reference: Tags C0278
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Based on interview, record review, and review of policies and procedures the Critical Access Hospital failed to follow its policy and procedure for restraining patients for 2 of 4 patients reviewed (Patients #).

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

Findings included:

1. The hospital's policy and procedure titled "Restraints" (Revised 04/17) stated that a written order was required for use of physical restraints. Any order for restraints must be preceded by attempt of less restrictive alternatives to restraints. If the less restrictive alternatives were ineffective, this was to be documented in the patient's medical record. Patients in restraints for violent or self-destructive behavior would be observed by a registered nurse at least every 15 minutes and assessed every hour. The assessment was to include the physical and emotional well-being of the patient; respiratory and circulatory status; signs of skin breakdown; whether less restrictive methods could be used; and behavioral changes that would indicate restraint is no longer necessary. Restraints would be discontinued at the earliest possible time.

2. Review of the medical records of four patients who had been restrained during their hospitalization revealed the following:

a. Patient #4 was a 19 year-old patient who was treated in the emergency department (ED) on 07/24/17 for a possible drug overdose. The patient was agitated and combative on admission and was placed in two point restraints. The patient was in restraints from 12:03 AM to 3:47 AM. The patient's record did not include documentation that less restrictive alternatives to restraints had been attempted and had failed. The record did not include documentation that the patient was assessed hourly using the assessment elements identified in the hospital's restraint policy. The record did not indicate that the patient was released from restraints at the earliest possible time.

b. Patient #5 was a 29 year-old patient who was evaluated in the ED on 08/26/17 for clearance for incarceration. The patient arrived in four-point restraints accompanied by law enforcement officers. The restraints were removed by hospital ED staff members and reapplied. The patient was in restraints from 11:16 PM on 08/26/17 to 12:29 AM on 08/27/17. The patient's record did not include an order to authorize use of physical restraints.

3. On 10/04/17 at 11:50 AM during an interview with Surveyor #1, the hospital's ED nurse manager (Staff #4) confirmed the findings above.
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ITEM #1 - OVERSIGHT OF INFECTION PREVENTION AND CONTROL PROCESSES

Based on interview and review of the hospital's infection control and prevention plan, the Critical Access Hospital failed to ensure that the infection control program included oversight of procedures relating to infection prevention in central processing, maintenance, physical therapy, dietary services, and surgery,

Failure to provide such oversight risks transmission of communicable diseases to patients, staff, and visitors.

Findings included:

1. The hospital's policy titled "Infection Prevention Program Description and Plan 2017" (Reviewed 08/17) showed that the program was to be comprehensive and include all hospital departments. Surveillance would be "need-based and departmentally focused". The infection prevention coordinator would "act in a consultative role to hospital care areas and departments."

2. During the hospital survey, Surveyor #1 and #2 determined that deficient practice existed in the following areas: Sterilization and high-level disinfection procedures; preventive maintenance of hospital equipment at risk for transmitting communicable diseases; surgical attire; refilling single-use containers of ultrasound gel in physical therapy; dietary services food storage procedures; and the hospital's water management plan.

3. On 10/05/17 between 8:45 AM and 9:40 AM Surveyor #1 interviewed the hospital's infection program coordinator (Staff #3). The interview showed that the infection control program had not provided oversight of procedures relating to infection prevention in central processing, maintenance, physical therapy, dietary services, and surgery,

Cross Reference: C0222 and Items #2 - #8 below) .


ITEM #2 - HIGH-LEVEL DISINFECTION OF ENDOSCOPES

Based on observation, interview, hospital policy review and document review, the Critical Access Hospital failed to implement policies and procedures designed to prevent exposure of infectious agents during the processing of high-level disinfection of endoscopes.

Failure to follow manufacturer's instructions for use and to establish annual competencies for staff places patients at risk of infection or illness.

References:
Cidex OPA manufacturer's instruction for use: "Date the bottle of test strips when opened (expires at 90 days or the expiration date on the bottle of test strips, whichever comes first)."

"Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008"; William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H. and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention, Page 93: "Quality Control; Provide comprehensive and intensive training for all staff assigned to reprocess semi-critical and critical medical/surgical instruments..."

Findings included:

1. The hospital's policy titled, "High Level Disinfection" (Policy #3174666; Approved 08/17) read on page 3, part 1: "Consistency of cleaning practice according to manufacturer written recommendations facilitates the disinfection process." In part 4, the policy read: "Manufacturer written instruction for use of chemical cleaners should be followed. Temperature, proper use, and dilution are important for efficient use of these products."

