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Based on record review, 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 4 of 4 patients reviewed (Patients #4, #5, #6, #7, #8).

This denies patients the right to obtain a formal opinion regarding the appropriateness of their discharge.

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:

Review of the records of 4 Medicare patients on 8/3/2011 revealed the following:

1. Patient #5 was a Medicare patient who was admitted on 6/15/2011 and discharged 6/18/2011. The patient's medical records included one copy of the "Important Message from Medicare" notice. The notice was not dated to indicate when the patient had received the notice.

2. Patient #6 was a Medicare patient who was admitted on 5/15/2011 and discharged on 5/19/2011. The patient's medical records included one copy of the "Important Message from Medicare" notice. The notice was not dated to indicate when the patient had received the notice.

3. Patient #7 was a Medicare patient who was admitted on 4/28/2011 and discharged on 5/4/2011. The patient's medical records included one copy of the "Important Message from Medicare" notice dated 4/28/2011. There was no evidence in the patient's record that the patient had received a second notice within 2 days of discharge.

4. Patient #8 was a Medicare patient who was admitted on 6/2/2011 and discharged on 6/8/2011. The patient's medical records included one copy of the "Important Message from Medicare" notice dated 6/6/2011. There was no evidence in the patient's record that the patient had received a notice within 2 days of admission.

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Based on observation and interview, the Critical Access Hospital failed to construct and maintain the physical plant in a manner that ensures the safety of patients, by:

a) Failing to provide appropriate backflow prevention at points of potential cross-contamination, and
b) Failing to organize a program to monitor air pressure relationships to ensure that they were consistent with Center for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health Care Facilities, 2003, Table B.2 .

Failure to provide appropriate backflow prevention risks contamination of the hospital potable water supply or clean surfaces by chemical or sewage backflow. Failure to monitor ventilation relationships consistent with CDC Table B.2, increases the risk of cross contamination, patient infection and compromises the quality of patient care.

Findings include:

a) During a tour of the hospital on 08/02/2011, it was observed that plumbing in the following locations did not meet appropriate cross-connection control standards:

i) Shower wands in patient rooms 204. 208 and 209, which reached to the floor of the shower but were not provided with atmospheric vacuum breakers, and
ii) A washing machine in the linen collection area, where mop heads, kitchen smocks and patient linens were laundered according to the hospital engineering manager.

b) In an interview on 08/03/2011, hospital engineering manager stated that there was no regular monitoring of air pressure relationships in the surgery department to ensure that the operating rooms had positive air pressure relative to the adjacent areas.

Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 08/04/2011.


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Item #1 - Patient Rights

Based on interview and review of the hospital's patient rights information, the hospital failed to develop a process for informing patient's of their rights according to State hospital regulations.

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

THIS IS A REPEAT VIOLATION - PREVIOUSLY CITED 2/11/2010

Reference: WAC 246-320-141: Hospitals must: (2) Provide each patient a written statement of patient rights from subsection (1) of this section;

Findings:

1. On 8/2/11 at 10:10 AM, an interview with the Chief Nursing Officer (Staff Member #1) revealed that all patients were given a handout to read entitled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient and outpatient care. Review of the contents of this form revealed it did not include all of the patient's rights identified in current hospital regulations.

The form did not inform patients that they had the right that they had the right to communication [WAC 246-320-141(1)(b)]; the right to be protected from neglect [WAC 246-320-141(1)(c)]; the right to complain about their care without fear of retribution or denial of care [WAC 246-320-141(1)(e)]; the right to timely complaint resolution [WAC 246-320-141(1)(f)]; the right to be informed of unanticipated outcomes of care [WAC 246-320-141(1)(h)]; the right to request no resuscitation or life-sustaining treatment [WAC 246-320-141(1)(l)]; the right to end of life care [WAC 246-320-141(1)(m)]; and the right to donate organs and other tissues according to RCW 68.50.500 and 68.50.560, including medical staff input and direction by family or surrogate decision makers [WAC 246-320-141(1)(n)]

2. On 8/2/2011 at 12:55 PM, an interview with the hospital's Chief Nursing Officer (Staff Member #1) and the Health Information Manager (Staff Member #2) revealed that the patient rights information handout had been revised in March 2010 to comply with current hospital regulations, but an old version of the patient rights information had been reprinted for distribution to patients.

This deficient practice was corrected during the survey.


Item #2 - Restraint Training for Physicians

Based on interview, and policy and procedure review, the hospital failed to specify training requirements for physicians who ordered restraints and seclusion and to document this training in accordance with State hospital regulations.

Failure to train healthcare providers to order and use restraints according to acceptable standards of practice risks physical and psychological harm, loss of dignity, and violation of patient rights.

References:

WAC 246-320-226(3)(f) - Hospitals must adopt, implement, review, and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with CFR 42.482.

42 CFR 482.13(f) Standard: Restraint or seclusion: Staff training requirements
(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.

