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Preventative maintenance on medical equipment

Based on observation, interview, and document review, the Critical Access Hospital failed to document and perform preventative maintenance on medical equipment.

Failure to document and perform preventative maintenance (PM) places patients at risk of injury due to medical equipment malfunction.

Findings included:

1. Record review of the hospital 's policy & procedure titled, "Bio-med Equipment Maintenance and Repair Program", Policy Stat ID: 9410472, Last reviewed 03/2021, showed that clinical equipment will be placed on a report that will show location, asset tag, description and work performed. The report should include medical equipment used for diagnosis, treatment, monitoring, and direct patient care.

Record review of the hospital's water management plan risk assessment titled, " Skyline Hospital Water Management Risk Assessment and Action Plan 2021-Physical Therapy", showed the Hydro-collator is to be cleaned every two weeks per manufacturer's recommendations.

Record review of "Hydrocollator Cleaning Log" showed a cleaning frequency of monthly.

2. On 09/21/21 at 1:45 PM, Surveyor #1 and Surveyor #8 with Physical Therapy Manager (Staff #801) toured Physical Therapy. A Hydro-collator was observed in the Physical Therapy area and marked with an asset tag number of SH51620.

3. On 9/21/21 between 12:00 PM - 12:45 PM, Surveyor #1 observed AMX4 X-Ray Mobile located in the hallway of the imaging department. Surveyor #1 recorded the serial number SN10437E02.

4. On 09/22/21 at 12:45 PM, Surveyor #8 obtained the hospital asset list and 2021 records of perventative maintenance (PM) from Maintenance Director (Staff #802). Surveyor #8 searched PM records and failed to find Hydro-collator and AMX4 X-Ray Mobile on the asset list and failed to find PM records.

5. On 09/23/21 at 11:40 AM, Surveyor #8 asked Staff #802 for assistance finding maintenance records for the Hydro-collator and AMX4 X-Ray Mobile. Staff #802 failed to find this equipment in the hospital electronic records and stated that maintenance records on the AMX4 X-Ray Mobile will be in Radiology.

6. On 09/23/21 at 12:35 PM Surveyor #8 and Surveyor #1 asked Director of Radiology (Staff #803) to provide PM records for AMX4 X-Ray Mobile. Staff #803 failed to provide PM records.

7. On 09/23/21 at 1:45 PM, Providence BioMed Technician (Staff #804) stated that both the AMX4 X-Ray Mobile and Hydro-collator were not on the asset list and PM was not recorded.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report found at
Shell # 3QD621

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Item # 1 Physcian Assistant Delegation Agreements

Based on document review and interview, the hospital failed to ensure that physician assistants had an active physician assistant delegation agreement with a supervising physician on the active medical staff as outlined in State Law for 2 of 2 physician assistant credentialing files reviewed (Staff # 1021 and #1022).

Failure to ensure physician assistants are properly supervised places patients at risk for unsafe care.

Findings included:

Item #1 Physician Assistant Delegation Agreements

1. Document review of Professional Services Agreements for 3 Physicians (Staff # 1018, #1019, and #1020) shows that mid-level oversight will be available by physicians in the Skyline Health Hospitalist service..

a. Document review of the Medical Staff By-Laws for Skyline Hospital dated 07/16 showed no evidence of oversight for mid-level providers.

b. Document review of the medical staff credentialing files for Physician Assistants (Staff #1021 and #1022) showed that the mid-level providers had no Washington State Delegation Agreement with a supervising physician.

2. On 09/23/21 at 10:30 AM, Surveyor #10 interviewed the Payroll Specialist/Interim Human Resource Manager (Staff #1023) and the Chief Financial Officer (Staff #1015) regarding the delegation agreement for the physician assistants. Staff #1023 and Staff #1015 verified that Washington State Delegation Agreement was not in the medical credentialing files for Physician Assistants (Staff # 1021 and Staff #1022). Staff # 1023 and #1015 stated that they were unaware they needed to submit a Washington State Delegation Agreement.

Item #2 Mid-Level Supervision Medical Staff By-laws

Based on document review and interview the hospital failed to provide policy, procedures and/or Medical Staff By-Laws that governpractice of mid-level providers.

Failure to provide policy, procedures and/or Medical Staff By-laws for mid-level providers places patients at risk for inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospitals document titled, "Skyline Hospital Medical Bylaws," dated 07/19 showed no evidence of governing rules for mid-level providers.

