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A. Based on observation and interview, the hospital failed to post, in a public area on each patient care unit, a complete nurse staffing plan and the nurse staffing schedule for each shift as required by Washington State law (RCW 70.41.420).

Failure to post the nurse staffing plan and the current nurse staffing schedule risks violation of an employee, patient or visitor's right to know that there was adequate and safe staffing levels to care for patients on each patient care unit.

Reference:

RCW 70.41.420

(3) Primary responsibilities of the nurse staffing committee shall include:

(b) Semiannual review of the staffing plan against patient need and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital.

(7) Each hospital shall post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. The staffing plan and current staffing levels must also be made available to patients and visitors upon request.

Findings:

1. A tour of the Medical Surgical Unit on 9/13/2011 with Staff Member #1 and Staff Member #2 revealed the following:

? A document related to staffing was found on a bulletin board in a public hallway on the Medical Surgical Unit.

? The document entitled "Staffing Plan for the Week" (9/10/2011 to 9/17/2011) did not clearly indicate the facility plan for the type of staff needed on each unit. The plan included a list of units and some staff (Charge, Emergency Room/Critical Care, OB [labor and delivery], Medical Surgical Unit, Nursing Assistant, Unit Secretary) and beside each item was an "X" or "XX" indicating a need but there was no explanation on the document indicating what "X" meant.

? Rather than post the staffing plan in each patient care area as required by RCW 70.41.420 the facility posted the plan only on the Medical Surgical Unit. The plan did not include the Operating Room.

? There were no dates or signatures on the staffing plan indicating that the staffing committee had reviewed the staffing plan semiannually.

? The daily staffing schedules were not posted in public areas on each patient care unit.

2. Staff Member #1 and Staff Member #2 confirmed these findings.


B. Based on interview, the facility failed to ensure that the pharmacist was involved in quality assurance activities within the facility.

Failure to involve pharmacy in quality assurance activities risks the health and safety of patients as it relates to medication administration and medication practices within the facility.

Reference:

WAC 246-873-110 Additional responsibilities of pharmacy service.

(1) General. The pharmacy service shall participate in other activities and committees within the hospital affecting pharmaceutical services, drugs and drug use.

(2) Quality assurance. The pharmaceutical service shall establish a pharmacy quality assurance program.

Findings:

During an interview with the Pharmacist (Staff Member #5) on 9/13/2011 he/she stated that he/she was not involved with any quality improvement projects or with the quality committee. The Pharmacist stated that he kept a log of medication issues that were reported to him but he was not involved in evaluation of data collected on medication issues that were reported to the quality department.

An interview with the Director of Quality Assurance (Staff Member #6) on 9/15/2011 confirmed that the Pharmacist was not involved in quality improvement meetings or activities at this time.




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C. Based on interview, the facility failed to appoint a nurse at the executive level to direct services when the position was vacated to assure adherence to Washington State hospital regulations.
Failure to do so places patients at risk for poor quality nursing care and poor health outcomes.
Reference: WAC 246-320-136 Leadership. The hospital leaders must:
(1) Appoint or assign a nurse at the executive level to:
(a) Direct the nursing services;

Findings:
1. In interview with the Chief Operating Officer, Staff Member # 23, on September 13, 2011 at 8:10 am, the facility had no interim chief nursing officer (CNO) subsequent to when the previous CNO " walked off the premises " without prior notice. The position had been vacant for approximately 2 weeks at the time. It was stated that the facility had not " gotten that far yet " related to replacement of the position.

2. In interview with the Director of Human Resources, Staff Member # 17, on 9-14-11, it was stated the Chief Executive Officer (CEO) who was hired the previous week and who was on leave after 2 work days on site and instructed staff not to hire a CNO in his/her absence. The plan was for him/her to return to work at the facility in approximately 3 weeks. This plan would create a vacancy of the position for a minimum of at least 5 weeks.

3. In interview on 9-15-11, the COO stated that a prior CNO had determined that two individuals could not share the duties of a CNO. As a result, the facility had not pursued an interim plan for two individuals share the duties for the CNO until a permanent replacement was found. During that discussion, the facility identified that they were operating under the assumption that charge nurses were adequate for direction of facility nursing services.

