HospitalInspections.org

.
Based on interview and review of patient rights information, the Critical Access Hospital failed to provide written notice to observation patients, inpatients, and swing bed patients that a doctor of medicine (MD) or doctor of osteopathy (DO) was not present in the hospital twenty-four hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. On 02/07/18 at 9:25 AM, Surveyor #7 interviewed a registered nurse working in the hospital's emergency department (ED) (Staff #701). During the interview, the nurse stated that an MD or DO was not on site twenty-four hours per day, seven days per week to care for patients. The nurse showed Surveyor #7 signs that had been posted in the ED to provide this information to ED patients.

2. On 02/07/18 at 11:15 AM, Surveyor #7 interviewed the hospital's Chief Nursing Officer (CNO) (Staff #702). During the interview, the CNO stated all patients admitted for observation, inpatient, or swing bed services are given a packet containing patient rights and privacy practices information. Review of the packet revealed it did not include information for patients that an MD or DO was not on site twenty-four hours per day, seven days per week. During the interview, the CNO confirmed that the hospital did not have a process to inform observation patients, inpatients, and swing bed patients.
.

.
Based on observation and interview, the Critical Access Hospital failed to store food under the appropriate conditions to ensure compliance with the 2009 Food and Drug Administration (FDA) Food Code.

Failure to provide temperature measuring devices to ensure proper food storage temperatures, places patients and staff at risk of foodborne illness.

Findings included:

1. On 02/07/18 at 1:00 PM Surveyor #1 observed that the small black refrigerator in the medication room did not have a thermometer to ensure foods were stored at the required temperature of 41 degrees or below. Surveyor #1 interviewed a registered nurse (Staff #102) regarding whose food is stored in the refrigerator. The registered nurse stated foods were mostly from staff but some were used to help patients swallow their medications. Foods stored in refrigeration used for patients require temperature measuring devices.

Reference: Temperature measuring devices (2009 FDA Food Code 4-204.112).
.

.
Based on interview and review of the hospital's quality plan, quality improvement program, and performance data, and 2016 state licensing survey report, the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements and responsibilities impaired the hospital's ability to provide quality care in a safe environment.

Reference: CFR 485.627(a) "The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment."

Findings included:

The Governing Body failed to ensure the hospital developed and implemented a effective quality assurance program for investigating and analyzing serious patient outcomes, and for developing and implementing action plans to minimize patient risk.

Due to the scope and severity of deficiencies detailed under the Conditions of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring, the Condition of Participation for Organizational Structure was NOT MET.

Cross-reference: Tag C0330
.

.
Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement policies and procedures for patient identification, as demonstrated by 3 of 5 patients observed (Patient #701, #702, #703).

Failure to systematically identify patients prior to administering care risks providing medications and other care to the wrong patient, which could result in patient harm.

Reference: WAC 246-320-226 - Hospitals must:
(3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address:
(b) Reliable method for personal identification of each patient;

Findings included:

1. On 02/06/18 at 12:50 PM, Surveyor #7 observed that four of five long-term care ("swing bed") patients currently receiving care in the hospital did not have identification bands (Patients #701, #703, #704, #705)

2. On 02/06/18 at 1:10 PM, Surveyor #7 interviewed the hospital's Chief Nursing Officer (CNO) Staff #702). During the interview, the CNO stated swing bed patients were identified using photographs which were kept with their medication administration record.

3. At the time of the interview, the CNO showed Surveyor #7 a binder containing the medication administration records. The binder did not contain photographs for Patients #701, #702, and #703.

4. The CNO stated that there was no written policy or procedure for identification of swing bed patients prior to medication administration or treatments.
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure policies and procedures for clinical care of patients were developed and reviewed annually by a professional group that included one or more physicians and one or more physician's assistants on the hospital's staff.

Failure to review and update hospital policies risk medical errors and patient harm.

Reference: 42 CFR 485635(a) - "The policies include the following:

(3)(iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.

(3)(iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

(3)(v) Procedures for reporting adverse drug reactions and errors in the administration of drugs.

(3)(vi) A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

(3)(vii) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of §483.25(i) of this chapter is met with respect to inpatients receiving post-hospital SNF [skilled nursing facility] care."

