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Based on interview, observation, review of code cart checklist documentation for 3 of 3 emergency code carts, and policy review, it was determined the hospital failed to document that its emergency code carts were maintained to assure the integrity and availability of the contents of the carts, in accordance with hospital policy.

Findings include:

1. Review of the Patient Care Services procedure titled, "Code Cart," revised 11/19/2009, reflected the following requirements: "For the hospital:...1. Department personnel will monitor the function and integrity of the code cart daily. 2. Each cart will be consistent in contents and be sealed with intact locking tags when not in use. 3. Each cart will be thoroughly checked monthly, after each use and when replacing outdated medications/supplies."

2. A tour of the Emergency Department (ED) and Intensive Care Unit (ICU) was conducted on 04/02/2013 at 0940 and 1045, respectively. During the tour, observation of the two ED code carts and one ICU code cart was conducted. The daily code cart checklist form included columns for documenting the date, medication drawer number, red tag drawer number, defibrillator inspection, and a space for signature. Additional instructions at the bottom of the page included "Code Cart Check shall be completed and recorded daily...To be opened and completely check the 1st of every month and after any opening for use."

3. The ED code cart checklists for the adult (red) and pediatric (blue) code carts were reviewed for 01/01/2013-03/31/2013. The checklist columns for documenting emergency equipment function, integrity, and availability for each shift was examined. Review of the checklists identified that many checks were not conducted in accordance with hospital policy. No daily checks were documented for the adult code cart for the following dates: 01/01/2013, 01/02/2013, 01/03/2013, 01/04/2013, 01/08/2013, 01/11/2013, 01/12/2013, 01/13/2013, 01/14/2013, 01/15/2013, 01/16/2013, 01/17/2013, 01/25/2013, 01/26/2013, 01/27/2013, 01/28/2013, 01/29/2013, 01/30/2013, and 01/31/2013.

Similar findings were noted for the months of 02/2013 and 03/2013.

No daily checks were documented for the pediatric code cart for the following dates: 01/01/2013, 01/02/2013, 01/03/2013, 01/04/2013, 01/08/2013, 01/11/2013, 01/12/2013, 01/13/2013, 01/14/2013, 01/15/2013, 01/16/2013, 01/17/2013, 01/18/2013, 01/25/2013, 01/26/2013, 01/27/2013, 01/28/2013, 01/29/2013, 01/30/2013, and 01/31/2013.

Similar findings were noted for the months of 02/2013 through 03/2013.

4. The ICU adult code cart checklist was also examined for the dates of 01/01/2013 through 03/31/2013. Review of the checklists identified that many checks were not conducted in accordance with hospital policy. No daily checks were documented for the adult code cart for the following dates: 01/01/2013 and 01/02/2013. The daily checks were completed from 01/03/2013 through 01/20/2013 then there was no documentation of daily code cart checks until 03/18/2013.

5. The ED findings were reviewed with I1, the ED manager, on 04/02/2013 at 1030. He/she stated that nursing staff were responsible for completing the daily code cart checklists. I1 confirmed that the checklists lacked documentation that they were completed daily in accordance with hospital policy.

6. The ICU code cart findings were reviewed with I2, the ICU manager, on 04/02/2013 at 1115. He/she stated that the nurses normally conduct daily code cart checks. However, an employee had been assigned to pick up the daily logs for storage purpose and the logs may have been misplaced.

Based on interview, documentation in 4 of 4 medical records reviewed of patients (Patient record #s 29, 30, 31, and 32) who received blood transfusion services and policy review, it was determined the hospital failed to ensure documentation of all of the elements for blood transfusions as required by hospital policy.

Findings include:

1. The policy titled "Blood Products Administration," revised 06/02/2011, was reviewed and identified the following internal requirements for administration of whole blood/packed red cells: "...Blood must be completely transfused within 4 hours of signing out the blood..." The policy further required vital signs (blood pressure, pulse rate, respiratory rate, and temperature) be checked as follows, "...Obtain baseline vital signs...Record data on the Transfusion Record form...record patient's vital signs immediately prior to transfusion...After 15 minutes, reassess and record patient's vital signs...Take temperature (record in Celsius), pulse, respirations, blood pressure at the beginning, 15 minutes into infusion, at completion, and as often as necessary."

