HospitalInspections.org

Based on review of the CAH's policies and procedures, employee records, credentialing records, and staff interview, it was determined that the Administrator failed:

1. to require that tuberculosis (TB) screening was completed for 10 of 22 CAH personnel members (Employees #3, #6, #7, #10, #14, #15, #17, #19, #22, #23) within the required time frame of the CAH's TB policy. This deficient practice posed a high risk to the health and safety of patients, and CAH personnel, when TB screening was not completed annually, according to the CAH's policy; and

2. to require that tuberculosis (TB) screening was completed for 14 of 17 medical staff members (Medical Staff #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #14, #15, #17) within the required time frame of the CAH's TB policy. This deficient practice posed a high risk to the health and safety of patients, and CAH personnel, when TB screening was not completed annually, according to the CAH's policy.

Findings include:

Policy and Procedure titled "Tuberculosis Prevention and Control Plan, #3531648, Revised 03/2016" revealed: "...Each new employee, direct patient care contracted personnel, volunteer who engages in activities in the facility and members of the Medical Staff will have a current negative TB skin test or a cleared chest X-ray...If employees, direct patient care contracted personnel...and members of the Medical Staff are not current, a TB skin test will be given...If employees, direct patient care contracted personnel...and members of the Medical Staff have a history of positive TB skin test...will be given a chest X-ray...A TB Skin test will be performed annually...PPD converters will complete the TB Screening Questionnaire every other year and chest x-ray every other year on the opposite year of the questionnaire...."

1. A review of employee records revealed that 10 of 22 CAH personnel members (Employees # 3, #6, #7, #10, #14, #15, #17, #19, #22, #23) had expired TB documentation in their records.

RN # 27, Infection Control and Employee Health, confirmed during interview conducted 4/26/18 at 13:20, that the TB data submitted to the surveyors was the most current at the time of the Federal Recertification survey. The TB data revealed a 45% non-compliance rate of TB monitoring of CAH personnel members.

2. A review of credentialing records revealed that 14 of 17 medical staff members (#1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #14, #15, #17 ) had expired TB documentation in their records.

RN # 27, Infection Control and Employee Health, confirmed during interview conducted 4/26/18 at 13:20, that the TB data submitted to the surveyors was the most current at the time of the Federal Recertification survey. The TB data revealed an 82% non-compliance rate of TB monitoring of CAH medical staff members.

Based on observation on tour, review of hospital's policies and procedures, documents, and staff interviews, it was determined that the facility failed to require that medical supplies used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of patients, when the facility cannot ensure that the potential risk for infection, negative outcomes and/or false laboratory testing may result when using expired supplies.

Findings include:

The Department requested a policy regarding outdated or expired supplies and no policy was provided.

Observation on hospital tour conducted 04/23/2018 (1350) through 04/24/2018 (0910), with RN, CNO #25, Cardiopulmonary Manager #3, and RN, Med-Surg Manager #10, identified fifty-seven (57) expired supplies from the following departments:

CARDIOPULMONARY: A total of eight (8) expired supplies were found in the Cardiopulmonary area, to include the Code Cart. Expired items included: ConMed Yankauer, Duracell Procell AA batteries, Compound Benzoin Tincture, and Portex intubation stylet 2.5mm - 4.5mm. The oldest outdate was 09/2012.

EMERGENCY (ED): A total of fifteen (15) expired supplies were found in the ED. Expired items were found in the gray code cart, red code cart, trauma room emergency cart, cabinets, and included the following: purple-top test tube, Chlora Prep swabstick, Baxter 5% Dextrose IV bag (500ml), Baxter catheter stabilization device, Portex intubation stylet 7.5mm-10.0mm, Duracell Procell D batteries, PDI lubricating jelly, Sourcemark silicone laryngeal mask airway, dual lumen stomach tube salem sump, and Shiley neonatal tracheostomy tube cufflers 3.5 NEO. The oldest outdate was 10/2013.

