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Based on record review and interview, the Critical Access Hospital failed to provide Medicare patients with a notice regarding their right to appeal being discharged, as required by federal regulations for 5 of 6 patients reviewed (Patients #1, #2, #3, #4, #5).

This limits patients' 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:

1. Review of the records of 5 Medicare patients on 11/27/2012 and 11/28/2012 revealed the following:

a. Review of the records of Patient #1 revealed that s/he had been discharged from inpatient status and readmitted to long-term care ("swing bed") status on 11/21/2012. The "Important Message From Medicare" information form had been signed by the patient on admission on 11/16/2012. There was no documentation in the patient's record that the patient had received second notification of their discharge rights within two days of discharge.

b. Review of the records of Patient #2 revealed that s/he had been discharged from the hospital on 10/5/2012. The "Important Message From Medicare" information form had been signed by the patient on admission on 10/1/2012. There was no documentation in the patient's record that the patient had received second notification of their discharge rights within two days of discharge.

Similar findings were found in the records of Patients #3, #4, and #5.

2. An interview with the hospital's Director of Patient Care Services on 11/28/2012 at 4:10 PM confirmed the findings above.
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Based on interview and review of medical staff privileging documentation, the critical access hospital failed to establish criteria for the granting of privileges in conscious sedation in a manner consistent with health care industry standards of practice.

Failure to establish appropriate criteria for the granting of privileges in conscious sedation risks patient injury or death through provision of sedation by medical staff who are not qualified by education, training or experience to do so.

Reference: American Society of Anesthesiologists
"STATEMENT ON GRANTING PRIVILEGES TO NONANESTHESIOLOGIST PHYSICIANS FOR PERSONALLY ADMINISTERING OR SUPERVISING DEEP SEDATION" (Approved by the ASA House of Delegates on October 18, 2006, and amended on October 17, 2012)

Because of the significant risk that patients who receive deep sedation may enter a state of general anesthesia, privileges for deep sedation should be granted only to nonanesthesiologist physicians who are qualified and trained in the medical practice of deep sedation and the recognition of and rescue from general anesthesia."

Findings include:

During review of medical staff privileges on 11/29/2012, the medical staff coordinator stated that privileges in conscious sedation may be granted to non-anesthesia providers based on criteria that include any one of several qualifying factors, including the one factor of holding certification in advanced cardiac life support (ACLS).

Review of the critical access hospital document "Tri-State Memorial Hospital, Clarkston, Washington, Privilege Request Form (revised 12/2002) found that the form stated that:

"Practitioners requesting these privileges must meet at least one of the following eligibility criteria...
1. Demonstrated successful completion of a residency or fellowship training program, including conscious sedation....AND/OR
2. Previous experience with evidence that the applicant has successfully performed conscious sedation....AND/OR
3. Evidence of participation in continuing education programs devoted to conscious sedation...AND/OR
4. Current ACLS training"

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1. Based on observation and interview, the Critical Access Hospital failed to ensure that healthcare providers followed Centers for Disease Prevention and Control (CDC) guidelines for use of multi-dose medication vials.

Failure to implement evidence-based control measures risks transmission of communicable diseases to patients.

Findings:

a. CDC guidelines for safe injection practices (2/9/2011) state that if a multi-dose vial enters the immediate patient treatment area, including operating rooms, the vial should be dedicated to that patient only and discarded after use.

b. During an interview on 11/28/2012 at 9:30 AM, the hospital's pharmacy manager stated that there was no hospital pharmacy policy directing healthcare providers to access multi-dose vials only in medication preparation areas.

c. On 11/28/2012 at 11:35 AM, Surveyor #1 interviewed a registered nurse (RN #1) who stated she had taken a multi-dose vial of insulin into Patient #1's room to teach her how to withdraw insulin from the vial and administer it to herself. The RN had returned the vial to the medication room and during the interview prepared to replace the vial in the automated medication dispensing machine. Surveyor #1 instructed the nurse to discard the vial.