2. On 10/05/17 between the hours of 9:00 AM, Surveyor #2 observed a surgical technician (Staff #16) pour enzymatic solution into an unmarked container of water without using a measuring device. When the surveyor asked the dilution proportion of the enzymatic solution to water, the technician stated, "It's a couple ounces per gallon of water." The technician did not follow hospital's policy and consult the manufacturer's directions for use to ensure proper concentration of enzymatic solution.

3. On 10/05/17 at 9:30 AM, Surveyor #2 observed a bottle of Cidex OPA with hand-written dates as opened on 10/2/17 and an expiration date of 01/02/18. The manufacturer's expiration date on the bottle was 11/28/17. The written expiration date exceeded the manufacturer's expiration date.

THIS IS A REPEAT FINDING - PREVIOUSLY CITED DURING A STATE LICENSING SURVEY IN JULY 2016.

4. On 10/05/17 at 9:45 AM, Surveyor #2 interviewed the surgical technician (Staff #16) responsible for cleaning and disinfecting endoscopes. During the interview, the surveyor asked the technician to provide documentation of competency for cleaning endoscopes. The technician provided a document titled, "Competency Assessment DSD-201", a competency in using the Medivator automatic endoscope reprocessor. The technician stated the only competency that had been performed involved the use of the reprocessor.

5. On 10/05/17 at 1:00 PM during an interview with Surveyor #2, the infection control program coordinator (Staff #3) confirmed that no other competencies had been performed to assess the technician's technique during equipment reprocessing procedures.

THIS IS A REPEAT FINDING - PREVIOUSLY CITED DURING A STATE LICENSING SURVEY IN JULY 2016.


ITEM #3 - STERILIZATION OF MEDICAL INSTRUMENTS

Based on observation, interview and document review, the hospital failed to ensure that staff used chemical indicators to ensure the sterilization process has occurred when processing medical instruments.

Failure to follow manufacturer's instruction for use places patients at risk for increased infection.

Reference: Titled, "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008" states on page 59, "Ability of the sterilizer to reach physical parameters necessary to achieve sterilization should be monitored by mechanical, chemical, and biological indicators. . . Typically, chemical indicators are affixed to the outside and incorporated into the pack to monitor the temperature or time and temperature."

Reference: Steris Vis-U-All High Temperature and ETO Self-Seal Sterilization Pouch Technical Data Document 450-100-5661 (9/1/07) states, "observe the chemical indicators on and in the pouch ... If the chemical indicator is unchanged, exposure to the sterilization process may not have occurred."

Findings:

On 10/05/17 at 10:00 AM, Surveyor #2 interviewed the surgical technician (Staff #16) responsible for reprocessing surgical instruments in the central sterile processing room. At the time of the interview, Surveyor #2 observed that the sterilization pouches containing medical instruments did not have chemical indicators inside the pouch.

The surveyor observed 3 different types of sterilization pouches (Steris Vis-U-All; MediChoice and Steris Eagle Pac). Of the 3 types of pouches, only 1 "Vis-U-All" appeared to have an internal chemical indicator affixed inside the pouch. The other 2 pouches did not.

After review of the manufacturer's instructions for use, the surveyor could only confirm that the "Vis-U-All" had an internal chemical indicator. The surveyor asked to see the manufacturer instructions for use for the MediChoice and Steris Eagle Pac. The technician was unable to provide manufacturer's instruction for use.


ITEM #4 - SURGICAL ATTIRE

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that surgery staff members wore surgical attire in a manner that covered all head and facial hair, as demonstrated by 3 staff members observed (Staff #5, #6, #7)

Failure to ensure that surgical hair covers are worn in a manner that covers all head and facial hair risks contamination of the surgical field with shedding hair, skin, and microbes, which can result in surgical site infections.

Findings included:

1. The hospital's policy and procedure entitled, "Operating Room Attire"(PolicyStat #3794896; Revised 08/17) showed that surgical staff members in restricted areas such as operating rooms were to cover all head and facial hair with a head cover or hood. "Skull caps" that failed to cover side hair above the ears and hair at the nape of the neck would not be worn in the surgical suite.

2. On 10/03/17 at 11:30 AM , Surveyor #1 observed surgical staff members prepare for a surgical procedure for Patient #6 in Operating Room #1. The Certified Registered Nurse Anesthetist (CRNA) (Staff #5), a scrub nurse (Staff #6), and the surgeon (Staff #7) each wore a "skull cap" that did not cover hair above their ears and at the napes of their necks. The CRNA wore a mask that did not fully cover his facial hair.