4. In review of facility document titled, " Okanogan Douglas Hospital Job Description Registered Nurse " (reviewed June 2010) it stated that the registered nurse was responsible to the " Charge Nurse & Chief Nursing Officer. " The facility failed to provide for an executive nurse to whom registered nurses were required to be responsible. Similar findings were noted in job descriptions titled " Licensed Practical Nurse " , " Post-Anesthesia Recovery Nurse " and " OB Nurse " . The facility failed to follow provision for direction and accountability of nursing provided in their nursing job descriptions.
In review of job description of the CNO the general summary states that that the CNO is " Responsible and accountable for nursing service care delivery in all patient care areas. Management for planning, organizing, staffing, directing and implementing nursing service functions with the facility in accordance with all state and federal regulations. " These job functions were not being provided at the facility at the time of the survey.

Based on interview and review of job descriptions, the hospital failed to develop policies and procedures that ensured that Licensed Practical Nurses (LPNs) delivered care to hospitalized patients under the supervision of a Registered Nurse (RNs) according to Washington state law.

Failure to provide LPNs with required supervision risks nursing staff practicing outside of the LPN's scope of practice and risks the health and safety of patients.

Reference:

WAC 246-840-700 - (2) (a) (i) (A) "The registered nurse is responsible for ongoing client assessment, including assimilation of data gathered from licensed practical nurses and other members of the health care team ..." (E) (ii) "The registered nurse is accountable for the safety of clients receiving nursing service by (A) Delegating selected nursing functions to others in accordance with their education, credentials and demonstrated competence ..."

(2) (b) (i) "The practical nurse assists in implementing the nursing process; (A) Assessment: The licensed practical nurse makes basic observations, gathers data and assists in identification of needs and problems relevant to the clients, collects specific data as directed, and, communicates outcomes of the data collection process in a timely fashion to the appropriate supervising person."

(2) (b) (i) (C) "Planning: The licensed practical nurse contributes to the development of approaches to meet the needs of clients and families, and, develops client care plans utilizing a standardized nursing care plan and assists in setting priorities for care."

(2) (b) (i) (E) "Evaluation: The licensed practical nurse, in collaboration with registered nurse, assists with making adjustments in the care plan. The licensed practical nurse reports outcomes of care to the registered nurse or supervising health care provider."


WAC 246-840-705 - (3) "Registered Nurses: The registered nurse functions in an independent role when utilizing the nursing process ..."

(4) "Licensed Practical Nurses: The licensed practical nurse functions in an interdependent role to deliver care as directed and assists in the revision of care plans in collaboration with the registered nurse."

Findings:

1. During a tour of the Medical Surgical Unit on 9/13/2011 the surveyor was told that the facility employs a couple of LPNs. On the day of the unit tour no LPNs were available for interview.

An interview with a RN on 9/14/2011 (Staff Member #4) revealed that the LPN was assigned patients in the same way that an RN was assigned patients. The RN (Staff Member #4) stated that the LPN would be responsible for assessing her/his assigned patients, documenting her/his patient assessments and updating patient care plans.

The RN (Staff Member #4) stated that LPNs do admit patients and perform and document an admission assessment and initiate patient plans for care. At this time, RNs were not required to perform an assessment of LPNs assigned patients nor were the RNs required to initiate the nursing care plans.

The only limitations placed on LPN practice were that LPNs do not administer IV (intravenous) medications or administer blood.

When the surveyor asked Staff Member #4 about the RNs responsibility to supervise the LPN the RN stated that the responsibility for supervision of the LPN was not clear. The RN reported that supervision of the LPN was discussed in a meeting about 18 months ago but no changes in RN/LPN practice resulted from the discussion.

2. The hospital's job description for the staff LPN (no effective date) stated that the "LPN provides direct and indirect nursing care" and the "LPN assists with the initiation and maintenance of accurate and concise nursing records and reports."

The LPN job description did not clearly define the LPNs role, according to state law, in "assisting" in the implementation of the nursing process. The facility had no policies or procedures that identified the specific responsibilities of the LPN when assisting the RN in implementation of the nursing process.

3. The hospital's job description for the RN (no effective date) stated that the RN was to "provide supervision of the LPN". However, the RN job description did not clearly define how supervision of the LPN's practice was to occur.

The facility had no policies or procedures that identified the specific responsibilities of the RN when supervising LPN practice.

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Based on record review, review of policy and procedure, and interview, the facility failed to ensure that blood was infused according to facility policy and procedure in 3 of 3 patient records reviewed (Patients #1, #2, #3).

Failure to follow blood transfusion policy and procedure places patients at risk for transfusion reactions and complications.

Findings:

1. The facility's policy and procedure entitled "Blood & Blood Components, Administration of " (Effective date 2/2/2006; Updated 3/11/2010) read as follows:

"Vital signs shall be taken prior to infusion, 15 minutes after infusion is started or if infusion is stopped and after completion of infusion."