Findings included:

1. The hospital's policy and procedure titled "Policy Management" (Policy #4547911; Revised 09/13) showed that all clinical hospital polices and procedures would be developed and reviewed annually by the appropriate hospital department manager, the medical staff, and the Chief Executive Officer.

2. On 02/07/18 at 8:40 AM, Surveyor #7 interviewed the hospital's Chief Operations Officer (COO) (Staff #703) regarding the process for development and review of hospital policies and procedures. The COO stated the hospital used an electronic routing and tracking system ("PolicyStat").

3. At the time of the interview, review of the system's "Manage Approval Workflows" revealed that hospital policies for pharmacy services, dietary services, radiology services, and the infection control program were not routed to a physician and at least one physician's assistant for input and approval as required by the regulation.
.

.
ITEM #1 - COMPOUNDED INTRAVENOUS FLUIDS

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop policies and procedures for safe preparation of intravenous (IV) medications and fluids, and to ensure staff who prepared IV fluids were trained and competent.

Failure to comply with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.

Reference: United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016)

Findings included:

On 02/08/18 at 8:50 AM, Surveyor #7 interviewed the hospital's Director of Pharmacy (Staff Member #709) regarding pharmacy services at the hospital. During the interview, the director stated that a pharmacist was not on site at all times, and that IV medications were prepared by nursing staff members for "immediate use" (administered to patients within one hour of preparation). The interview revealed that there were no policies and procedures to direct staff on how to prepare IV according to USP 797 safe compounding standards, and no process for training nursing staff members and assessing competency in IV preparation and administration.


ITEM #2 - CONTROLLED SUBSTANCE ACCOUNTABILITY

Based on observation, interview, and record review, the Critical Access Hospital failed to implement policies and procedures to inventory and track controlled substances.

Failure to closely monitor use of controlled substances risks diversion, tampering, and/or unauthorized use, which can endanger staff and patients.

Findings included:

1. On 02/06/18 at 10:55 AM, Surveyor #7 interviewed a licensed practical nurse (LPN) (Staff #710) and asked how controlled substances stored in the hospital's automated drug dispensing device were controlled and tracked. The LPN stated that two staff nurses counted the drugs at the change of each shift and recorded the results in a log book located at the nurses station.

2. Review of the log book revealed that the log had areas for the signature of the nurse going off duty and the nurse coming on duty and for the nurses to check "yes" or "no" to indicate if the controlled substance count was correct. Review of the log for shift counts dated 12/04/17 to 02/06/18 revealed the following:

a. The log did not have two signatures for 14 of 126 shifts reviewed.

b. The log had no notation that the count was correct or incorrect on 21 of 126 shifts reviewed.

c. The log indicated the count was incorrect on 3 of 126 shifts reviewed with no notation of the actions taken to resolve the discrepancies.

3. On 02/08/18 at 9:00 AM, Surveyor #7 interviewed the hospital's Director of Pharmacy (Staff Member #709) regarding the documentation findings in the controlled substances log book. During the interview, the director confirmed that the documentation indicated the controlled substances had not been accurately inventoried and tracked.

4. The hospital's policy and procedure developed by the hospital's contracted pharmacy service titled "Controlled Substances Management on Patient Care Units" (Policy #3230113; Approved 01/17) stated that controlled substances would be counted "according to the controlled substance policy of the remote hospital site." The hospital did not have its' own policy and procedure for inventorying and tracking controlled substances.
.

.
ITEM #1 PATIENT CARE EQUIPMENT

Based on observation, interview, and document review, the Critical Access Hospital failed to provide patient care equipment that could be disinfected.

Failure to provide equipment that can be disinfected places patients and staff at risk of infections.

Reference: "One Touch Ultra 2 User Guide", Page 23: "Cleaning your meter" wipe with soft cloth dampened with water and mild detergent. Do not use alcohol or another solvent to clean your meter."

Findings included:

1. The Critical Access Hospital's Policy titled, "One Touch Blood Glucose" Policy ID 1373749 (Last Reviewed 1/17) stated, "Clean the one touch meter with an alcohol pad." This policy was inconsistent with the manufacturer's directions for use.

2. On 02/07/18 at 2:00 PM, Surveyor #1 interviewed a Registered Nurse (RN) (Staff #102) regarding the process for disinfecting the hospital's blood glucose meter. The RN stated she disinfects the meter after each patient use using a sanitizer wipe. Review of the meter manufacturer's directions for use revealed this meter could not be disinfected with alcohol or another solvent. Because of this, the meter should not have been used for multiple patients.

