HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to ensure that patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.

Failure to properly maintain supplies places patients at risk for infection and delays in treatment.

Findings included:
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1. During the survey, the following observations were made:

ACUTE CARE UNIT:
a. On 06/05/18 at 9:30 AM, during inspection of the medication room, Surveyor #9 found 3-24 gauge angio- catheters and 2- butterfly angio-catheters expired on 06/17, Hemocult card developer expired 04/18, 1- 8 oz. Betadine solution expired 04/17.
b. On the hemorrhage cart 2-20 gauge angio catheters expired 05/18, 1-18 gauge angio catheter expired on 04/18, 2- blue top blood collection tubes expired 03/31/18.
c. On the crash cart- 1 package of pediatric electrodes expired 04/18

NURSEY:
On 06/05/18 at 10:30 AM, Surveyor #9 found an Infant Thoracentesis tray with 2 packages of Povidone/Iodine swabs expired 06/17, 1-20 ml syringe expired 12/17 and 1-16 gauge angio catheter expired 05/18.

EMERGENCY DEPARTMENT:
a. On 06/05/18 at 11:00 AM, Surveyor #9 found on the crash cart 1- package of pediatric electrodes expired on 04/18, on a cut down tray iodine swab sticks 2 packages expired 04/18 and 1-16 gauge angio catheter expired on 05/18.
b. In the trauma bay there were 6-Namoline adapters expired on 07/17 and Hemo cult cards that expired 01/17.

PRE-OPERATIVE/RECOVERY UNIT:
On 06/05/18 at 11:30 AM during inspection of the crash cart, Surveyor #9 found a package of pediatric electrodes expired on 08/17 and a package of adult electrodes expired on 11/17.

2. On 06/05/18 at 11:45 AM, Surveyor #9 discussed the findings of expired supplies with a Nurse Coordinator (Staff #901) who stated that the staff nurses were to check monthly for outdated supplies and notify central supply to replace expired items.

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Based on interview, and review of the Governing Body Bylaws and Medical Staff Bylaws, the Critical Access Hospital failed to ensure that the pathologist was approved by the Medical Executive Committee and the Governing Body.

Failure to approve the arrangement for the pathologist places patients at risk for unsafe care.

Findings included:

1. The hospital's Governing Body Bylaws under, Article V Medical Staff, section 2, page 11, stated the following: "Evaluate the professional competence of medical staff members and applications for clinical privileges; Make recommendations to the Board concerning initial medical staff appointments, reappointments and the granting, denial, reduction, or termination of clinical privileges."

2. The hospital's Medical Staff Bylaws stated in part on page 13, under Appointment to Medical Staff that the Medical Executive Committee make recommendations to the Governing Body on appointments and re-appointments.

3. On 06/05/18 at 2:30 PM, Surveyor #1 interviewed the laboratory manager (Staff #102) in regards to the oversite of laboratory services. The laboratory manager stated that they contracted with a pathologist (Staff #103) from Central Washington Hospital who does monthly on-site visits.

4. On 06/07/18 at 9:00 AM, Surveyor #1 reviewed the latest contract which had expired in May 30, 2016. The expired contract was for a different pathologist (Staff #104).

5. On 06/07/18 at 2:00 PM, Surveyor #1 interviewed the Medical Credentialing Manager (Staff #105) and discovered the pathologist that the hospital is currently using did not go through the initial application process as required by the hospital's governing body bylaws and medical staff bylaws. The surveyor was unable to verify documentation of the current pathologist's initial appointment, credentialing, and contract.

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Based on observation, interview, and document review, the Critical Access Hospital failed to meet all applicable provisions of the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.

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ITEM #1 Governing Bylaws

Based on document review and interview, the Critical Access Hospital failed to ensure that the governing body reviewed and approved the Governing Bylaws on an annual basis.

Failure to review and approve Governing Bylaws risks failure of the hospital to provide appropriate health care services to the community.

Findings included:

1. The hospital's governing bylaws titled, "Governing Bylaws of Public Hospital District No. 3 Adams County, Washington," Adopted on 10/22/09, stated that the Bylaws were to be reviewed on an annual basis. Surveyor #9 was unable to verify in the document or in Governing Body meeting minutes that the Bylaws had been reviewed since 10/22/09.

2. On 06/06/18 at 2:30 PM, Surveyor #9 discussed the finding with the Chief Executive Officer (Staff #902). She agreed that the Governing Bylaws were to be reviewed annually but acknowledged that currently there is no way to identify that the review had taken place.

ITEM #2 Medical Staff Bylaws

Based on document review and interview, the Critical Access Hospital failed to ensure that the Medical Staff Bylaws were reviewed and approved by the Governing Body on an annual basis.