The facility's policy and procedure entitled "Blood Transfusion Reactions" (Effective 3/20/2006; Updated 3/11/2010) included monitoring the patient for the following signs/symptoms: Temperature rise; hypertension (high blood pressure); hypotension (low blood pressure); shaking chills; hives; increased heart rate; decreased heart rate; chest, flank, or back pain; shortness of breath; itching; facial flushing; anxiety; restlessness; skin rash; wheezing; pink or red urine; abnormal bleeding; nausea; vomiting; and reduced urine output.

2. Review of the medical records of 3 patients who received blood transfusions while hospitalized revealed the following:

a. Patient #1 was a 90 year-old patient admitted on 8/5/2011 for treatment of a hip fracture. During Patient #1's hospital stay Patient #1 received 2 units of blood. During the first transfusion nursing staff documented a heart rate, and temperature at the start of the transfusion, 15 minutes after the transfusion was started, and at the end of the transfusion.

Nursing staff had not documented respiratory rates and blood pressures during the transfusion. The same was found during the transfusion of the second unit of blood.

3. Similar findings were found in the medical record of Patient #2 and Patient #3.

4. The facility's policy and procedure for administration of blood did not define which patient vital signs were to be included in the nursing assessment. Typically, a complete set of vital signs includes a patient's heart rate, respiratory rate, temperature and blood pressure. Without a full set of vital signs nursing staff may not identify signs/symptoms of a transfusion reaction as listed in the blood transfusion reaction policy.

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Based on interview the facility failed to have a system in place that would assure the safety of patients, staff and visitors of the facility during non-medical emergencies. More specifically, the facility failed to have a plan in place that would protect vital supplies of emergency fuel and water.

Findings include:

1. On 9/15/2011 during discussions with Staff Member #7 the surveyor was informed that informal agreements had been made with local suppliers for emergency fuel and water but no written agreements (MOU's) had been entered into to assure their delivery if needed during an emergency.


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Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 9/13/2011 - 9/15/2011.

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CONDITION NOT MET

Based on review of hospital policies and procedures; record review; staff interviews; the hospital's quality assurance program and quality assurance documentation; and past Washington State Department of Health survey results; it was determined that the hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure, Provision of Services and Hospital Wide Periodic Evaluation and Quality Assurance Review.

References Tags C-240-241; 270, 271, 276, 278, 279, 291, 294; and 330, 331, 332, 333, 334, 335; respectively grouped from above as well as C152 and C385.

Failure to ensure that the hospital meets established organizational structure requirements impairs the facility's ability to provide quality care in a safe environment.

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Based on review of hospital policies and procedures; record review; staff interviews; the hospital's quality assurance program and quality assurance documentation and provision of services; and past Washington State Department of Health survey results; the Governing Body failed to do the following:

The Governing Body failed to ensure that an annual CAH program evaluation was performed according to facility policy and regulatory requirements (Refer to Tags
C-331, 332, 333, 334, 335).

The Governing Body failed to ensure that the facility had an effective, hospital-wide quality assurance program (Refer to Tag C-342).

The Governing Body failed to assure safety and quality provision of services. (Refer to Tags C-270, 271, 276, 278, 279, 291, 294).


Failure to ensure that the facility implements approved policies, procedures, and programs impairs the hospital's ability to provide quality care in a safe environment.

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CONDITION NOT MET

Based on review of hospital policies and procedures; staff interviews; the hospital's quality assurance program and quality assurance documentation; and past survey in 2007; it was determined that the failed to meet the requirements for the Condition of Participation for Provision of Services. There are repeat citations notes in this area from the prior federal survey.

References Tags C-271, 276, 278,279,291 and 294.

Failure to ensure that the hospital meets established provision of services requirements impairs the facility's ability to provide quality care in a safe environment.

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A. Based on record review, and review of policy and procedure, the facility failed to ensure staff followed the facility's policy and procedure for monitoring, and documenting restraint use in 1 of 2 records reviewed (Patient #4).

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

Findings:

1. The facility's policy and procedure entitled "Restraint" (no effective date) read as follows:

Under the section entitled "Patient Monitoring and Assessment" the policy stated monitoring will include an hourly assessment of patient positioning, circulatory status, and skin integrity.

Under the section entitled "Reporting" it stated that in the acute care setting all episodes of restraint will be documented on the Assessment Record and the Restraint Assessment Form. The Emergency Department staff will assess the patient and document on Outpatient form following the restraint policy.

