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Based on review of medical staff credentialing records, the hospital failed to ensure that all members of the medical staff were legally qualified for membership, by failing to maintain updated records of medical staff licensure and Drug Enforcement Agency certification.

Failure to ensure current legal qualifications for membership on the medical staff risks provision of patient care by unqualified personnel.

Findings include:

During review of medical staff credentialing records on 02/16/11, it was found that 4 of 9 members did not have evidence of current state licensure (MD 1, 2, 3, 4) and 2 of 9 members did not have evidence of current DEA registration (MD 3 and 4).

Based on medical staff record review and administrative interview, the critical access hospital failed to implement its agreement with the Rural Health Quality Network with respect to credentialing of medical staff for 1 of 9 medical staff members reviewed (MD #6).

Failure to implement the agreement with respect to credentialing of medical staff risks appointment of unqualified members to the Critical Access Hospital medical staff.

Findings include:

During review of medical staff credentialing records on 02/16/11, it was found that the medical staff included a general surgeon (MD #6) who was recently appointed to the medical staff. In an interview on the same date, the critical access hospital administrator acknowledged that no other general surgeons were on the medical staff to assist with review of MD #6's qualifications. The critical access hospital had not used the resources of the Rural Health Quality Network for the credentialing of MD #6.

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Based on observation, record review and staff interviews, the Critical Access Hospital failed to provide a safe and secure environment for the provision of patient care.

Findings:

The critical access hospital failed to assure patients were protected from fire hazards and failed to provide adequate routes of emergency egress from the hospital (see Tag C0231 and associated Life Safety Code survey).

The hospital had designated an emergency exit from the west end of the basement of the old building that was not properly signed, and was exposed to the hazards of the boiler room, high hazard storage areas and obstructions in the route of egress.

Additional life safety code violations included placement of propane fuel next to the windows of the emergency egress stairwell, failure to ensure that the essential electrical system was installed and tested to the requirements of the Code, failure to document that the approved, automatic sprinkler system was properly commissioned, failure to update the hospital fire plan and train hospital personnel in evacuation methods, failure to conduct fire drills in the hospital, failure to ensure separation of occupancies on the hospital campus, failure to maintain other exits in an operable condition, storage of combustibles in the egress corridors, storage of excessive quantities of oxygen exposed to an egress corridor, failure to seal vertical penetrations, failure to maintain emergency lighting in the surgery suite, and failure to maintain fire extinguishers in accessible and operable condition. Other violations of the Code were also observed and cited on the attached Life Safety Code survey.

These additional violations of the Code exacerbated the exit situation by creating an increased risk of fire, and decreased protection from sprinkler systems and emergency electrical systems.

There were 8 patients in the hospital at the time the survey began at noon on 02/14/11. Five of the patients were Swing Bed patients (Skilled Nursing Care level) and one was an infant.

These findings are described in detail on the accompanying Life Safety Code survey.

Failure to maintain an environment that meets the requirements of the Life Safety Code creates a risk of serious injury or death for patients, staff and visitors in the hospital, and impairs the hospital's ability to provide quality care in a safe environment.

BECAUSE OF THE SEVERITY OF THE DEFICIENCIES, CONSULTATION WAS HELD WITH OFFICIALS OF THE WASHINGTON STATE PATROL, FIRE PROTECTION BUREAU AND WITH THE WASHINGTON DEPARTMENT OF HEALTH.

A STATE OF IMMEDIATE JEOPARDY WAS DECLARED ON 02/15/11.

HOSPITAL CORRECTIVE ACTION:

The hospital administration was notified of the finding of Immediate Jeopardy on 02/15/11.

The hospital initiated corrective action, consisting of removal of the propane located adjacent to the hospital stairwell, sealing of vertical penetrations, removal of the excessive oxygen stored in the surgery corridor, and repair of the stairwell door that did not close. These corrections were completed by 5:00 pm on 02/15/11.

The hospital provided an acceptable written mitigation plan for exiting from the west end of the basement corridor by noon on 02/16/11, including immediate disabling of the overhead door that was obstructing the exit passageway.