ITEM #2 WATER MANAGEMENT PLAN

Based on observation, interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide 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, 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: Conduct a risk assessment to identify of growth of waterborne pathogens; Implement ASHRAE or CDC tool kit to include control measures; and 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.

Reference: Manitowoc Ice Machine Operations Manual on page 2-16 specifies installing ice machine with an open trapped and vented drain/ air gap.

Findings included:

1. On 02/07/18 between the hours of 9:00 AM and 11:30 AM, during a tour of the hospital with the hospital's plant manager (Staff #101), Surveyor #1 identified areas that were at risk of growing waterborne pathogens. The surveyor observed the following: Shower heads with hoses not hung properly to allow for drainage; and an ice machine not sloped to drain to prevent water from stagnating in the drain line.

2. Review of the water management plan showed that the hospital's waterborne pathogen risk assessment had identified water stagnation risks for showers and ice machines. The plan did not provide direction to staff for mitigation of these risks, including hanging shower hoses to drain after use and installation of ice machines according to the manufacturer's specifications. The water management plan must implement a standard of practice from a national organization such as CDC or ASHRAE to reduce Legionella and other waterborne pathogens.

3. The hospital's plant manager showed documentation of chlorine residual provided by the city water treatment facility but confirmed that they had not identified testing protocols and acceptable ranges for control measures or corrective actions to take when control limits are not maintained.
.

.
Based on observation and interview the facility failed to provide signage identifying hazardous radiation areas.

Failure to provide signage identifying hazardous radiation areas places patients, staff and visitors at risk of potential radiation exposure.

Reference: 42 CFR 485.635(b)(3) Clear signage identifying hazardous radiation areas;

Findings included:

1. On 02/06/18 at 1:00 PM, Surveyor #1 observed that the entry doors to the imaging department did not have radiation safety signage. During an interview with the manager of the imaging department (Staff #101) at the time of observation the manager stated the facility had not ordered the radiation safety signage for the entry doors of the imaging department.
.

.
Based on interview and review of personnel records, the Critical Access Hospital failed to develop a systematic process for orienting and evaluating nursing personnel hired through temporary worker staffing agencies, as demonstrated by 2 of 4 nurses reviewed (Staff #704, #707).

Failure to orient nursing care staff to the hospital and their job responsibilities and to evaluate their job performance risks inappropriate, ineffective patient care and poor patient care outcomes.

Findings included:

1. On 02/07/18 at 10:00 AM, Surveyor #7 interviewed the Chief Nursing Officer (CNO) (Staff #702). During the interview, the CNO stated that the hospital had hired four registered nurses through temporary worker staffing agencies to work in the hospital's inpatient unit (Staff #704, #705, #706, #707)..

2. During the interview, Surveyor #7 reviewed the personnel files of two of the nurses (Staff #704, #707). The files did not contain evidence that the nurses had been oriented to the hospital and their job responsibilities. The COO confirmed that the hospital did not have a systematic process for orienting and evaluating nurses hired through temporary worker staffing agencies.
.

.
Based on interview and record review, the Critical Access Hospital failed to ensure that nursing staff members developed an individualized plan of care for all inpatients, as demonstrated by 3 of 3 inpatient records reviewed (Patients #706, #707, #708)

Failure to develop an individualized plan of care risks inappropriate, inconsistent, and delayed treatment.

Findings included:

1. On 02/07/18 at 2:15 PM, Surveyor #7 reviewed the records of three inpatients who received care at the hospital between 12/18/17 and 01/26/18 (Patients #706, #707, #708). The review revealed that the records did not include plans for nursing care provided to the patients.

2. During an interview with Surveyor #7 at the time of the record review, the hospital's Chief Nursing Officer (CNO) (Staff #702) confirmed the records did not include nursing care plans and stated that the hospital did not currently have a policy and procedure for ensuring nursing care plans were developed for all inpatients.
.

.
Based on interview and record review, the Critical Access Hospital failed to ensure that the medical records of outpatients who received blood and other treatments at the hospital included a pertinent medical history and assessment of the patient's health status and health care needs when admitted for care, as demonstrated by 2 of 2 outpatient records reviewed (Patients #709, #710).