2. Review of the records of 2 patients who were restrained during their hospital stay revealed the following:

a. Patient #4 was a 24 year-old patient who was admitted on 3/8/2011 to the Emergency Room then transferred to acute care on 3/9/2011 for observation while awaiting placement and transfer to a psychiatric facility for treatment of a psychiatric condition. Review of Patient #4's medical record revealed that the patient was in restraints from 3/9/2011 at 8:00AM to 3/10/2011 at 1:10PM.

Emergency Department (ED) restraint documentation (3/9/2011 8:00AM to 3/9/2011 7:30PM): There was no "Outpatient Form" specific to restraint documentation in Patient #4's ED record. ED nursing documentation for restraints was found on a form entitled "ER Nurses Notes". Nursing staff documented vital signs approximately every hour but did not document the specific assessments required by the facility's restraint policy.

Acute Care - Observation restraint documentation (3/9/2011 7:30PM to 3/10/2011 1:10PM): The required assessments of the patient were documented on the Restraint Assessment Form on 3/9/2011 at 7:35PM, 11:35PM and on 3/10/2011 at 2:30AM, 4:10AM, 6:50AM, 11:20AM, 12:20PM, 12:50PM, and 1:10PM when the patient was removed from restraints.

Assessments of Patient #4 were not completed and documented hourly as required by the facility's restraint policy.


B. Based on record review and review of policy and procedure, the facility failed to review and revise the restraint policy to ensure that it was consistent with 42 CFR ?482.13(e) Standard: Restraint or seclusion, as required by Washington State law.

Failure to include in facility policy that use of restraints should never be ordered on an "as needed (PRN)" basis risks violation of patient rights.

Reference:

CFR 42.482.13 (e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)

Findings:

1. Review of the facility policy entitled "Restraint" (no effective date) revealed that the facility had not included in the policy that restraints were never to be ordered PRN (as needed).

2. Review of Patient #4's medical record revealed that a physician (MD #1) wrote an order for restraints on 3/10/2011 at 6:50AM that stated "D/C restraints OK to replace if danger to self or others."


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Based on observation and interview the facility failed to implement appropriate and safe medication administration practices for patients receiving intravenous medications.

Failure to assure appropriate and safe medication administration practices creates risks for poor patient outcomes, including disability and death.

Findings:

1. a. On 9-15-11 Patient # 9 had an open reduction internal fixation surgery to the right ulnar bone for a fracture. Near the conclusion of the surgery and while the patient was stable for that phase of care, the anesthesia provider, Staff Member # 14 was called to the emergency room to care for a patient that was unstable. Prior to departing to the emergency department the anesthesia provider handed a syringe labeled as " Fentanyl " to the recovery room nurse , Staff Member # 15, already located in the operating room suite, and requested that the recovery room nurse administer the medication the Fentanyl. The recovery room nurse did not ask specific questions related to the request for medication administration or record it as a verbal order.
When the patient was moved and positioned in the recovery room area, the recovery room nurse administered the medication. Upon being asked by the surveyor what dose he/she had administered, he/she responded " 100 milligrams. " Fentanyl is administered in " micrograms " (mcgs) and it was clarified that he /she meant to say micrograms. When the recovery room nurse was asked how he/she knew if the dosage was 100 micrograms he/she acknowledged not knowing because the syringe was not labeled and she/she was not sure if it was drawn up from a " vial or carpoject. " When the anesthesia provided returned to the recovery room suite he/she said that there was 50 mgs of Fentanyl in the syringe (which had already been administered to the patient by the recovery room nurse).

b. In review of related documentation of the Fentanyl the following issues were noted:
? There was no verbal order for the registered nurse to administer Fentanyl. Therefore, the medication was administered without an order.
? The anesthesia provider documented the 50mcgs of Fentanyl was administered between 6:45am-7:00 am and that medication was not administered.
? The recovery room nurse documented that he/she administered 100mcg intravenously Fentanyl at 7:10 am and that dose was not administered. The patient actually received 50 mcg s intravenously.

In summary, the documentation did not support the administration of the medication and the recovery room nurse did not have knowledge of the dose that he/she administered at the time of the administration.

c. Per facility policy titled, " MEDICATION ORDERS Telephone, Verbal and Written " (approved 6-11-07) page 2 of 3 states " To prevent medication errors related to verbal/telephone orders, all individuals licensed and approved by the hospital to receive and record these types of orders must strictly observe the following practices " ....Obtain all criteria information ... " which included drug dosage (strength or concentration), quantity and route among several other elements. It also stated " Write down order " , Repeat the entire order to the prescriber ... ", " Repeat the frequency and/or instructions " . The facility failed to follow its own procedure for medication orders.