3. On 10/03/17 at 12:25 PM during an interview with Surveyor #1, the hospital's surgical services nurse manager (Staff #8) confirmed that surgical staff members should cover all head and facial hair when in the surgical suite.


ITEM #5 - CLEANING FREQUENCY OF THERAPY EQUIPMENT

Based on observation, interview and document review, the hospital failed to follow manufacturer's instructions for use to prevent contamination and exposure from infectious agents from patient care equipment.

Failure to provide develop and implement policies according to manufacturer's instructions for use places patients and staff at risk for infections and/or communicable diseases.

References:
Chattanooga Hydrocollator User Manual page 19-20 part 6, states, "Regularly clean and drain the tank (every two weeks)."

Therabath - Paraffin Bath Operator's Manual Copyright 2010 states on page 4 clean the unit after every 40 treatments, when the paraffin is no longer clear, or whenever sediment accumulates on the bottom.

Findings included:

1. The hospital policy titled "Cleaning Procedures" (PolicyStat #2979337; Reviewed 11/16) stated in Part 4 that the hydrocollator unit would be cleaned and refilled with distilled water every month.

2. On 10/04/17 between the hours of 1:00 PM and 1:50 PM, Surveyor #2 interviewed a physical therapy aide (Staff #15) in the rehabilitation clinic about the process for cleaning and disinfecting the hydrocollator and "Therabath" (Paraffin Wax Bath). The physical therapy aide stated that the hydrocollator and paraffin wax bath were cleaned monthly.

3. The hospital policy failed to reflect the manufacturer's instructions for use, which stated the hydrocollator should be cleaned every two weeks.

4. The hospital did not have a policy and procedure for cleaning the paraffin wax bath.


ITEM #6 - REFILLING SINGLE-USE CONTAINERS

Based on observation, interview and document review, the hospital failed to prevent contamination of product before patient care.

Failure to prevent contamination of product places patients and staff at risk for infections.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012), states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings included:

On 10/4/17 between the hours of 1:00 and 1:50 PM, Surveyor #2 observed a small single-use bottle of "Eco Lotion" (Ultrasound gel) in the rehabilitation room. Surveyor #2 interviewed physical therapy aide (Staff #15) regarding the reuse of the ultrasound gel. The therapy aide stated that physical therapy department staff members refill the single-use bottle from a larger container of ultrasound gel.


ITEM #7 - DIETARY SERVICES

Based on observation and interview, the Critical Access Hospital failed to follow the requirements of the 2009 Food and Drug Administration Food Code (FDA).

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings included:

1. On 10/03/17 at 10:30 AM, Surveyor #2 observed in the refrigerator walk-in raw chicken in a container stored over an opened case of tomatoes. The dietary cook (Staff #14) confirmed that in order to prevent contamination of the tomatoes the raw chicken should be stored on the bottom shelf.

Reference: FDA Food Code, (2009 FDA Food Code 3-302.11).

2. On 10/03/17 at 10:45 AM, Surveyor #2 observed staining on the particle board shelving in the dry food storage area. The surveyor determined that the shelves were not constructed with materials that were non-absorbent and easily cleanable. The dietary cook (Staff #14) confirmed this finding during an interview at the time of the observation.

Reference: FDA Food Code, (2009 FDA Food Code 4-101.19).


ITEM #8 - WATER MANAGEMENT PLAN

Based on interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30, subject line, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings included:

On 10/04/17 at 9:00 AM, Surveyor #2 interviewed the hospital's maintenance department manager (Staff #13) about the hospital's water management plan. The manager stated that the hospital was aware of the requirement but had not yet implemented a plan.
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Based on interview and record review, the Critical Access Hospital failed to develop an effective process to ensure pathology reports were included in the patient's medical record prior to considering the record complete, as demonstrated by 1 of 4 medical records reviewed (Patient #7).

Failure to ensure medical records are accurate and complete risks omissions in patient care, medical errors and potential patient harm.

Findings included:

1. On 10/04/17, Surveyor #1 reviewed a sample of 4 surgical records with assistance of the emergency department nurse manager (Staff #4). The record review showed that Patient #7 was a 50 year-old patient who had a laprascopic cholecystectomy on 09/12/17. The records indicated that the patient's gall bladder was sent to a laboratory for pathological examination following the surgery. The records did not include the pathology results.