2. Patient record #s 29, 30, 31, and 32 were reviewed. A "Transfusion Record" laboratory form revised 02/2011, was contained within each of the patient records. The form included blood product information, and areas for documenting the blood transfusion start date/time and stop date/time. The form also included areas for documenting vital signs at designated time frames as follows: "Pre transfusion," "15 minutes after start," and "Post transfusion." Each of the time frames were followed by columns for documenting blood pressure, pulse, respirations, and temperature readings. The form did not include an area for documenting the actual time vital signs were taken.

3. Patient record #30 was reviewed. The "Transfusion Record" laboratory form reflected that the patient received a transfusion of RBCs (red blood cells). The transfusion start date/time was 12/15/2012 at 0145 and the transfusion stop date/time was 12/15/2012 at 0430. Vital sign readings (blood pressure, pulse, respirations and temperature) were documented on the form after each of the following time frames: "Pre transfusion," "15 minutes after start," and "Post transfusion." However, the form lacked documentation of the actual time the vital signs were taken. The EMR (electronic medical record) was reviewed and lacked documentation that vital signs were collected in accordance with timeframes required by hospital policy. The following were examples: Vital signs were recorded on 12/15/2012 at 0454 (24 minutes after the transfusion was stopped). However, the record lacked documentation that vital signs were recorded at the completion of the transfusion as required by hospital policy.

Review of Patient record #30 reflected the patient received a second transfusion of RBCs. The transfusion start date/time was 12/15/2012 at 0430 and the transfusion stop date/time was 12/15/2012 at 0800. Vital sign readings were documented on the form after each of the following time frames: "Pre transfusion," "15 minutes after start," and "Post transfusion." The form lacked documentation of the actual time the vital signs were taken. Review of the EMR reflected that vital signs were recorded on 12/15/2012 at 0454 (24 minutes after the blood transfusion was started), however they were not recorded 15 minutes after the transfusion was started per hospital policy. Vital signs were recorded on 12/15/2012 at 0841 (41 minutes after the transfusion was stopped). However, the record lacked documentation that vital signs were recorded at the completion of the transfusion as required by hospital policy.

4. Patient record #29 was reviewed. The "Transfusion Record" laboratory form reflected that the patient received a transfusion of RBCs. The transfusion start date/time was 01/22/2013 at 1826. The transfusion stop date/time was blank. Review of the record identified it lacked documentation of the transfusion completion time in order to ensure vital signs were recorded at the completion of the transfusion, and the blood transfusion was completely transfused within 4 hours as required by hospital policy.

5. Similar findings were identified during review of Patient record #s 31 and 32.

6. An interview was conducted with I9, the Surgical Nurse Manager on 04/04/2013 at 0840. Patient record #s 29, 30, 31 and 32 were reviewed during the interview. He/she acknowledged that the blood transfusion lab form lacked documentation of the actual time vital signs were collected. He/she further said that staff were directed not to duplicate their vital signs documentation, and therefore the actual time vital signs were collected would not be consistently documented within any portions of the medical record.

Based on observation, interview, and review of medical staff rules and regulations, it was determined that the hospital failed to ensure all patients who presented to the ED 24 hrs/day were triaged by a nurse and medically screened by a physician.

Findings include:

1. The review of the "RULES & REGULATIONS FOR THE PROFESSIONAL STAFF OF GRH," approved 10/19/2011, reflected "XIII. EMERGENCY FACILITY...C. Presenting for Care and Medical Screening Examination: a. Any individual who comes to the Hospital Emergency Department requesting examination or treatment will receive an appropriate medical screening examination...2. An individual will be considered to have come to the Hospital Emergency Department if the individual is anywhere on the Hospital premises (including its parking lot, driveway, or sidewalk) and is requesting emergency care...3. In providing a medical screening examination, the Hospital shall not discriminate against any individual because of diagnosis, financial status, race, color, national origin, or handicap."