2. a. On 4-20-11 Patient # 10 had an attempted endoscopy for evaluation of difficulty swallowing and received 4mg of Versed and 125 mcg of Fentanyl intravenously. There was no conscious sedation record completed by the registered nurse. However the registered nurse, Staff member # 15, documented on the " Post Conscious Sedation Monitoring " form that the patient received 4mg of Versed and 125mcg of Fentanyl. There was no record of a physician order for Fentanyl or Versed on the " Endoscopy Orders " for nurse administration of medications.

b. Per policy and procedure titled " Procedural Sedation and Analgesia " (10-09-07) in the Intra-procedural section 4. stated " RN certified in procedural sedation will administer IV medication as ordered by the physician. " and section 7 stated " Observe and document on Procedural sedation Record. "
In summary, the documentation did not support the appropriate and safe nursing administration of the medication. Failure to obtain a physician order prior to registered nurse administration of patient medication risks patients receiving care from a professional practicing outside the scope of their licensure and creates the risk for the patient to have a poor health outcome.

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I. Based on observation and interview the facility failed to ensure the control of potential infections by implementing appropriate nationally recognized standards of prevention.

Failure on the part of the facility to implement nationally recognized infection control standards puts patients at risk from nosocomial infection.

The following breaches of infection control standards were observed during the course of the survey:

A. Sterilization of Instruments - Non-Emergent Flashing

References:

Steam sterilization of patient care items for immediate use (ANSI/AAMI ST37:1996); AORN 2011 Perioperative Standards and Recommended Practices, RP Sterilization Recommendation IV.g; and CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.

Findings Include:

1. On 9/14/2011 the surveyor reviewed surgical department flash sterilization logs (Control Record) for the period of May 31 through September 14, 2011. Logs provide information on the character of the load being run (date, load number, time, contents, well #, exposure time, biological indicator incubation results positive or negative and initials of staff). For the most part all loads were "flash" sterilized as indicated by the recorded "contents".

2. Sterilization logs show that on the seven Fridays recorded from the period of May 31 through September 14, 2011, 93 loads were run for an average of greater than 13 loads per typical Friday.

3. The contents of the majority of instruments run on Fridays are related to orthopedic procedures and contain implantable items such as frag sets (plates and screws).

4. On 9/14/2011 during an interview with Staff Member #11 the surveyor was informed that "flash" loads were run in open trays without the benefit of covers or wraps. And, it was indicated that flashing was performed routinely due to a lack of instrumentation.

B. Sterilization/Disinfection Records-REPEAT FEDERAL CITATION from 2007

1. On 9/14/2011 the surveyor reviewed surgical department flash sterilization logs (Control Record) for the period of May 31 through September 14, 2011. Logs reviewed lacked documentation to indicate that biological indicators had been used for 49 loads and 7 controls.

2. On 9/14/2011 the surveyor asked for OPA efficacy test logs related to endoscope processing. The last available logs for review were for 6/9/2010.

C. Efficacy Testing

1. On 9/15/2011 the surveyor noted that disinfection efficacy test strips (Cidex) used in the respiratory therapy department were expired.

D. Environmental Infection Controls

1. On 9/14/2011 at approximately 2:35 PM the surveyor observed that the door to operating room 1 was in the open position while a surgical procedure was being performed.

E. Storage of Sterile/Clean Supplies

1. On 9/13/2011 the surveyor noted that sterile and clean supplies were being stored in a space utilized as an employee breakroom where food and beverages would be consumed. At the time of the observation the doors to the space were in the open position preventing the space from having a positive air pressure relationship to adjoining spaces (corridor).

F. Surgical Attire

1. On 9-15-11 Patient # 9 underwent an open reduction and external fixation for an ulnar fracture. The following observations were noted in the operating room suite per surveryor #278394.

a. The circulating nurse, Staff member #13, performed a surgical site scrub with a betadine type solution. During the scrub his/her mask when affixed so loosely over her nose and mouth are that there was an approximate 1-2 inch gap on each side of the mask rather than being secured to the face. This created an opportunity for staff airway contamination of the surgical field just prior to the incision being performed.