THIS IS A REPEAT CITATION - PREVIOUSLY CITED 2/11/2010

Findings include:

1. The hospital's policy and procedure entitled, "Restraints" (Policy #NS-041; Reviewed 10/2010) under section "VIII. Staff Education", stated that education and competencies for application of restraints and seclusion would be completed by all RN staff with direct care responsibilities. The policy did not specify training requirements for physicians who ordered restraints and seclusion.

.2 On 8/4/2011, an interview with the hospital's Chief Nursing Officer (Staff Member #1) revealed that physicians had received informal training regarding the hospital's restraint policy and procedure, but this training had not been documented.

The hospital did not have a policy and a process for determining and documenting that physicians had a working knowledge of hospital's restraint and seclusion policy


Item #3 - Non-physician Surgical Assistant Privileges

Based on observation, review of policies and procedures, and interview, the Critical Access Hospital failed to adopt and implement policies and procedures for granting surgical privileges to non-physician surgical assistants who were not employees of the hospital in accordance with State hospital regulations (Dental Assistant #1).

Failure to verify the training and competency of surgical assistants risks unqualified and unsafe practitioners assisting with surgical procedures.

Reference: WAC 246-320-236: If providing surgical services, hospitals must: (1) Adopt and implement policies and procedures that: (c) Identify practitioner's privileges for operating room staff;

Findings:

1. On 8/3/2011 at 9:00 AM, Physician #3 was observed while performing dental surgery. Dental Assistant #1 was assisting the surgeon during the surgical procedure.

An interview at that time with a surgical department staff member (Staff Member #4) revealed that the dental assistant worked for the surgeon and was not a hospital staff member.

2. The hospital's policy and procedure entitled "Identification of Non-Staff Members to Treat, Assist, or Observe Patients in Surgery" (Policy #SUR-033; Revised 12/2007) delineated the categories of non-employees who were permitted to apply to be present in the operating rooms. The categories included support persons of C-Section patients, interpreters, nursing students, medical students, company representatives and guards for prisoners.

The categories did not include assistants to surgeons. The policy did not identify what evidence of training and competency the assistant was to provide in order to receive authorization to assist during surgery.

The hospital Chief Nursing Officer confirmed these findings

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Item #1 - Hand Hygiene

Based on observation, review of facility policies and procedures, and interview, the Critical Access Hospital failed to ensure that staff members performed hand hygiene according to facility policy and acceptable standards of practice for infection control for 3 staff members observed (Staff Members #5, #6, #7).

Failure to follow acceptable standards of practice for infection control risks transmission of communicable diseases to patients and staff members.

Reference: "Guidelines for Hand Hygiene in Health-Care Settings" (MMWR RR-16, October 2002; Centers for Disease Control and Prevention

Findings:

1. The hospitals policy and procedure entitled "Hand Hygiene" (Policy AP-47; Reviewed 6/2011) read as follows: "Policy/Procedure: II. Indications for Hand Hygiene: B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in clinical situations listed below. C. Decontaminate hands: before and after having direct contact with patients and their environment;... after contact with a patient's intact skin (i.e. when taking a pulse or blood pressure, and lifting a patient;... after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; after removing gloves."

2. On 8/2/2011 at 10:20 AM, while caring for Patient #2 in Room 207, Staff Member #5 touched the patient and equipment in his room, then did not decontaminate her hands prior to leaving the patient's room.

3. On 8/3/2011 at 8:25 AM, while preparing Patient #3 for surgery, Staff Member #6 touched the patient's body, then did not decontaminate her hands prior to leaving the patient's room. At 8:26 AM, Staff Member #6 administered medication to the patient, then touched the patient's body, then did not decontaminate her hands prior to leaving the patient's room.

4. On 8/3/2011 at 1:20 PM, while caring for a patient with methicillin-resistant staphylococcus aureus in the Emergency Department, Staff Member #7 exited the patient's room (Exam Room #4), removed her gloves, then did not decontaminate her hands prior to touching items around the Emergency Department nurses's station.

5. An interview with the hospital's Infection Control Coordinator (Staff Member #8) confirmed that the staff members above did not decontaminate their hands according to hospital policy and procedure and acceptable standards of practice.



Item #2 - Transmission Precautions

Based on observation, review of facility policies and procedures, and interview, the Critical Access Hospital failed to ensure that staff members implemented barrier and transmission precautions according to facility policy and acceptable standards of practice for infection control for 1 patient observed (Patient #4).

Failure to implement isolation policy and procedures consistent with acceptable standards of practice risks transmission of multidrug-resistant organism infections between patients and staff.

Reference: CDC guidelines Management of Multidrug-Resistant Organisms (MDRO) in Healthcare Settings, 2006.

"V.A.5.c.i. In acute-care hospitals, implement Contact Precautions routinely for all patients infected with target MDRO's and for patients that have been previously identified as being colonized with target MDRO (e.g., patients transferred from other units or facilities who are known to be colonized)."