2. An interview with the Admitting Manager, I6, on 04/02/2013 at approximately 1000 reflected the patient admission process. I6 stated that all patients and visitors came in the front entrance to the hospital. The patient/visitor walked up to the desk and the admitting staff offered assistance. When the person stated they needed to see the emergency physician, the admitting staff called the ED RN who responded and escorted the patient into the triage room to where patients were assessed by the nurse. The patient was then escorted into the ED to be medically screened by the ED physician. I6 further stated that on the night shift from approximately 2245 when there was only one admitting personnel working until 0700, the admitting staff posted a sign at the desk informing visitors to ring the "bell" if they needed medical assistance. I6 stated the admitting rep would quickly assist the patient and would notify the ED staff if their services were needed.

I6 was asked to clarify what happened on the night shift when a patient arrived to the hospital seeking assistance following a sexual assault. He/she stated that the admitting staff would ask the patient if he/she needed to be evaluated by a physician for physical harm or if the complaint was primarily for the sexual assault exam. When the patient stated that they needed a sexual assault exam, I6 clarified the patient was given rape counseling information and provided with instructions to go to an address of a rape clinic a few blocks away. I6 was asked if a nurse or physician evaluated the patients who chose to leave at the time. I6 stated the admitting staff had been given directions to follow an algorithm developed by the hospital and county health personal. This plan did not include an RN triage or provider medical screening exam.

3. It was determined that the system developed by the hospital in conjunction with the county health department did not follow the rules and regulations of the medical staff or this regulation.

A team of State Fire Marshals conducted an onsite Fire & Life Safety Survey as part of the validation survey.

Findings include:

Based on observations, documentation review, and interviews with hospital staff, the State Fire Marshals determined that the hospital failed to ensure that the physical environment was constructed, arranged, and maintained to ensure the safety of patients.

The hospital also failed to respond appropriately to an actual fire drill. Required inspections of fire alarms, sprinklers, doors, fire extinguisher, and generators were not completed as required. In addition, fire drills and in-service trainings were not conducted as required. The cumulative effect of these systemic problems resulted in an Immediate Jeopardy situation and a threat to the health and safety of patients and staff.

Findings include:

Refer to the detailed findings listed at K tags:

A. Based on interview, policy review and the review of sterilizer log documentation, it was determined that the hospital failed to ensure its policies and procedures for identifying and controlling infections related to sterilization of surgical instruments were enforced. Biological Indicator (BI) monitoring was not performed to ensure the effectiveness of the flash sterilization process in accordance with hospital policy.

Findings include:

1. A tour of the hospital's surgical services department was conducted with I9 on 04/03/2013 at 1530. A flash sterilizer (used for sterilizing surgical instruments) was observed in the semi-sterile area adjacent to OR (operating room) #3. During the tour, I9 provided a log book titled, "Flash Log" which contained surgical instrument load records, and BI monitoring records for the flash sterilizer.

2. On 04/03/2013 at 1540, I9 was asked to provide the hospital policy for BI monitoring for the flash sterilizer. He/she provided a policy titled, "Sterilization and Disinfection," revised 10/22/2009. The policy was reviewed and reflected, "...The efficacy of the sterilizing process will be monitored at regular intervals with reliable biological indicators...A biological and chemical indicator will be placed with instrumentation being sterilized."

3. BI log book records for the flash sterilizer for 01/02/2013 to 04/01/2013 were reviewed with I9 and I11, a RN (registered nurse). Review of the records identified they lacked documentation that BI monitoring was performed in accordance with hospital policy. The following were examples:

Review of the log book records reflected the flash sterilizer was used for three instrument loads on 01/11/2013 (Load #s 7377, 7378, and 7379), three instrument loads on 02/01/2013 (Load #s 7390, 7391, and 7392), two instrument loads on 02/08/2013 (Load #s 7396 and 7397), and four instrument loads on 03/11/2013 (Load #s 7415, 7416, 7417, and 7418). The records lacked documentation of BI monitoring for any of those loads.

5. During an interview with I9 on 04/05/2013 at 0930, he/she stated that hospital policy required BI monitoring for every instrument load for the flash sterilizer. He/she acknowledged the sterilizer records lacked documentation that BI monitoring was conducted in accordance with hospital policy.