2. On 09/23/21 at 11:45 AM, Surveyor #10 interviewed the Quality Improvement Manager, (Staff #1011) regarding policy, procedures or Medical Staff Bylaws the govern the oversight of the mid-level providers. Staff # 1011 confirmed the hospital did not have policies, procedures or information documented in their current medical staff by laws regarding oversight of mid-level providers.

Item #2 Mid-Level Supervision Medical Staff-By-laws

Based on document review and interview the hospital failed to provide policy, procedures and/or Medical Staff By-Laws that govern practice of mid-level providers.

Failure to provide policy, procedures and/or Medical Staff By-laws for mid-level providers places patients at risk for inadequate care and adverse patient outcomes.

Findings Included:

1. Document review of the hospitals document titled, "Skyline Hospital Medical Bylaws," dated 07/19 showed no evidence of governing rules for mid-level providers.

2. On 09/23/21 at 11:45 AM, Surveyor #10 interviewed the Quality Improvement Manager, (Staff #1011) regarding policy, procedures or Medical Staff Bylaws the govern the oversight of the mid-level providers. Staff # 1011 confirmed the hospital did not have policies, procedures or information documented in their current medical staff by laws regarding oversight of mid-level providers.

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Based on document review and interview, the hospital failed to maintain a list of services furnished under arrangement or agreements that described the nature and scope of the services provided.

Failure to maintain a list of services describing the nature and scope of the services provided by the contractors created a situation where the facility could not know which services were contracted and could not ensure the quality of those services.

Findings included:

1. Document review of a list of hospital patient care services furnished under arrangement or agreements (contracts), no title, no date, showed a word type document that included hospital contracted services listed in line item format.

2. On 09/23/21 at 1:30 PM, Surveyor #10 and the Quality Improvement Manager (Staff #1011) reviewed the Critical Access Hospital's (CAH) process for tracking and reviewing services furnished under arrangement. Review of the list provided to the Surveyor showed that the document failed to describe the nature and scope of the services provided and contain all the minimum requirements including:

a. The service(s) being offered;

b. Whether the services are offered on- or off-site;

c. Whether there is any limit on the volume or frequency of the services provided; and

d. When the service(s) are available.

3. At the time of the review, Staff #1011 verified that the list did not contain all required elements and stated that the list for contracted services needed to be updated with the current contracts.
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Based on interview, document review, review of the hospital's quality and performance improvement program, the hospital failed to ensure that performance measures for all patient care services furnished under arrangement or agreements (contracted) were developed and evaluated by a designee with experience and knowledge in the service to be reviewed, and failed to ensure that all patient care services furnished under arrangement or agreements were evaluated through the hospital's quality program in 4 of 4 contracts reviewed.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospital's Quality Plan for 2021, no review date, showed no evidence of a process that the hospital follows for patient care contracted services provided under arrangement or agreement.

a. Document review of the hospital's policies and procedures and Medical Staff By-laws, showed that there was no evidence of oversight of the patient care services provided under agreement or arrangement.

b. Document review of the hospital's contracted service evaluations for patient care contracts including the hospital's contracts with the following:

-Northwest Emergency Solutions

-Pipeline

-Lab Corp

-Contracted Pharmacist (Staff #1016)

c. The review showed no evidence that services provided by 4 of 4 contracted services had been evaluated by the hospital.

3. On 09/23/21 at 1:30 PM, Surveyor #10 interviewed the Quality Improvement Manager (Staff # 1011) regarding the missing evaluations for contracted services. Staff #1011 stated that due to circumstances and the pandemic the hospital had to eliminate the administrative assistant position. This position was involved in the organization of contracted service reviews and providing the departments with their evaluation forms for contracted services yearly. Staff #1011 verified the that contracted services list above is missing evaluations and stated that the hospital would review their current process and documents.
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Based on medical record review and interview, the Critical Access Hospital failed to ensure that Swing Bed patients medical records included documentation of a History and Physical after discharge from the Acute Care Unit for 2 of 5 patients (Patient #1010 and #1011).

Failure to ensure a complete and timely documented medical record puts patient at risk for unrecognized and unmet care needs and inconsistent and unsafe care due to the lack of complete and accurate information that is readily accessible to hospital personnel.

Findings included:

1. Review of the Critical Access Hospital's document titled, " Skyline Hospital Medical Staff By-laws, " dated 07/19, showed that a complete admission history and physical examination shall be recorded within 24 hours of admission.