Findings:

1. The hospital's policy and procedure entitled "Resistant Microorganism Guidelines for Infection Control" (Policy AP-062; Reviewed 6/2011) stated that patients known to be infected or colonized with methicillin-resistant staphylococcus aureus were to be placed in contact isolation precautions. These precautions included wearing gloves upon entering the room to avoid self-contamination, washing hands between change of gloves while in the room, and removing gloves prior to leaving the room. Gowns were to be worn upon entering the room when patient contact was anticipated. The patient was to remain in isolation throughout their hospital stay. Isolation was to be discontinued only after consultation with Infection Control or the Medical Staff Liaison for Infection Control.

2. On 8/3/2011 at 1:20 PM, Staff Member #7 was observed while caring for Patient #4, who had been coming to the hospital daily since 6/15/2011 for infusion of antibiotics for treatment of methicillin-resistant staphylococcus aureus (MRSA) in his hip. Staff Member #7 did not implement contact precautions while caring for Patient #4. Staff Member #7 did not wear a gown while caring for Patient #4. Staff Member #7 exited the patient's room (Exam Room #4), removed her gloves, then did not decontaminate her hands prior to touching items around the Emergency Department nurses's station.

At the time of the observation, Staff Member #7 stated that contact precautions were not necessary when caring for Patient #4.

3. During an interview on 8/3/2011 at 2:45 PM, the hospital's Infection Control Coordinator (Staff Member #8 confirmed that Staff Member #7 did not follow hospital policy when caring for a patient with MRSA.

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Based on interview and personnel file review, the Critical Access Hospital failed to annually assess the competence of nursing staff responsible for administration of medications for procedural ("conscious" or "moderate") sedation according to accepted standards of practice for 3 of 4 registered nurses reviewed (Staff Members #7, #9, #10).

Failure to annually assess the competence of staff when performing procedural sedation risks improper treatment and adverse patient outcomes.

Findings:

The Washington State Nursing Commission policy statement entitled "Policy Statement for Registered Nurses Performing Procedural Sedation (January 14, 2000)" reads as follows:

"To ensure that nurses assisting in procedural sedation receive appropriate and continuous training and support, the Nursing Care Quality Assurance Commission recommends that all providers and institutions using nurses in procedural sedation should have in place written policies and procedures that contain, at a minimum, the following elements:...4) Specific yearly evaluation and continuing competency requirements."

An interview with the nurse executive on 08/04/2011 revealed that nurses who worked in the Emergency Department and Acute Care unit administered procedural sedation and monitored patients under procedural sedation.

Review of human resource records on 08/04/2011 found no evidence that 3 of 4 registered nurses working in the Emergency Department or Acute Care unit had been evaluated for competency in administration and monitoring of procedural sedation. The nurses were Staff Members #7, #9, and #10.

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Based on record review, review of facility policies and procedures, and interview, the Critical Access Hospital failed to ensure that patients and/or guardians were either given a surgical consent form to read and sign that was in a language they understood; or that the contents of the form was translated verbally; for 1 of 1 patient reviewed (Patient #1).

Requiring patients or their guardian to sign a consent form that is written in a language they do not understand does not constitute informed consent.

Reference: RCW 70.050 Informed Consent
(1) If a patient while legally competent, or his or her representative if he or she is not competent, signs a consent form which sets forth the following, the signed consent form shall constitute prima facie evidence that the patient gave his or her informed consent to the treatment administered and the patient has the burden of rebutting this by a preponderance of the evidence:(a) A description, in language the patient could reasonably be expected to understand, of:
(i) The nature and character of the proposed treatment;(ii) The anticipated results of the proposed treatment;(iii) The recognized possible alternative forms of treatment; and(iv) The recognized serious possible risks, complications, and anticipated benefits involved in the treatment and in the recognized possible alternative forms of treatment, including nontreatment;

Findings:

1. Patient #1 was a 4 year, 6 month old patient who was admitted on 7/31/2011 for treatment of appendicitis. The patient underwent an appendectomy on 8/1/2011. The patient's parents did not speak English. Communication with the parents required Spanish-speaking healthcare providers or the hospital's certified translator.

The patient's record included a form entitled "Special Consent to Operation, Post-Operative Care: Medical Treatment, Anesthesia, or Other Procedure". The consent form was written in English and had been signed by the surgeon (Physician #1) and the patient's mother.

2. During an interview via the hospital's translator (Staff Member #3) on 8/2/2011 at 1:50 PM, the patient's parents stated that the surgeon had explained the surgical procedure to the parents prior to surgery. The parents stated they were then asked to sign the form without contents of the form being translated for them into Spanish.

3. An interview on 8/3/2011 with a surgical department staff member (Staff Member #4) revealed that surgical consent forms were available to physicians both in English and Spanish. During the interview, the staff member stated that two of the surgeons on staff (Physician #1 and #2) routinely used English surgical consent forms instead of Spanish consent forms. .

4. The hospital's policy and procedure entitled "Guidelines for Medical Records Documentation" (Policy #HIM003; Reviewed 12/2010) read as follows: General Information. (13) Evidence of properly executed informed consent for procedures and treatments specified by Medical Staff policy, or by Federal or State law, if applicable, shall be documented in the medical record.

Informed consent had not been documented in the patient's record according to facility policy and procedure and State law.

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