Failure to review and update the Medical Staff Bylaws risks ineffective and inadequate care of patients.

Findings included:

1. The hospital's medical staff bylaws titled, "Medical Staff Bylaws, Rules & Regulations and Associated Manuals," Revised 9/14/12, on page 46 showed that the Medical Staff Bylaws were to be reviewed annually. There were no dates listed under "Annual Review Dates."

2. On 06/06/18 at 2:30 PM, Surveyor #9 discussed the finding with the Chief Executive Officer (Staff #902). She acknowledged that the review of the Medical Staff Bylaws had not been documented.

ITEM #3 Contract Review

Based on document review and interview, the Critical Access Hospital failed to ensure that Service Contracts were reviewed on a regular basis.

Failure to review contracts and deliverables may lead to failure to ensure that patients receive high quality care.

Findings included:

1. The hospital supplied a list of nine service contracts for care and services rendered for the hospital's patients. The contract review checklists for the services including- emergency room physicians, mobile Magnetic Resonance Imaging (MRI), radiology, laboratory services, dietary services, pathology, ambulance and pharmacy revealed that the contracts were last reviewed in 2016 but should have been reviewed annually according to the checklists.

2. On 06/07/18 at 10:00 AM, Surveyor #9 discussed the finding with the Chief Executive Officer (Staff #902). She acknowledged that the contracts had not been reviewed in 2017.

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ITEM #1 - Patient/Family Education Regarding Restraints

Based on interview, record review and review of hospital policy and procedures, the Critical Access Hospital failed to educate patients and families regarding the patient's behaviors that resulted in the use of restraints and the demonstrated behaviors needed in order to discontinue restraints in 3 of 3 records reviewed (Patient #901, #902, #903).

Failure to follow hospital policy and procedure regarding restraint education for patients and family members places patients at risk for prolonged use of restraints and may result in psychological harm.

Findings included:

1. The hospital's policy titled, "Restraints," Policy #4206615, approved 11/17 showed that a patient or their family will be provided with explanations of behaviors that resulted in the use of restraints and behaviors required for discontinuation.

2. On 06/07/18 at 3:00 PM, Surveyor #9 reviewed patients' records (Patients #901, 902, 903) who were in restraint/seclusion due to violent or self-destructive behavior. The record review showed that there was no documentation indicating that the patient or family were educated regarding behaviors that resulted in the use of restraints and behaviors required for discontinuation of restraints.

3. At the time of record review, Surveyor #9 discussed this finding with the Chief Nursing Officer (Staff #904) and she acknowledged that there currently was no area to document patient/family education.

ITEM #2 - Release Of Patients in Seclusion/Restraints

Based on interview, record review, and review of policy and procedure, the Critical Access Hospital failed to ensure that patients were released from restraints at the earliest possible time in 2 of 3 records reviewed (Patients #901 and #902).

Failure to release patients from restraints at the earliest possible time risks violation of patient rights and emotional harm.

Findings included:

1. The hospital's policy titled, "Restraints," Policy #4206615, approved 11/17 showed that restraints could only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time.

2. On 6/07/18 at 3:00 PM, Surveyor #9 reviewed the medical records of Patients #901, #902, and #903. In 2 of 3 records reviewed, Surveyor #9 found the following:

a. Review of Seclusion/Restraint Records for Patient #901 showed that the patient, a 40 year old female, was placed in 4-point restraints at 9:45 PM until she "was evaluated." It was unclear from the documentation who was to evaluate the patient. The registered nurse (RN) documented that the patient was "thrashing" at 10:45 PM, 11:00 PM, 11:15 PM, and 11:30 PM. At 11:03 PM and 11:10 PM, the RN administered Lorazepam 1 mg. (an anti-anxiety medication and Haloperidol 5 mg. (an antipsychotic medication) respectively to the patient by intramuscular injection. The RN documented that the patient was sedated and sleeping from 11:45 PM to 3:00 AM. At 12:40 AM, the RN (Staff #903) removed the patient's left wrist restraint due to minor abrasions caused by the physical restraint. The patient remained in restraints, although sedated, until 4:00 AM.

b. Document review of Seclusion Restraint Records for Patient #902 showed that the patient, a 13 year old female, was placed in 4- point restraints at 4:45 AM even though nursing documentation at 4:45 AM showed that the patient was sleeping. The RN documented at 5:00 AM, 5:15 AM and 5:30 AM that the patient was asleep, but she remained in restraints due to concern for self-harm. No alternative interventions to avoid use of restraint were documented by Staff #903. There was no documentation to indicate the patient was combative.