d. On 11/25/2012 at 12:40 PM, Surveyor #1 observed and interviewed a certified registered nurse anesthetist (CRNA #1) who was providing anesthesia to Patient #6 during a surgical procedure in OR #1. The CRNA's anesthesia cart contained four multi-dose vials of medication: doxapram hydrochloride, labetolol hydrochloride, atropine sulfate, and lidocaine 2%. The vials containing doxapram hydrochloride, labetolol hydrochloride, and atropine sulfate were open and dated. The vial containing lidocaine 2% was open and not dated.
CRNA #1 confirmed that medication from the vials had been withdrawn and the open vials of medication returned to the anesthesia cart for future use.


2. Based on observation and interview, the Critical Access Hospital failed to ensure that healthcare providers followed the recommendations of the Association for Professionals in Infection Control (APIC) when transporting medication vials and syringes.

Failure to implement evidence-based infection control measures risks transmission of communicable diseases to patients.

Findings:

a. The APIC position paper entitled "Safe Injection, Infusion, and Medication Vial Practices in Health Care" (April 2011) states that medication vials and syringes should never be stored or transported in clothing or pockets of healthcare providers.

b. On 11/28/2012 at 11:35 AM, Surveyor #1 interviewed a registered nurse (RN #1) who stated she had taken a multi-dose vial of insulin into Patient #1's room to teach her how to withdraw insulin from the vial and administer it to herself. The RN stated she placed the vial of insulin in her pocket after the medication had been administered.

c. On 11/28/2012 at 12:43 PM, Surveyor #1 observed CRNA #1 place two syringes of medication in his/her pocket. At 12:44 PM, Surveyor #1 observed the CRNA withdraw a set of keys from the same pocket. At 12:48 PM, Surveyor #1 observed the CRNA withdraw two quarters from the same pocket. The two syringes of medications remained in the CRNA's pocket during this timeframe and were exposed to these items.


3. Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to document that patient education regarding transmission-based precautions had been performed for 1 of 1 patients reviewed (Patient #2).

Failure to educate patients regarding transmission-based precautions risks patient anxiety related to isolation from staff and other patients and non-adherence to infection control measures.

Findings:

a. Patient #7 was admitted on 11/25/2012 with abdominal pain and a history of diarrhea. The patient was placed in contact enteric precautions for possible infection with Clostridium difficile. During an interview on 11/27/2012, the patient stated she did not know why s/he was in isolation and that staff had not informed him/her of the reasons for isolation.

.Review of the patient's medical record on 11/27/2012 revealed the record lacked documentation that the patient had been educated regarding contact enteric precautions.

b. The hospital's policy and procedure entitled "Isolation: Precautions/Transmission-Based Guidelines Precautions" (Reviewed 9/2012) stated that "the patient, his/her family, and all visitors would be educated as to the reason for initiating Transmission-Based Precautions, and how to comply with them." The policy stated that this education was to be documented in the patient's medical record.
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Based on review of facility policies and procedures and interview, the hospital failed to ensure that all hospital 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. During an interview on 11/28/2012 at 7:30 AM, the hospital's surgery nurse manager stated that the policies and procedures for the surgery department had not been reviewed since 2009.

2. Review of the hospital's long-term care ("swing bed") program on 11/28/2012 revealed that the swing bed program policies and procedures had not been reviewed since March 2009.

3. An interview with the hospital's performance improvement coordinator on 11/28/2012 at 7:30 AM revealed that this deficiency had been cited during the hospital's Joint Commission accreditation survey of October 2012, and that all hospital policies and procedures were currently being reviewed.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that the results of a physician's history and physical examination were available for review prior to administration of medications by a registered nurse for procedural ("conscious") sedation as directed by hospital policy for 2 of 2 patients reviewed (Patients #12, #13).

Failure to obtain and review a patient's medical history and physical examination prior to administration of medications for procedural sedation risks adverse outcomes related to undetected physical problems and co-morbidities.