Failure to perform a complete admission assessment for all patients treated at the hospital risks adverse events during care and poor patient outcomes.

Findings included:

1. On 02/07/18 at 4:15 PM, Surveyor #7 reviewed of the records of two outpatients who received blood transfusions at the hospital between 01/17/18 and 01/31/18 (Patients #709, #710). The review revealed that the records did not include information regarding the patient's medical history, health status, and health care needs.

2. During an interview with Surveyor #7 at the time of the record review, the hospital's Chief Nursing Officer (CNO) (Staff #702) confirmed the records did not include this information and stated that the hospital did not currently have a policy and procedure for ensuring this information was obtained from outpatients prior to receiving care at the hospital.
.

.
Based on interview, record review, and review of hospital policies and procedures the Critical Access Hospital failed to ensure staff members followed its policy and procedure for restraining patients, as demonstrated by 2 of 4 patient records reviewed (Patients #711, #712).

Failure to follow established policies and procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. The hospital's policy and procedure entitled "Restraints Use" (Policy #1289033; Revised 01/17) stated that a health care provider would write an order for restraints on a Patient Restraint Order Form. The order would include the date of the order, the start and stop time, the reason for restraint use, and type of restraint to be used.

2. On 02/07/18 at 3:00 PM, Surveyor #7 reviewed the records of four patients seen in the hospital's emergency department between 02/04/17 and 11/06/17 who required use of physical restraints for protection of the patient and staff. The review revealed that the records for Patients #711 and #712 did not include an order from a health care provider authorizing restraint use.

3. During an interview with Surveyor #7 at the time of the record review, the hospital's Chief Nursing Officer (CNO) (Staff #702) confirmed the records did not include orders for restraint use and that the hospital's restraint policy and procedure had not been followed.
.

.
Based on interview and review of the hospital's quality plan, quality improvement program and performance data, and 2016 state licensing survey report, the Critical Access Hospital failed to develop and implement an effective quality assurance program for investigating and analyzing serious patient outcomes, and for developing and implementing action plans to minimize patient risk.

Failure to develop and implement an effective quality assurance program limited the hospital's ability to provide quality care in a safe environment.

Reference: 485.641(b) "The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes."

Findings:

1. The hospital failed ensure that data regarding patient falls and medication errors were aggregated and analyzed for common factors through the hospital's quality program.

2. The hospital failed to ensure that data regarding medication therapy were reported to and analyzed through the hospital's quality program.

3. The hospital failed to develop action plans to improve patient care services, as demonstrated by three quality indicators reviewed.

4. The hospital failed to implement and monitor action plans developed in 2016 to correct deficiencies cited during a state licensing survey.

Due to the scope and severity of these deficiencies, the Condition was NOT MET

Cross Reference: Tags C0336, C0338, C0342
.

.
Based on interview and review of the hospital's quality improvement program and performance data, the Critical Access Hospital failed to ensure that data regarding patient falls and medication errors were aggregated and analyzed for common factors through the hospital's quality program.

Failure to systematically collect, aggregate, and analyze data regarding patient injuries limits the hospital's ability to develop action plans to prevent future injuries.

Findings included:

1. On 02/18/18 at 11:30 AM, Surveyor #7 interviewed the hospital's Quality Improvement Coordinator (Staff #702) and reviewed the hospital's quality program and performance data. The review included data regarding patient falls and medication errors. The interview and data review revealed that these events were analyzed individually. Data were not aggregated and analyzed for patterns, trends, and common factors between events to determine if care delivery system changes were required to prevent future occurrences.
.

.
Based on interview and review of the hospital's quality improvement program and performance data, the Critical Access Hospital failed to ensure that data regarding medication therapy were reported to and analyzed through the hospital's quality program.

Failure to systematically collect and analyze data regarding medication use limits the hospital's ability to improve patient care outcomes.

Findings included:

On 02/18/18 at 11:30 AM, Surveyor #7 interviewed the hospital's Quality Improvement Coordinator (Staff #702) and reviewed the hospital's quality program and performance data. The interview and data review revealed that data regarding medication therapy was not collected and analyzed through the hospital's quality program. The coordinator stated that this process was "under development".
.