3. At the time of the record review, Surveyor #9 discussed this finding with the Chief Nursing Officer (Staff #904) who acknowledged the finding that the patients remained in restraints even through the RN (Staff #903) had documented they were sedated or sleeping.

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Based on review of hospital policies and interview, the Critical Access Hospital failed to ensure that policies were reviewed annually.
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Failure to provide annual review of hospital policies and procedures risks poor patient care outcomes.
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Findings included:

1. The hospital's policy titled, "Policy on Policies," Policy #BP-001, Revised 06/16, showed that the facility failed to ensure that policies were evaluated on an annual basis and included review by a medical staff member.

2. The following policies were not reviewed annually:

Policy on Policies- Policy #BP-001, Reviewed 06/16
Patient Rights and Responsibilities- Policy BP-023, Reviewed 07/16
Visiting Acute Care and Obstetrical Unit- No Policy #, Reviewed 08/11
Housekeeping OB Routines Daily- Policy #HSKP 059, Revised 01/13
Routines for ED & Radiology Daily- Policy #HSKP 063, Revised 01/13
OR Daily Routines- Policy #HSKP 065, Revised 01/13

3. On 06/07/18 at 2:30 PM, Surveyor #9 discussed the finding with the Chief Executive Officer (Staff #902). She acknowledged that all policies had been reviewed annually and stated that she and the managers were in the process of setting up a plan to ensure annual review.

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ITEM #1 Disinfectant Solution

Based on observation, interview and review of product information, the Critical Access Hospital staff failed to ensure that hospital disinfectant used to clean patient rooms was diluted per the manufacturer's directions for use.

Failure to adhere to manufacturer directions places patients, staff and visitors at risk for infections due to reduced efficacy of the disinfectant cleaner.

Findings included:

1. The product label for "Virex Plus II", under Usage Information, Directions, Manual Cleaning, stated in part, "Use 1/2 oz. per gallon of water. ..."

2. On 06/05/18 at 11:00 AM, Surveyor #1 observed a housekeeper (Staff #101) cleaning a patient room in the emergency department. During the observation, the housekeeper measured the disinfectant into an attached measuring cup on the disinfectant bottle. The surveyor observed that the measurement of disinfectant in the attached cup was less than ½ an ounce. The housekeeper than poured the disinfectant into a red container and filled the container with water.

During the observation the surveyor interviewed the housekeeper on the process of disinfectant dilution ratios. The housekeeper stated, she did not fill the measuring cup to the ½ oz. mark because staff would complain about the smell. The surveyor asked about the size of the red container, the housekeeper was unable to ensure that the container used was a one gallon container.
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ITEM #2 Water Management Plan

Based on observation, interview and document review, the Critical Access Hospital failed to meet all the required elements in the hospital's water management plan that is designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to meet all the requirements in the 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 (6/2/2017): 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. The plan must meet the following criteria:

a) Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system;

b) Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;

c) Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained."

Findings included:

1. On 06/06/18 between the hours of 1:00 AM and 2:15 PM, Surveyor #1 reviewed the water management plan with the maintenance manager (Staff #106). During the review of the plan's risk assessment, the hospital identified shower heads with attached hoses and a jetted tub. The surveyor asked to see what control measures were put in place to prevent water stagnation in these areas. The surveyor also requested to see corrective action plans when control measures were not met. The facility had not developed control measures or corrective action plans to prevent water stagnation in these areas.

2. On 06/08/18 between the hours of 9:30 AM and 10:00 AM, Surveyor #1 toured the hospital's patient rooms with environmental services manager (Staff #107). The surveyor observed patient rooms in the acute care unit and the OB department with shower hoses that were hung allowing the water to stagnate in the hose. The surveyor asked if all the patient rooms had the same set up. The environmental service manager confirmed that all patient rooms had shower hoses that were hung in this manner. The environmental services manager also showed the surveyor the jetted tub in the OB department. The tub had been covered with a plywood board. The environmental service manager stated that they no longer use it.
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ITEM #3 Immediate Use Sterilizer

Based on interview and document review, the Critical Access Hospital failed to ensure that staff employed immediate use steam sterilization only for emergent need or for clean patient-care items that cannot be packaged, sterilized, and stored before use.

Failure to follow nationally recognized practices, places patients at risk for infections.

Reference: Rutala WA, Weber DJ: CDC Healthcare Infection Control Practices Advisory Committee. Titled, "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" page 61 stated, "Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time."