B. Based on observation and policy review, it was determined the hospital failed to ensure its policies and systems for controlling and preventing infections were implemented. Hand hygiene practices in the operating room were not performed as required by hospital policy.

Findings include:

1. Review of the hospital policy titled, "Hand Hygiene," revised 07/09/2009 reflected "It is the policy of this facility that hand hygiene is regarded as the single most important means of preventing the spread of infections." The policy included the following internal requirements: "All personnel shall wash or disinfect their hands to prevent the spread of infection and disease to other patients, personnel, and visitors...Appropriate hand hygiene must be performed under the following conditions...Before and after contact with the patient or anything that the patient has had contact with...Before preparing or handling medications, clean or sterile supplies...The use of gloves does not replace hand washing...Wash or sanitize hands before and after glove use."

2. A surgical procedure was observed in OR #3 on 04/03/2013 at 1350. I9 was present during the observation. The patient required general endotracheal anesthesia for the procedure. At 1351 I14, a CRNA (certified registered nurse anesthetist), assisted with transferring the patient from a gurney to the operating room table. I14 placed his/her hands underneath the patient's back and lower body during the transfer. At approximately 1353, I14 touched a gas adjustment knob and a monitor screen attached to the anesthesia equipment. At 1355, I14 prepared an IV (intravenous) medication by drawing it up into a syringe, and administered the medication to the patient intravenously. No hand hygiene was performed between any of these tasks as required by hospital policy. At 1356, I14 donned (put on) gloves and administered two additional intravenous medications. No hand hygiene was performed prior to donning the gloves. From 1359 to 1401, I14 applied a mask to the patient's face, and touched the patient's face and mouth areas while inserting an endotracheal tube (a tube inserted through the mouth and into the trachea/windpipe). He/she then removed the gloves. He/she did not perform hand hygiene after removal of the gloves as required by hospital policy. At 1402, I14 donned a second pair of gloves and continued to touch the patient's face, mouth and endotracheal tube. He/she did not perform hand hygiene before donning the second pair of gloves or at any time during the observation.

3. These findings were reviewed with I9 on 04/03/2013 at 1420. He/she acknowledged there was a lack of hand hygiene during the surgical procedure.

C. Based on observation, interview and review of documentation, it was determined the hospital failed to ensure a system for controlling and preventing infections was fully developed and implemented, including a policy for cleaning hydrocollator equipment used for rehabilitation patients.

Findings include:

1. A tour of the hospital's Rehabilitation Department was conducted with I16, the Rehabilitation Program Director, on 04/03/2013 at 0930. During the tour, a hydrocollator heating unit (used for heating and storing reusable fabric/cloth hot packs) was observed. The inside of the unit contained 13 hot packs immersed in hot water. The water was cloudy and discolored.

2. During an interview with I16 on 04/03/2013 at 1000, he/she stated the hot packs contained in the hydrocollator were used multiple times each day during therapy treatments of rehabilitation patients. I16 stated that the hot packs were wrapped in a toweling material and applied over surgical incisions, soft tissue injuries, and other skin areas for pain management (such as back pain). He/she was asked for policies and procedures for cleaning the unit, and any documentation that cleaning had been performed. I16 stated, "We do not have a policy for that." He/she stated that the hydrocollator was cleaned on weekends, however he/she had no documentation that the cleaning had been done.

3. On 04/03/2013 at 1015, I16 provided a user manual for the hydrocollator titled, "Hydrocollator Heating Units, date stamped 04/21/2010. The manual contained manufacturer recommendations and instructions for cleaning the hydrocollator. Review of page 12 of the manual reflected that cloudy water in the unit may be caused by too long a period between cleanings. Review of page 19 and 20 of the manual reflected that the hydrocollator tank should be drained, cleaned and inspected at minimum intervals of every two weeks.

4. These findings were reviewed with I16 on 04/03/2013 at 1030. He/she acknowledged the lack of a developed and implemented policy for cleaning the hydrocollator unit.

D. Based on observation, interview, and policy review, it was determined the hospital failed to ensure a system for controlling and preventing infections, including development and implementation of a hospital policy that ensured safe and effective cleaning of surgical instrument carts.