Findings:

1. The hospital's policy and procedure entitled "Conscious Sedation " (Revised June 2009), under the section "Patient Assessment" (page 5 of 10) read in part as follows: "The RN shall obtain and/or review from the physician the following patient information prior to sedation: 1. A history and physical no more than 30 days old."

2. Review of the records of two patients who were sedated by registered nurses during magnetic resonance imaging (MRI) procedures revealed that neither record contained a physician's written patient history and physical examination.

The records of Patient #12 (age 70) included a form entitled "Pre-Operative Patient Information Form" that read in part: "This form is to be filled out in the event that a H&P is not available in Pre-Op Holding". The form had been signed by the radiologist performing the MRI, but the areas for documenting the patient's physical examination and medical history were blank. The nursing admission assessment indicated that the patient had a history of bronchitis, hypertension, and a "rapid heart rate". The nurse determined that the patient's sedation risk classification was "Medium Risk".

The records of Patient #13 (age 75) included the results of the nursing admission assessment, which indicated that the patient had a history of shortness of breath, pneumonia, and insulin-dependent diabetes. The nurse's findings after examination of the patient indicated that the patient's lung sounds were diminished in the right base, and that the patient had an irregular heart rate. The nurse determined that the patient's sedation risk classification was "Medium Risk", and that the patient's Mallampati Classification score was a "Class 3", which is associated with more difficult intubation of the airway.

3. These findings were confirmed by the hospital's Director of Patient Care Services during an interview on 11/29/2012 at 11:00 AM.
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1. Based on record review, review of policies and procedures, and interview, the Critical Access Hospital failed to ensure that staff members developed and implemented an activity program for 4 of 4 long-term care ("swing bed") patients reviewed (Patients #1, #9, #10, #11).

Failure to develop and implement an activities plan for long-term care patients risks impairment of physical, mental, and psychosocial well-being.

Findings:

a. The hospital's policy and procedure entitled "Swing Bed Program (SWB) - Activities Program" (Reviewed March 2009) stated that a registered nurse, social worker, or "designee" would develop a plan for meeting the activity needs of swing bed patients based on the patient's activities assessment and the assessment of other disciplines involved in the care of the patient.

b. Review of the medical records of four swing bed patients revealed that 4 of 4 records included a comprehensive activities assessment but no plan for activities based on the assessment findings

c. On 11/27/2012 at 10:30 AM, an interview with the nurse manager of the acute care and swing bed unit confirmed that an activities assessment was being performed on all swing bed patients admitted to the hospital, but that there was no process for incorporating an activities plan into the patient's plan for care.
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2. Based on record review, review of policies and procedures, and interview, the Critical Access Hospital failed to ensure that the hospital long-term care ("swing bed") activities program was directed by an individual who met the professional requirements identified in the regulation.

Failure to develop and implement an activities program that is directed by a qualified professional impairs the hospital's ability to provide a meaningful and therapeutic healthcare environment for long-term care patients.

Findings:

a. The hospital's policy and procedure entitled "Swing Bed Program (SWB) - Activities Program" (Reviewed March 2009) stated that the hospital's swing bed (long-term care/"Swing Bed" program) would be directed by an occupational therapist.

b. An interview with the hospital's Director of Patient Care Services on 11/28/2012 at 8:50 AM revealed that the hospital did not have an occupational therapist activities director as stated in hospital policy nor any other individual qualified to direct the program according to the regulation..
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Based on interview and review of the hospital's patient rights information, the Critical Access Hospital failed to develop a process for informing patient's of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f).

Failure to inform patients of their visitation rights limits the patient's ability to exercise those rights.

Findings:

1. On 11/26/2012 at 4:00 PM, an interview with the Director of Patient Care Services and The Director of Quality and Risk revealed that patients were given a brochure to read entitled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient care and outpatient care. In addition, patients were given a booklet entitled "Intensive Coronary Care Unit Information Booklet" when admitted to the intensive care unit.

Review of the contents of these handouts revealed they did not include the patient's visitation rights identified under 42 CFR 485.635(f)(2).

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