Following verification of the corrective action and review of the exit mitigation plan, the hospital administration was informed that immediate jeopardy was removed at 3:00 pm on 02/16/11. However, numerous Life Safety and other Environment deficiencies remained uncorrected at the time of the survey exit on on 02/16/11.

Due to the scope and severity of deficiencies detailed in Tag C0231 in addition to deficiencies cited at Tags C0221, C0222, and C0225, the Condition of Participation for Physical Plant and Environment was NOT MET.

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Based on interview and observation, the critical access hospital failed to implement an effective security plan for the obstetrics department.

Failure to implement an effective security plan for the obstetrics department risks abduction of patients.

Findings include:

During a tour of the critical access hospital on 02/14/11, it was observed that the east door from the obstetrics department was unlocked. This door communicated with a corridor. The exterior exit to the critical access hospital was adjacent to the junction where the east door from obstetrics met the corridor.

During a tour of the labor and delivery department on 02/16/11, the obstetrics department manager stated that the alarm on the east door was not audible at the acute care nurses station. On occasion, there would be a patient in the obstetrics unit but no nursing staff located closer than the acute care nurses station.

1) Based on observation, interview and review of medical equipment manuals, the hospital failed to develop a plan for routine preventive maintenance of the medical air carbon monoxide (CO) monitor.

Failure to develop a plan for routine preventive maintenance of the CO monitor risks injury to patients through delivery of contaminated air.

Findings include:

During a tour of the hospital on 02/14/11, it was observed that the south (new) wing of the hospital had a medical air compressor installed. The medical air compressor had a CO monitor attached to the air supply line. Hospital facilities management staff stated that there was not a plan to calibrate or maintain the CO monitor. Review of the CO monitor manual on 02/16/11 found that the manufacturer stated that the CO monitor must be calibrated every 3 months, and the sensor replaced annually.

2) Based on observation and interview, the critical access hospital failed to ensure that surgical equipment was not contaminated before patient use.

Failure to ensure that surgical equipment was not contaminated before patient use risks hospital-acquired infections in surgical patients.

Findings include:

During a tour of the critical access hospital on 02/14/11, it was observed that endoscopes were hanging in the open air in a room identified as a soiled utility room adjacent to the hospital operating room. During an interview on 02/16/11, the manager of the sterile processing department stated that the endoscopes were processed in a high-level disinfection machine and then transported to the utility room and hung on the rack open to the soiled utility room atmosphere. The endoscopes were then transported to the endoscopy suite when needed for patient procedures.

1) Based on observation, interview and review of critical access hospital infection prevention documentation, the critical access hospital failed to ensure that a construction site located near the surgery department was maintained in accordance with the completed Infection Control Risk Assessment (ICRA).

Failure to conform to the requirements of the ICRA risks hospital-acquired infection in surgery patients.

Findings include:

During a tour of the critical access hospital on 02/14/11, it was observed that an area adjacent to the surgery department was undergoing demolition. Walls were broken open, debris was present in the area, the construction curtain was pulled back to expose the area to the corridor, and the doors leading from the construction area to the surgery department were open. In an interview on 02/15/11, the hospital infection prevention manager stated that the ICRA required that barriers remain in place during construction. Review of the ICRA on 02/16/11 confirmed this requirement.


2) Based on observation, the critical access hospital failed to provide cleanable interior surfaces in a critical area (the sterile processing department storage area).

Failure to provide cleanable interior surfaces in a critical area risks contamination of sterile surgical instruments and subsequent patient infection.

Findings include:

During a tour of the critical access hospital sterile processing department on 02/16/11, it was observed that a wall behind the sterilizer had exposed unfinished wood studs. The room in which this wall was located was used as storage for sterile supplies.

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 02/16/11.

Based on observation, record review and staff interviews, it was determined that 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 resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual
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:

Due to the scope and severity of deficiencies detailed under the Condition of Participation for Physical Plant and Environment, and for failing to provide a Director of Pharmacy, the Condition of Participation for Organizational Structure was NOT MET.

Refer to Tags C0220, C0221, C0222, C0225, C0231, and C0276.