2. Review of the electronic medical records for 2 of 5 patients (Patient #1010 and #1011) showed the following:

a. On 06/27/21 Patient #1010 was admitted to Skyline Hospital acute care unit for cellulitis with open wounds. Patient #1010 was discharged from the acute care unit and admitted as a Swing Bed patient on 07/07/21. The review showed that a discharge note was created on 07/07/21. There was no evidence that a history and physical was documented on 07/07/21 for Patient #1010 admitted from the acute care unit to the Swing Bed program.

b. On 08/28/21 Patient #1011 was admitted to Skyline Hospital acute care unit following a bike accident. Patient #1011 was discharged from acute care unit and admitted as a Swing Bed patient on 09/01/21. The review showed that a discharge note was documented on 09/01/21. There was no evidence a history and physical was documented on 09/01/21 for Patient #1011 admitted from the acute care unit to the Swing Bed program.

3. On 09/22/21 at 10:45 AM Surveyor #10 interviewed the House Supervisor (Staff #1013) regarding the missing history and physicals for the patients admitted from the hospitals acute care unit to the Swing Bed program. Staff #1013 confirmed the missing history and physicals for Patient #1010 and #1011.

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Item #1 - Sterilization room handwashing station

Based on observation and interview, the Critical Access Hospital failed to provide a handwashing station in the Central Sterile Department decontamination room.

Failure to provide hand-washing stations places staff at increased risk of exposure to infectious microorganisms during reprocessing of patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.7.1 Clean workroom. If the room is used for preparing patient care items, it shall contain a work counter, a hand-washing station, and storage facilities for clean and sterile supplies.

Findings included:

1. On 09/23/21 at 9:50 AM, Surveyor #1 and Central Sterile Technician Supervisor (Staff #102) observed a Central Sterile Technician (CST) (Staff #101) reprocess a colonoscopy scope in the decontamination room. Observation of the decontamination room showed a three compartment sink not equipped with soap or paper towels. During the cleaning of the colonoscopy scope, Staff #101 removed his gloves, and lightly rinsed his hands in the third compartment sink and placed on new gloves.

2. At the time of the observation, Surveyor #1 interviewed the CST Supervisor (Staff #102) about handwashing requirements. Staff #102 confirmed that the decontamination room was not provided with the equipment to properly wash hands between glove use.

Item #2 Reprocessing medical equipment

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure staff reprocessed endoscopes according to manufacturer's instructions for use.

Failure to follow manufacturer's instructions for use when reprocessing endoscopes places patients at risk of infection and/or illness.

Reference: Olympus Endoscope Disinfection Guide indicated to immerse endoscope completely in disinfection solution.

Findings included:

1. Document review of the policy and procedure titled, " High Level Disinfection of Endoscopes," policy number 8836352, dated 11/20, showed that the internal and external parts of the endoscope need to be immersed in the disinfectant solution.

2. On 9/23/21 at 9:30 AM, Investigator #1 and CST Supervisor (Staff #102) observed a Central Sterile Technician (CST) (Staff #101) performing a reprocessing procedure of an endoscope. During the procedure, Staff #101 did not submerge the entire scope in the disinfectant solution. The handle of the scope was outside of the disinfection solution.

3. Following the procedure, Investigator #1 interviewed CST Supervisor (Staff #102) about the process. Surveyor #1 and CST Supervisor (Staff #102) reviewed the "Endoscope Disinfection Guideline" posted on the wall in the decontamination room which showed a picture of the endoscope completely submerge in a sink with a description that indicated to completely immerse endoscope in the disinfection solution. Staff #102 confirmed that the endoscope was not completely submerge in the disinfection solution.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop a policy and procedure for sheltering in place for patients, staff, and volunteers who remain in the hospital during an emergency.

Failure to develop policies and procedures for sheltering in place risks unsafe conditions for patients, staff, and volunteers who remain in the hospital during an emergency.

Findings included:

1. Document review titled, "Emergency Management Plan", dated 03/21, showed that there was no policy or procedure for sheltering in place during an emergency.

2. On 09/22/21 between the hours of 10:00 AM and 11:45 AM, Surveyor #1 interviewed the Emergency Preparedness Coordinator (Staff #102) about the elements of the emergency preparedness program. Surveyor #1 was unable to locate a policy and procedure for sheltering in place for staff, patient, visitor and volunteers in an emergency event. Staff #102 indicated that she would look into it.

3. On 09/22/01 at 1:00 PM Staff #102 reviewed hospital's policies and procedures for evacuation with Surveyor #1, and confirmed that the plan did not have a policy and procedure for sheltering in place for staff, patients, visitors and volunteers in an emergency event.
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