2. According to the Association of periOperative Registered Nurses, their document titled " Perioperative Nursing Data Set, 2nd edition states that donning a surgical mask " covers both mouth and nose, is tied securely, and minimizes venting. " And according to the American College of Surgeons July 2000 Bulletin titled " Guideline for prevention of surgical site infection " there is a recommendation under surgical attire that states " Wear surgical mask that fully covers mouth and nose. This is a level 1B ranking recommendation which means " Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and strong theoretical rationale. " The application of a mask by the circulating nurse did not meet these guidelines.





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II. Based on an interview with the infection control program coordinator (Staff Member #3), the hospital failed to ensure that personnel managing the infection control program had training in the principles and practices of infection control.

Failure to ensure that staff managing the infection control program had training in the principles and practices of infection control risks inability of the infection control manager to appropriately assess and reduce infection risk, and to recognize and intervene in infection incidents.

Findings:

1. During an interview with the hospital infection control program coordinator (Staff Member #3) on 9/14/2011, he/she stated that he/she did not have specific training in the principles and practices of infection control.



2. Based on interview and review of policy and procedure, the facility failed to develop a written infection control and surveillance program.

Failure on the part of the facility to implement and maintain an infection control program puts patients and staff at risk of acquiring infections and diminishes the hospital's ability to deal with infections once acquired.

Findings:

1. During an interview with the Infection Control Program Coordinator (Staff Member #3) on 9/14/2011 he/she stated that the facility had a written infection control plan.

The Infection Control Program Coordinator presented a policy entitled "Infection Control Program" (Effective 6/7/2007) that defined the role of the Infection Control Program Coordinator but did not include a facility infection risk assessment nor did it include measurable goals and objectives in order to evaluate the program or strategies for reducing risks that were specific to the facility.

The Infection Control Program policy had not been reviewed or updated since January of 2009.

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A. Based on observation the facility failed to implement policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC). Failure on the part of the facility to comply with the food service codes puts patients, staff and visitors of the facility at risk of food borne illness. And the facility failed to have readily available a current copy of it's therapeutic diet manual.

Specific references made in the findings below are found in the Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code.

Findings include:

1. On 9/14/2011 the surveyor asked a member of the kitchen staff (Staff Member #9)about food worker card status and was informed that documentation was held within the HR files. It was further indicated by the staff member that his/her card was expired. (see Chapter 2-103.12)

2. On 9/14/2011 the surveyor noted that the kitchen 3 compartment sink was not served by an indirect drain. (see Chapter 5-402.11)

3. On 9/14/2011 the surveyor noted that 1 of 2 stem thermometers tested against a calibrated digital stem thermometer was not properly calibrated so as to provide an accurate reading. The facility's two thermometers read 20 degrees F and 34 F degrees respectively when placed in a ice bath solution. The calibrated digital stem thermometer had a reading of 33.5 degrees F. (see Chapter 4-502.11)

4. On 9/14/2011 the surveyor asked Staff Member #9 to test the strength of the sanitizing solution being used in the kitchen. A Hydrion QT-10 test strip was used to determine the strength of the solution. No sanitizer was found to be available in the solution tested. It was determined that the dispenser reservoir was nearly empty and the feed hose was clogged. (see Chapter 4-015.114)

5. On 9/14/2011 the surveyor asked Staff Member #9 to provide for review a copy of the facility's current therapeutic diet manual. Presented for review was the 8th edition of the Simplified Diet Manual of the Iowa Dietetic Association. Dietary policy and procedures (reference #2120 revised 6//1/2009) indicates that the 10th edition is to be used.


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B. Based on interview, review of medical records and review of policy and procedure the facility failed to assure the provision of dietary services, including basic assessment measures for patients in swing beds.
Failure to do so creates risk for patients to have poor nutritional status that could negatively impact their health outcomes and the provision of other health services.
Findings:
1. On 9-15-11, Staff Member #16 stated that the dietician was not regularly seen on the hospital units. A dietary screen by nursing that is rated as " High " risk will initiate a referral to the dietician.
2. In review of medical records of patients with infections, 3) Patient #11, 12, 14) of 4 had no weights recorded/obtained by staff. Other care omissions were also noted:
? Patient #11 was an elderly patient admitted on 11-24-10 with a urinary tract infection and mental status changes. The patient had no height or weight recorded and no nutritional labs work however the nursing staff had ordered " Boost prn " . The patient record had no professional dietary services entries.

? Patient B #12 was an elderly patient admitted on 4-4-11 with a post operative wound infection with multi-resistant staph aureus after treatment of a femur fracture. There were no weights recorded and the albumin level was 3.2-3.3 which below normal. The patient record had no professional dietary services entries.
? Patient #13 was an elderly patient admitted on 2-15-11 with cellulitis of the lower extremities. The nursing staff did start the nutritional screen but it was not completed with the risk score. The patient ' s albumin and albumin/globulin ratio were low showing altered nutritional status. The patient record had no professional dietary services entries.