Findings include:

1. Review of a policy titled, "Cleaning and Care of Operating Room Case Carts, Transfer Carts and Soiled Utensil Carts," revised 07/2012 identified the following internal requirements: "After the cart is emptied at the door of the decontamination room, it is pushed to the steam gun recess. Since this recess opens to the corridor, a cover gown must be worn...A polyethylene detergent tank holding 2 1/2 gallons mounted to the wall will be filled with water and one-half ounce of hospital approved detergent germicide."

2. A tour of the corridor on the basement level of the hospital was conducted with I12, the Central Processing Services Coordinator on 04/03/2012 at 1550. An open recessed area directly off the corridor was observed. A wall mounted steam (pressure) washer was observed within the recessed area.

3. During an interview with I12 on 04/03/2013 at 1550, he/she stated that the recessed cleaning area was for cleaning carts that were used to transport (contaminated) surgical instruments from the OR to the decontamination area. I12 stated the corridor adjacent to the cleaning area was used by patients to go to the MRI (magnetic resonance imaging) and mammography departments.

4. The process for cleaning an operating room cart was observed on 04/04/2013 at 1115. I18, a Central Processing Services/Certified Technician brought the cart to the recessed (cleaning) area. He/she used the wall mounted (pressure) steam system to clean the inside and outside of the cart. As the cart was being cleaned, steam filled the recessed (cleaning) area and entered the adjacent corridor. I18 did not wear a cover gown during the observation. Five individuals walked through the adjacent corridor and past the cleaning area while the cart was being cleaned. One individual stopped in the corridor just outside the cleaning area and observed part of the cleaning process. While the individual was observing, steam was visible and chemical fumes were noted in the corridor where the individual was standing. There was no ventilation system within the recessed (cleaning) area or immediate corridor. The area had no door, curtain or other mechanism for preventing steam and any potential airborne contaminants or fumes from entering the patient accessible corridor.

5. An interview was conducted with I18 on 04/04/2013 at 1125. I18 described the cleaning process for the carts. He/she stated that the wall mounted container in the cart cleaning area was filled with water and hepastat (a disinfectant), which was then used to steam clean the carts. He/she verified there was no ventilation system in the cleaning area.

6. An interview was conducted with I12 on 04/04/2013 at 1130. He/she was asked how much hepastat was placed in the wall mounted container to clean the instrument carts. He/she stated "a little squirt" and "It calls for 1/2 ounce, but I only use 1/4 ounce." I12 acknowledged that hospital policy required 1/2 ounce of disinfectant, but he/she only used 1/4 ounce because otherwise the chemical was too strong and caused his/her skin to break out in a rash. I12 was asked if a cover gown was worn while cleaning the carts. He/she stated, "We used to do that, but we don't anymore."

7. An interview was conducted with I9 on 04/05/2013 at 0850. He/she stated that an average of 4-6 surgical carts were steam cleaned daily, but at times there were as many as 10 carts cleaned in a day.

Hospital personnel did not wear a cover gown while cleaning the carts, and the dilution of disinfectant used during the cleaning process was not in accordance with hospital policy. Further, the hospital policy was not developed and implemented addressing provisions to ensure patients and personnel were protected from exposure to airborne contaminants and fumes emitted during the cleaning process.

8. These findings were reviewed with I9 and I13, the Technical Services Facilities Director on 04/05/2013 at 1105.


29709

Based on review of policies and procedures it was determined that the hospital failed to have a system in place to annually review all patient care policies by a professional group per this regulation.