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Based on interview, the critical access hospital failed to develop policies and procedures to guide staff in the use of the vacuum extraction device in the obstetrics unit.

Failure to develop policies and procedures to guide staff in the use of the vacuum extraction device risks serious injury to newborn infants through excessive vacuum pressure, excessive duration of extraction, or excessive attempts to use the vacuum extraction device.

Findings include:

During an interview on 02/16/11, the manager of the obstetrics unit stated that there was not a written policy to guide providers in the use of the vacuum extraction device.

Based on observation, review of policies and procedures and interview the hospital failed to assure a licensed pharmacist was responsible for the overall administration of the pharmacy services as directed by WAC 246-873-040.

Failure to designate a pharmacist as responsible for overall administration of pharmacy services places patients at risk for harm due to poor quality services, including serious injury and death due to medication errors.

Reference: WAC 246 873 040

(1) Director of pharmacy. The pharmacy, organized as a separate department or service, shall be directed by a licensed pharmacist appropriately qualified by education, training, and experience to manage a hospital pharmacy. The patient care and management responsibilities of the director of pharmacy shall be clearly delineated in writing and shall be in accordance with currently accepted principles of management, safety, adequate patient care and treatment. The responsibilities shall include the establishment and maintenance of policies and procedures, ongoing monitoring and evaluation of pharmaceutical service, use and control of drugs, and participation in relevant planning, policy and decision-making activities. Hospitals which do not require, or are unable to obtain the services of a full time director shall be held responsible for the principles contained herein and shall establish an ongoing arrangement in writing with an appropriately qualified pharmacist to provide the services. Where the director of pharmacy is not employed full time, then the hospital shall establish an ongoing arrangement in writing with an appropriately qualified pharmacist to provide the services described herein. The director of pharmacy shall be responsible to the chief executive officer of the hospital or his/her design.

Findings:

1. During an interview on 2-15-11 at 10:00 AM Pharmacist #1, who was employed by the company " Medication Review " , stated that while on site at the hospital s/he fulfilled the role of half-time pharmacy manager. S/he stated that his supervisor (Pharmacist #2) shared the manager role and provided services on one other day of the week. Pharmacist #1 did not know who had been designated as Pharmacy Director.

Pharmacist #1 stated that s/he did not have access to the pharmacy policy and procedure manual and did not know where it was located.

Pharmacist #1 stated that the contract pharmacists do not review all incidents of medication errors and that the pharmacists are only involved if and when particular medication errors were brought to their attention by the Director of Nursing.

2. On 2-15-11, Surveyor #29784 located the Pharmacy Policies and Procedure Manual. The signature form in the front of the manual indicated that the manual was last reviewed on 7-7-09 by a Pharmacist and Medical Director. The area for the signature of the Chief Operations Officer was blank.

The hospital ' s policy and procedure entitled, " Review And/Or Revision of Policy " (Policy # AD1074, Revised 3-19-10), Item #1, stated that hospital policies and procedures would be reviewed annually.

3. During an interview on 2-16-11 at 11:15 AM, the Director of Nursing (Staff Member #2 and the Chief Executive Officer (Staff Member #4) stated that Pharmacist #2 was the in charge of pharmacy services and reported to the Director of Nursing. On 2-18-11 it was clarified by the CEO that the pharmacy contract that started on 9-1-10 did not contain language about a director of pharmacy services and that there was no job description for that position. The contract stated that the contractor for pharmacy services would establish policies and implement and evaluate procedures. There was no time frame for completion of this process. The CEO stated this service had not been provided despite policies and procedures having not being administratively reviewed for 31 months.

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Based on observation, review of policies and procedures, and interview, hospital leaders failed to ensure that hospital policies and procedures were developed, adopted, implemented, and revised to provide direction to staff when providing patient care.

Failure to systematically develop and update healthcare policies and procedures places patients at risk for poor outcomes, including serious disability and death, related to inadequate and/or inconsistent healthcare quality.