? Patient #14 was a 40 year old patient admitted on 12-25-10 with multi-resistant staph aureus infection of the right knee 12 days after arthroscopy. The patient was diabetic. The staff did not obtain an onsite weight measurement of the patient and no nutritional lab work was obtained. The patient record had no professional dietary services entries.


3. In review of a policy titled Scope of Services (undated), on page 4 of 10 section F. relates to " Dietary. " The policy notes that dietary personnel include a dietician but there was no further specification as to the related role and/or responsibilities of the dietician. There was more specification given to other health professionals scope of service as compared to the dietician.
Per the job description of the Clinical Dietician (dated 9-1-2004 per the Human Resources Manager, Staff #17) item #2 states " Conducts nutrition screening and assessments on patients within 14 days using appropriate standards of care. " And item #4 states " Records all pertinent nutritional information in the medical chart, (calorie counts, totals, nutrition assessments, summary of teaching, etc.) "
There was not a current job description that would identify the expected level of dietary care for the patients noted above.

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

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

Findings:

On 9/13/2011 a list of requested documents was presented to the facility. The list included a request for a list of services that were provided within the facility by contractors. The facility presented the surveyors with a notebook that had physician contracts for preceptor services, a physical therapy agreement, and an imaging agreement with another hospital.

An interview with Staff Member #1 and Staff Member #23 on 9/15/2011 revealed that the facility did not have a policy or a list that included the nature and scope of services for all contracted services provided within the facility. Staff Member #1 and Staff Member #23 did not know if the notebook containing facility contracts included all services provided within the facility by arrangement or agreement.

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Based on record review and interview, the facility failed to ensure that nursing admission assessments were completed for 4 of 4 IV (intravenous therapy) Unit patient records reviewed (Patient #5, #6, #7, #8).

Failure to perform a complete admission assessment risks not meeting the healthcare needs of patients through formulation of a comprehensive plan of care.

Findings:

1. Review of the medial records of 4 patients admitted to the IV Unit for infusion therapy revealed the following:

a. Patient #4 was a 40 year-old patient admitted on 9/1/2011 for 14 days of antibiotic therapy for a wound infection and daily dressing changes. Review of Patient #4's medical record revealed that vital signs were documented but a complete nursing admission assessment that included an assessment of the patient's wound had not been completed

b. Similar findings were found in the medical record of Patient #5, Patient #6, and Patient #7.

2. An interview with Staff Member #2 revealed that a patient assessment form had been developed for the IV Unit after the last survey on 4/8/2010 when the facility was cited for lack of initial nursing admission assessments. Staff Member #2 was unsure why the new assessment form was not being used but thought it might be related to the recent change to an electronic medical record.

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Based on interview and record review, the facility failed to ensure that staff providing care to patients receiving serial treatments in the IV (intravenous therapy) Unit had access to patient information from previous visits.

Failure to develop a system to provide access to patient information for serial treatments in the IV Unit risks patient harm resulting from unrecognized changes in patient condition.

Findings:

1. During a tour of the IV Therapy Unit on 9/13/2011 Patient #4's record was reviewed and revealed the following:

a. Patient #4 was a 40 year-old patient admitted on 8/16/2011 for antibiotic therapy. Patient #4 had visited the IV Unit daily since admission for treatment. Review of the patients file on 9/13/2011 revealed that there was a copy of the Physician's H&P, a copy of the physician's order for care and treatment, and nursing documentation for the patient's visit on 9/13/2011.

2. The surveyor asked Staff Member #2 how nursing staff caring for IV Therapy patients receiving serial treatments access information from previous patient visits. Staff Member #2 stated that each patient visit has a different identification number and the information was filed away after the patient's visit. In order for staff to access information from previous visits staff would need to know the identification number for each visit then information could be accessed in the electronic medical record.

The surveyor asked the unit secretary to look up the visit numbers for Patient #4's previous visits for IV therapy. After looking up the patient visits the unit secretary presented to the surveyor a sheet of paper with 28 different visit identification numbers.

3. Staff Member #2 confirmed that nursing staff would not know the previous visit identification numbers unless the numbers were provided by the unit secretary or medical records staff. Staff Member #2 agreed that nursing staff did not have access to information pertaining to previous visits for serial treatments in the IV unit.