Findings include:

1. During the CAH Validation survey, it was determined that many policies were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of hospital patient care policies that have not been reviewed for more than a year:

-Grand Ronde Hospital (GRH), Patient Care Services, "Blood and Body Fluids Post Exposure Plan," revised 12/2006;
-GRH, Point of Care, "Blood Glucose and Ketones, Measurement of," revised 11/17/2009;
-GRH, Surgical Services, "Cleaning and Processing Anesthesia Equipment," revised 10/22/2009;
-GRH, Rehab Therapy Services, "Cleaning Whirlpools, Sterile," revised 08/31/2011;
-GRH, Education, "CPR Certification," last revised 01/11/2011;
-GRH, Education, "Departmental Mandatory Educational Requirements," revised 01/11/2011;
-GRH, Patient Care Services, "Discharge: Transfers, Interhospital," revised 09/30/2010;
-GRH, Patient Care Services, "Emergency Contraception," revised 06/29/2010;
-GRH, Patient Care Services, "Multi-Drug Resistant Organism, Management of the Patient Infected or Colonized with," revised 08/31/2011;
-GRH, Patient Care Services-Materials Services, "Outdates: Checking Expiration or Pull Dates," revised 07/22/2010;
-GRH, Patient Care Services, "Patient Hand-Off: Caregiver to Caregiver Report," revised 02/2006;
-GRH, Health Information Management, "Patient Informed Consent," revised 07/2011;
-GRH, Patient Care Services, "Pharmacy: Automatic Stop Orders for Selected Medications," revised 08/25/2011;
-GRH, Patient Care Services "Pharmacy: Controlled Substances, Disposition and Control of," 08/26/2011;
-GRH, Patient Care Services - Pharmacy, "Pharmacy: Emergency Code Carts," revised 08/26/2011;
-GRH, Patient Care Services - Pharmacy, "Pharmacy: Medication Errors," revised 08/26/2011;
-GRH, Laboratory - Quality, "Reportable Diseases," revised 10/18/2010;
-GRH, Patient Care Services, "Restraint Management," revised 09/02/2010;
-GRH, Laboratory-Blood Bank, "Transfusion Reaction Workup," revised 11/03/2010;
-GRH, Laboratory - Blood Bank, "Transfusion Services Utilization Plan," undated; and
-GRH, Patient Care Services, "Stroke Team Activation," revised 09/13/2011.

Based on interview and policy review, it was determined that the hospital failed to develop and implement a policy ensuring transfer and discharge rights of Swing-bed patients, including the development of a transfer and discharge notice with all of the elements required by this regulation.

Findings include:

1. The hospital Swing-bed policy manual was reviewed. The policies lacked provisions for ensuring the required transfer and discharge notice was formulated and implemented for Swing-bed patients.

2. An interview was conducted with I8, the Medical/Surgical Manager on 04/04/2013 at 1615. I8 stated he/she was the coordinator for the Swing-bed program. He/she acknowledged that the hospital had not developed a transfer and discharge notice that included all of the required elements, or a policy with provisions ensuring the required transfer and discharge notice was provided to Swing-bed patients. He/she said the hospital had not admitted a Swing-bed patient for years, and therefore the Swing-bed policies had not been reviewed or updated since 2006. The Swing-bed policy manual contained a brochure titled, "Leaving the nursing facility," revised 09/2002. I8 stated the brochure was provided to Swing-bed patients prior to their discharge.

Review of the brochure above identified it lacked the following transfer and discharge notice requirements: The reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was to be transferred or discharged.

3. These findings were reviewed with I8 on 04/04/2013 at 1620. No further information was received.

Based on policy review, it was determined the hospital failed to fully develop a policy ensuring that individuals who had been found guilty of abuse, neglect or mistreatment of patients were not employed by the hospital as required.

Findings include:

1. Review of the policy titled, "Patient Abuse Prevention, Recognition and Reporting," revised 11/2005, reflected the following internal requirements: "...Screening: Criminal background checks are performed by the personnel department on all employees hired at the Grande Rounde Hospital. References are checked with previous employers and licenses are verified with the appropriate licensing board prior to the new employee providing patient care. Efforts are directed at uncovering information related to any past criminal prosecutions prior to hire." The policy failed to address provisions for ensuring individuals who had been found guilty of abuse, neglect or mistreatment of residents were not employed by the hospital.

2. An interview was conducted with I17, the Risk Manager on 04/04/2013 at 1405. I17 stated he/she checked with the Human Resources department manager who acknowledged that current hospital policies did not include provisions addressing the requirement that individuals who had been found guilty of abuse, neglect or mistreatment of residents were not employed.