.
ITEM #1 - IMPLEMENTATION OF ACTION PLANS TO IMPROVE HOSPITAL PERFORMANCE

Based on interview and review of the hospital's quality program and performance data, the Critical Access Hospital failed to develop action plans to improve patient care services, as demonstrated by three quality indicators reviewed.

Failure to develop, implement, track, and evaluate action plans and to revise those plans as needed limits the hospital's ability to improve patient outcomes.

Findings included:

1. The hospital's policy titled "Quality Improvement Plan" (Policy #4478682; Approved 01/18) stated that the hospital's quality program activities would include developing and monitoring action plans when departmental and service-related performance goals were not achieved.

2. On 02/18/18 at 11:30 AM, Surveyor #7 interviewed the hospital's Quality Improvement Coordinator (Staff #702) and reviewed the hospital's quality program and performance data. The interview and data review revealed that the hospital had not developed action plans when two emergency department indicators and one medical staff quality indicator had not met performance goals. The coordinator stated that the hospital did not have any active performance improvement projects.


ITEM #2 - IMPLEMENTATION OF ACTION PLANS TO CORRECT DEFICIENT PRACTICE

Based on interview and review of the hospital's 2016 state licensing survey report and quality improvement program and performance data, the Critical Access Hospital failed to implement and monitor action plans developed in 2016 to correct deficiencies cited during a state licensing survey.

Failure to systematically identify problems, implement corrective action plans, and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings included:

1. During the hospital's state licensing inspection in November 2016, the hospital was cited for deficient practice for failure to develop, implement, track, and evaluate performance improvement action plans for two emergency department quality indicators; and failure to ensure that data regarding patient mortality and medication use were reported to the hospital's quality committee. The hospital developed and submitted an action plan for correction of this deficiency to the Department of Health. The plan stated the deficiencies would be corrected by 01/16/17.

2. The hospital's policy titled "Quality Improvement Plan" (Policy #4478682; Approved 01/18) stated that the hospital's quality program activities would include developing and monitoring action plans for correction of state-cited deficiencies.

3. On 02/18/18 at 11:30 AM, Surveyor #7 interviewed the hospital's Quality Improvement Coordinator (Staff #702) and reviewed the hospital's quality program and performance data. The interview and data review revealed that deficiencies regarding the hospital's program cited in November 2016 had not been corrected.

Cross Reference: C0338; C0342, Item #1
.

.
Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to notify long-term care ("swing bed") patients in writing of an impending transfer or discharge in accordance with 42 CFR 483 Subpart B Requirements for Long Term Care Facilities.

Failure to notify swing bed patients of the reason for transfer or discharge, the effective date, the location to which the resident is being transferred or discharged, and information regarding the appeal process risks violation of the patient's rights as long-term care residents.

Reference: 483.12(a)(6) "Contents of the notice. The written notice specified in paragraph (a)(4) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement that the resident has the right to appeal the action to the State;
(v) The name, address and telephone number of the State long term care ombudsman;"

Findings included:

1. The hospital's policy and procedure titled "Swing Bed Program" (Policy #3906956; Approved 08/17) stated that the hospital would have policies regarding the rights of all swing bed patients, and that each patient or the patient's family would be provided with a copy of these rights at the time of admission.

2. On 02/05/18 at 12:55 PM, Surveyor #7 reviewed a copy of the hospital's list of resident rights. The list of rights informed swing bed patients that they would be notified in writing before they were transferred to another facility or discharged.

3. On 02/07/18 at 4:00 PM, Surveyor #7 reviewed the records of three swing bed patients who were discharged from the hospital between 11/08/17 and 12/08/17. The records did not include evidence that the patient's had been informed in writing of their discharge and the process for appealing their discharge to the State long-term care ombudsman.

4. During an interview with Surveyor #7 at the time of the record review, the hospital's Chief Nursing Officer (CNO) (Staff #702) confirmed the records did not include this information.
.

.
Based on interview and record review, the Critical Access Hospital failed to provide social services under the supervision of a qualified social worker for 5 of 5 long-term care patients reviewed (Patients #701, #702, #703, #704, #705).

Failure to develop and implement a social services program supervised by a qualified social worker risks not meeting the patient's psychosocial needs.