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CONDITION NOT MET

Based on review of hospital policies and procedures; staff interviews; the hospital's quality assurance program and quality assurance documentation; review of deficiencies cited during the Critical Access Hospital survey, it was determined that the facility failed to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.

Refer to Tag 331, 332, 333, 334, 335 and 342.

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


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Based on interview the facility failed to provide their Critical Access Hospital Periodic Evaluation.
Failure to do so creates risk that standards of practice are not being adhered to and that laws and regulation may not be incorporated into policies and procedures.
*Reference Related Components:
C-0332 ?485.641(a)(1)(i) The utilization of CAH services, including at least the number of patients served and the volume of services;
Survey Procedures ?485.641(a)(1)(i)
C-0333
?485.641(a)(1)(ii) A representative sample of both active and closed clinical records; and
C-0334
?485.641(a)(1)(iii) The CAH ' S health care policies.
C-0335
?485.641(a)(2) The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed.
Findings:
1. In interview with the Chief Operating Officer (COO), Staff Member # 23, on September 15, 2011 at 2:00 pm the facility was unable to locate any Critical Access Hospital Annual Periodic Evaluations. The most recent Periodic Evaluation was last located with a former employee. The COO recalled presenting related information to the former employee in paper document form and it has not been seen since that time. The COO was able to locate no previous annual periodic evaluations during the onsite survey or subsequently per request.
*Note that this citation includes Tags 331, 332, 333, 334 and 335.
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A. Based on record review and interview, the hospital failed to take appropriate action to address hand hygiene deficiencies found through the quality assurance program.

Failure to address deficiencies found through the quality assurance program places all patients at risk of harm related to the potential negative outcome associated with improper hand hygiene practices.

Findings:

During an interview with the infection control coordinator (Staff Member #3) on 9/14/2011, it was discovered that the facility was involved in a hand hygiene project where use of alcohol gel along with other data was reported on-line to an organization that would analyze the data and give the facility feedback in the form of a percentage that indicated compliance with hand hygiene practices. The facility's goal was to reach 72 percent compliance. Review of the data showed that the facility's numbers were 49 percent in 2009 and 48 percent in 2010. The infection control coordinator did not know why the facility ' s percentages were so low.

An interview with the Quality Assurance Coordinator (Staff Member #1) on 9/15/2011 confirmed that the facility had been collecting the hand hygiene data for about three years and that the data had not been analyzed by the facility in order to figure out why the facility's scores were so low.




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B. Based on interview and document review the facility failed to take remedial action in addressing deficiencies found through the quality assurance program.

Failure to do so inhibits performance improvement based on findings and neglects to institute needed improvements which may result in poor quality patient care.

THIS IS A REPEAT FEDERAL CITATION FROM 2007

Findings:

1. In interview with Staff Member #1 on 9-15-11 the facility had not identified a frequency for updating the Performance Improvement Measures since 2008 and there was no defined frequency for regularly updating the plan. As a result some of the data gathering activities would not have been relevant to current facility patient care activities.



2. In interview with Staff Member #1 on 9-15-11 the Board of Directors did not participate in prioritizing performance measures. There was no documentation related to addressing deficiencies.

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Based on interview and record review, the facility failed to provide written notification realted to discharge/transfer to residents in swing beds with contact information to the State Long Term Care Ombudsman.

Failure to do so creates risk that residents may unable to exercise their rights related to placement from a swing bed which may have negative health consequences.

Findings:
1. In an interview with the Discharge Planner, Staff Member #16, residents being discharged from the facility were not being informed in writing about access to the State Long Term Care Ombudsman. Failure to provide this information may deprive a resident of the right to appeal aspects of the discharge plan.
In review of the facility form titled " An Important Message from Medicare About Your Rights " with Staff Member #14, he/she stated that there was a plan to update the form with that information but it had not occurred.
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Based on interview, the facility failed to provide an ongoing activities program directed by a qualified professional.
Failure to do so creates risk that residents ' physical, mental, and psychosocial well-being was not being addressed and residents ' care experience could be detrimental to their well-being.
REPEAT FEDERAL CITATION FROM 2010
Findings:
1. On September 14, 2011 in an interview with the Director of Human Resources, Staff Member #17, it was revealed that there was not a staff member designated to direct activities for the swing bed patients.
In interview with Staff Member#24, it was revealed that there was a box of games/puzzles located in a large clear plastic box on the medical surgical unit. It was explained that the games/puzzles in the box were offered as the recreational activities to residents in swing beds. This type of approach does not meet programmatic requirement.
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