2. On 10/05/17 at 8:45 AM, Surveyor #1 interviewed the hospital's medical records manager (Staff #9). The interview showed that Patient #7's record had been considered closed and complete. Medical records staff memers did not know that the pathology report was not in the patient's record. The system used by medical records staff members to track pathology reports was not effective for Patient #7.
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Based on interview and review of the hospital's process for granting surgical privileges, the Critical Access Hospital failed to ensure information regarding the types of surgical procedures surgeons could perform at the hospital was available to staff members working in the surgical services department.

Failure to ensure information regarding surgical privileges is available to all surgical staff members risks medical errors and patient harm.

Findings included:

1. On 10/03/17 at 12:25 PM during an interview with Surveyor #1, the hospital's surgical services nurse manager (Staff #8) stated that information regarding the types of surgical procedures surgeons could perform at the hospital was not available to staff members working in the surgical services department.

2. On 10/03/17 at 12:50 PM during an interview with Surveyor #1, the hospital's executive assistant responsible for coordinating the medical staff credentialing and privileging process (Staff #10) confirmed that information regarding medical staff surgical privileges were not available in the surgical services suite and the area where surgical procedures scheduling is done.

3. On 10/04/17 at 3:00 PM, Surveyor #2 reviewed the surgical privileging process and reviewed the credentialing files for the hospital's primary general surgeon (Staff #7). The surveyor confirmed the hospital had granted privileges to the surgeon, but this information was not readily available to surgery and scheduling staff members.
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Based on a record review and interview, the Critical Access Hospital failed to provide evidence that patients were discharged in the company of a responsible adult or had been exempted by the practitioner who performed the surgical procedure for 2 of 4 patients reviewed (Patients #8, #9).

Failure to ensure patients are accompanied at discharge by a responsible adult places the patient at risk for misunderstanding discharge instructions, which could result in undetected surgical complications and delayed post-procedure care.

Findings included:

1. On 10/03/17 at 12:05 PM during an interview with Surveyor #1, a registered nurse working in the hospital's post anesthesia recovery unit (Staff #11) stated that it was hospital policy for all patients undergoing surgical procedures or procedures involving anesthesia to be discharged in the company of a responsible adult.

2. Review of the medical records of Patient #8, a 77 year-old patient who underwent an endoscopic procedure with procedural sedation on 09/28/17, and Patient #9, a 73 year-old patient who underwent an endoscopic procedure with procedural sedation on 09/28/17, showed the records lacked evidence that the patients had been discharged in the company of a responsible adult.
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Based on review of hospital policies and procedures; staff interviews; review of the hospital's quality assurance program and quality assurance documents; review of the hospital's infection control program and infection control practices; and review of deficiencies cited during the hospital's Washington State hospital licensing survey in July 2016, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program impaired the hospital's ability to provide quality care in a safe environment.

Reference: 485.641(b) "The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes."

Findings:

1. The hospital failed to 1) compile a complete inventory of all facility and medical equipment; 2) ensure that such equipment was included in the hospital's preventive maintenance program; and 3) maintain the equipment according to the manufacturer's directions for use.

2. The hospital failed to evaluate the quality of services provided all hospital departments as directed by the hospital's quality plan.

3. The hospital failed to correct deficient practice identified during its Washington State hospital licensing survey in July 2016.

Due to the cummulative effect of these deficiencies, the Condition of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring was NOT MET.

Cross Reference: Tags C0222, C0278, C0337
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Based on interview and review of the hospital's quality assurance program, the Critical Access Hospital failed to evaluate the quality of services provided by all hospital departments as directed by the quality plan. The quality program did not have a process for evaluating hospital maintenance services, medical records services, and central processing services.

Failure to meet established organizational structure requirements resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that all patient care services and other services affecting patient health and safety are evaluated.

Findings included:

1. The hospital's policy titled "2017 Skyline Hospital Quality Improvement Plan" showed that each hospital department would report quality data regarding department work processes and services to the quality improvement coordinator. The quality improvement coordinator would review the data and work with the departments to identify patterns or trends that have the potential to adversely effect the quality of care or services provided and correct identified problems.

2. During the survey, surveyors identified deficient practice in the hospital's maintenance department, central processing department, and the medical records department.

3. On 10/05/17 between 9:50 AM and 10:40 AM, Surveyor #1 interviewed the hospital's quality improvement coordinator (Staff #12) and Chief Nursing Officer (Staff #3) and reviewed the hospital's quality assurance program. During the interview, the staff members stated that the quality program did not have a process for evaluating hospital maintenance services, central processing services, and medical records services.
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