Findings included:

On 02/06/18 at 9:40 AM, Surveyor #7 interviewed the hospital's Chief Nursing Officer (CNO) (Staff #702) regarding how social services were provided to the hospital's long-term care ("swing-bed") patients, including five swing bed patients currently receiving care at the hospital (Patients #701, #702, #703, #704, #705). The CNO stated that social services were provided by a nursing assistant (Staff #708) who did not have a bachelor's degree in social work or other human services-related field. The hospital did not have a qualified social worker on staff.
.

.
Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed a care plan for each long-term care ("swing bed") patient that included individualized interventions and timetables for meeting treatment goals, as demonstrated by 5 of 5 swing bed patients reviewed (Patients #701, #702, 703, #704, #705).

Failure to develop and implement a comprehensive plan for care that includes measurable objectives, interventions, and timetables for meeting treatment goals risks deterioration of the patient's condition and health status.

Findings included:

1. The hospital's policy and procedure titled "Swing Bed Care Plans and Care Conference" (Policy #1016787; Revised 01/17) showed that nursing staff members would develop an individualized plan of care for each swing bed resident within fourteen days of admission. The plan would include problems, interventions, goals, and discharge plans.

2. On 02/16/18 between 2:55 PM and 4:20 PM, Surveyor #7 reviewed the records of five long-term care ("swing bed") patients currently receiving care in the hospital (Patients #701, #702, 703, #704, #705). The record review revealed that each care plan included the directive to "Follow safe swallowing guidelines". The plans had not been individualized for each patient to state what those guidelines were. The nursing plans for care did not include timetables for meeting treatment goals.

3. During an interview with Surveyor #7 at the time of the record review, the hospital's Chief Nursing Officer (Staff #702) confirmed the findings above.
.

.
Based on document review and interviews with administration and maintenance staff, the facility has failed to provide a written policy for alternate power sources.

Failure to provide written policy for alternate power sources places patients, staff and vistiors at risk of injury and/or death.

Findings included:

On 02/14/2018 between the hours of 10:30 AM and 1045 AM during document review, the fire marshal revealed that there is not an established policy to have the generator maintained for the following:

1. Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
2. Emergency lighting.
3. Fire detection, extinguishing, and alarm systems.

The above was discussed and acknowledged by the facility staff.

.
Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures to ensure that patient records are 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 02/07/18 between the hours of 9:00 AM and 10:00 AM, Surveyor #1 interviewed the hospital's emergency preparedness safety officer (Staff #103) regarding the communication plan during emergencies. The surveyor asked how the hospital would ensure the preservation of patient information and have it readily available in the event of an emergency. The hospital's emergency preparedness safety officer stated that the hospital did not have a process for securing and having patient information readily available in an emergency event.
.

.
Based on interview and record review, the Critical Access Hospital failed to provide initial emergency preparedness training to all new and existing staff.

Failure to train staff on how to respond during emergencies places patients and staff at risk of injury and/or death in the event of a man-made and/or natural disaster.

Findings included:

1. On 02/07/18, Surveyor #1 reviewed the hospital's emergency preparedness plan titled, "EARH Emergency/Disaster Response Plan" (Policy number 4487293; Reviewed 01/18.) The plan did not address training requirements for the following key players identified in the plan: Chief Executive Officer (CEO), Chief Operations Officer (COO), Chief Nursing Officer (CNO), Charge Nurse (CN), Department Managers/Supervisors and Medical Chief of Staff (COS).

2. On 01/24/18 at 9:00 AM, Surveyor #1 interviewed the facility's emergency preparedness safety officer (Staff #103) regarding the process for training staff in emergency preparedness. The emergency preparedness coordinator stated that all staff receives emergency preparedness training as part of their orientation. The emergency preparedness coordinator was unable to show documentation of training for key players identified in the "EARH Emergency/Disaster Response Plan".

.
Based upon record review, observation and interview the Critical Access Hospital failed to meet the generator requirements of Emergency Preparedness. The facility has failed to maintain and test the emergency generator in accordance with NFPA 110.

Failure to test the generator could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff and/or visitors within the facility.

Findings included:

On February 14, 2018 at 1045 AM the fire marshal through interview, record review and observation with the hospital's plant manager (Staff#101) revealed that the hospital failed to maintain and test the emergency generator in accordance with NFPA 110. Annual fuel quality testing was not completed.

The above was discussed and acknowledged by hospital's plant manager..
.