Findings included:

On 06/07/18 at 10:10 AM, during a tour of the central sterile processing department, surveyor #1 observed the immediate use sterilizer log titled, "Immediate Use". In an interview with the reprocessing technician (Staff #108) the surveyor asked to describe the reasons for processing medical instruments using the immediate use method. The technician stated the facility does not have enough instruments or loaner sets for all scheduled cases.

In review of the hospital's log, Surveyor #1 observed the following items that did not meet the national standard of practice:

a. 02/14/17 Instrument flashed: Ankle Ligament Repair Set; Reason for flashing: Extra set had been used
b. 02/14/17 Instrument flashed: Ankle Ligament Repair Set; Reason for flashing: Only one set
c. 03/16/17 Instrument flashed: 2 Hystroscope Grasper; Reason for flashing: Loaner set
d. 03/16/17 Instrument flashed: 2 Hystroscope Grasper 1 Scissor; Reason for flashing: Immediate need
e. 08/29/17 Instrument flashed: Wright Medical 2 drill bits; Reason for flashing: Loaner set
f. 09/09/17 Instrument flashed: Dental Descaling Tips; Reason for flashing: Immediate use
g. 11/14/17 Instrument flashed: Biopsy Forceps; Reason for flashing: Only have 2 sets; scheduled 3 procedures
h. 01/30/18 Instrument flashed: Wright Medical 4 drill bits; Reason for flashing: Loaner set

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Based on review of documents and interview, the critical access hospital failed to ensure that the Governing Body reviewed the Quality Improvement Plan.

Failure to review the Quality Improvement Plan could lead to poor quality of care and poor patient health outcomes.

Findings included:

1. The hospital's document titled, "2017 Quality Improvement Plan," dated 02/07/17 showed that the governing body had the following responsibilities: 1. To annually review and approve the Quality Improvement Plan 2. To assure the provision of necessary resources to ensure quality improvement activities are conducted 3. Receive at least quarterly reports of quality program findings and results 4. To review the annual evaluation of the Quality Improvement program's effectiveness and make recommendations for organizational changes to improve performance.

2. On 06/07/18 at 9:30 AM, Surveyor #9 reviewed the document mentioned above and discussed it with the Chief Executive Officer (Staff #902). She acknowledged that a 2018 Quality Improvement Plan had not been drafted or presented to the Governing Board. She also acknowledged that a final evaluation of the 2017 Quality Improvement Plan's effectiveness had not been completed.

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Based on interview, the Critical Access Hospital failed to provide evidence of compliance with the Condition for Participation at 42 CFR 485.645: "Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds")".

Failure to provide services for swing-bed patients for a prolonged period of time risks decline in staff competency and patient care delivery systems, which can result in adverse patient outcomes related to substandard care

Findings included:

1. On 06/06/18 at 9:00 AM Surveyor #1 interviewed the hospital's The chief administrator (Staff # 109) regarding the swing-bed program. The chief administrator (Staff #109) stated that the hospital had not had a "swing-bed" patient since 2015 or longer.

2. The Chief Administrator did not provide current evidence at the time of the recertification survey that it was in compliance with all of the requirements under 42 CFR 485.645.

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Based on observation, documentation review and interview the Critical Access Hospital failed to develop policies and procedures for emergency preparedness specifically for provisions of subsistence needs for ensuring adequate energy sources necessary to maintain temperature, emergency lighting, fire protection, extinguishing and/or the alarm system.

Failure to provide subsistence needs places patients and staff at risk of harm due to the hospitals inability to provide for safety and care needs during an emergency event.

Findings included:

On 06/07/18 between the hours of 9:15 AM and 3:30 PM, the fire marshal interviewed and reviewed documentation with the Maintenance Manager (Staff #106). The documentation from the hospital's generator contractor stated that the generators could not provide adequate energy sources necessary to maintain temperature, emergency lighting, fire protection, extinguishing and/or the alarm system for greater than 34 hours.

In the exit interview the administrator (Staff #109) and maintenance manager confirmed that the facility did not have the required components in the emergency preparedness plan.

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Based on interview and document review, the Critical Access Hospital failed to develop policies and procedures to ensure that patient records were secure and readily available to support continuity of care during an emergency.

Failure to have policy and procedures in place to ensure patient information is secure and readily available in an event of an emergency, places patients at risk of injury and/or death.

Findings included:

On 06/06/18 between the hours of 10:30 AM and 11:30 AM, Surveyor #1 interviewed the Maintenance Manager (Staff #106) and reviewed the hospital's emergency preparedness plan. The interview and review of the documents revealed that the plan was missing policies and procedures that would ensure preservation of patient information; protect confidentiality of patient information; and secure and maintain the availability of patient records in the event of an emergency. This was confirmed by the Maintenance Manager.

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