Findings:

1. The hospital ' s policy and procedure entitled, " Review And/Or Revision of Policy " (Policy # AD1074, Revised 3-19-10), item #1 read as follows: " Reviews of policies and procedures shall take place at a minimum of every two year (or more often as mandated by law, code or other specified regulation). Critical Access Hospital rules mandate annual review of policies inpatient care and facility support areas. It will be the originating Department Managers responsibility to review the policies at the established time. "

2. On 2/15/2011, the following hospital areas policies and procedures were found to be out of compliance with the above administrative policy:

a. The Dietary policies and procedures had not been reviewed and approved since 9-21-2007

b. The Anesthesia Department policies and procedures had not been reviewed and approved since 9-3-2002.

c. The Acute Care policies and procedures had not been reviewed and approved since 10-05-2009

d. The Administration policies and procedures, which included the Emergency Preparedness plan, the Environment for Care Life Safety Plan, the Safe Patient Handling Plan, and the Fire Plan, had not been reviewed and approved since 7-13-2004.
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e. The Pharmacy policies and procedures had not been reviewed and approved since July 2009. Additionally, the existing pharmacy department policies were not available to the contract pharmacist (Pharmacist #1) when he was onsite on 2/15/2011.

A telephone interview with the hospital ' s Chief Executive Office on 2/18/2011 at 11:15 AM revealed that the pharmacy contract did not designate a Pharmacy Director, who would be responsible for reviewing policies and procedures. The existing pharmacy policies and procedures did not reflect the current system for provision of pharmacy services through a contract service.

Based on record review and interview, the facility failed to develop an initial nursing assessment specific to pediatric patients for 3 of 3 pediatric patients reviewed (Patients #4, #5, #6).

Utilization of a admission assessment designed for adult patients risks non-detection of pediatric healthcare needs.

Findings:

Review of the records of 3 pediatric patients on 2/14/2011 and 2/16/2011 revealed that the admitting nurse had assessed the patient using an adult patient admissions assessment. This assessment did not assess needs related to a pediatric patient, such as developmental level, immunization status, nutritional needs, and family involvement.

An interview with the Patient Care Coordinator (Staff Member #3) on 2/16/2011 at 10:00 AM confirmed that the hospital had not developed an initial nursing assessment specific to pediatric patient healthcare needs.

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Based on record review, review of hospital policies, and interview, the facility failed to develop an individualized plan for patient care according to facility policy for 3 of 8 patients reviewed (Patients #1, #2, #3).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. The hospital's policy and procedure entitled "Care Planning" (Policy # NU 10003; Revised 4/26/2010), read as follows: "Policy: It is the policy of North Valley Hospital to provide an individualized, interdisciplinary Plan of Care for all patients using written/computerized plan of care.... Procedure: The Plan of Care shall be individualized, based on the diagnosis/problem and patient assessment....All staff using the computerized/written Plan of Care is responsible for interdisciplinary collaboration to establish goals and appropriate interventions, as well as ongoing evaluations and revisions."

2. Review of 8 patient care records on 2/14/2011 and 2/16/2011 revealed the following:

a. Patient #1 was an 84 year-old patient who had been admitted on 1/31/2011 for surgical treatment of osteomyelitis of the right foot. The patient also had dementia and was at risk for falling. Problems on the patient's plan of care included anxiety, pain, and confusion. The patient's plan for care did not include interventions that addressed these problems.

b. Patient #2 was a 48 year-old patient who had been admitted on 1/26/2011 for treatment of pain and end of life care related to metastasized lung cancer. Problems on the patient's plan of care included pain, nausea, and impaired mobility. The plan for care did not include identified problems and interventions related to decreased nutrition, anxiety, and impaired coping.

c. Patient #3 was a 94 year-old patient who had been admitted to swing bed services (long-term care) on 2/12/2011 for rehabilitation following a stroke. Problems on the patient's plan of care included impaired skin integrity, risk for unstable blood glucose, and impaired gas exchange. The plan for care did not include identified problems and interventions related to impaired physical mobility and impaired swallowing.

3. An interview with the Director of Nursing (Staff Member #2) on 2/14/2011 confirmed that the plans of care for the above patients had not been individualized according to hospital policy and procedure

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