MED-SURG/SWING BED: A total of thirty-four (34) expired supplies were found in the Nursing/Swing Bed unit. Expired items were found in the code cart, infant/peds box, and included the following: Duracell Procell C batteries, Portex intubation stylet 5.0mm-7.0mm, Duracell Procell D batteries, green top test tubes, red/gray top test tubes, Yankauer, Compound Benzoin Tincture, green top microtainer, yellow top microtainer, BD sterile needles, suction connecting tubing with male connector, triflex gloves, brown infusion set, Safe Step huber needle set, PDI Povidone Iodine swabstick, BD insyte autoguard, and Baxter 5% Dextrose IV bag (500ml). The oldest outdate was 08/2013.

Policy titled: Code Cart Security, effective date: 06/98, revised 04/18, requires: "...It is the policy of White Mountain Regional medical Center to maintain appropriate, and adequate supplies...all dated or expiring items are replaced when appropriate...the integrity of the code carts in the Emergency, Cardiopulmonary, Medical Surgical, and Surgical Services Departments will be verified each day...daily check includes a review of the functionality of the carts basic equipment...these checks will be documented on the Daily Code Cart Checklist...."

This policy was revised after the Code Cart inspections in the above departments: Cardiopulmonary, Emergency Room, and Med-Surg/Swing Bed, and was provided to the surveyors on 04/24/2018 at 1330, by RN, Med-Surg Manager #10, and Cardiopulmonary Manager #3.

RN, CNO #25, Med, Cardiopulmonary Manager #3, and RN, Med-Surg Manager #10, all confirmed during tour conducted 04/23/2018 (1350) through 04/24/2018 (0910), that the above identified supplies were expired. As the surveyor identified the expired supplies, the expired supplies were bagged per each department. RN, Med-Surg Manager #10 revealed that code cart checks are completed monthly, and results are logged in the computer. Additionally, it was confirmed by RN, CNO #25, that expired supplies are not to be used in the hospital, and should be discarded and/or removed from inventory no later than the expiration date.

All 57 expired supplies were individually logged by the surveyor, and the expired supplies were given to the Director of Compliance and Quality Assurance #26 at the exit conference conducted 04/26/2018.

Based on document review and staff interviews, it was determined, the CAH's professional healthcare staff failed to ensure that patient care policies were reviewed at least annually. This deficient practice poses a potential risk to the health and safety of patients when staff are not providing care based on the most up to date reviewed/revised current standards of practice information available.

Findings include:

Review of sixty-one (61) hospital policies revealed 91% were out of compliance with annual review standards.

Four (4) policies were last approved 08/27/2008, no date listed for next revie;,
One (1) policy was last approved 07/2011, next review due 06/2012;
One (1) policy was last approved 12/28/2013, no date listed for next review;
One (1) policy was last approved 05/2015, next review due 04/2016;
Four (4) policies were last approved 02/2016, next review due 01/2017;
Forty three (43) policies were approved 03/2016, next review due 03/2017;
Five (5) policies were last approved 03/2016, next review due 04/2017;
One (1) policy was last approved approved 03/2016, next review due 03/2019;
One (1) policy was last approved approved 01/2017, next review due 01/2018.

Review of Medical Staff Bylaws of White Mountain Regional Medical Center, last approved 07/28/16, revealed the duties of the Medical Staff Executive Committee (MEC) required: "...coordinate the activities and general Policies and Procedures of departments...review, revise, and make recommendations for revisions to the Medical Staff Bylaws, Rules and Regulations, and Policies and Procedures as necessary, but at least once every thirty-six (36) months...."

Review of MEC Meeting Minutes from 03/2017- 04/2018 revealed no mention of reviewing and approving patient care policies.

Review of the Board of Directors Meeting Minutes for 06/22/17 revealed: "...the Board of Directors recommended each Board Member log into PolicyStat to review any Policies that have been revised...any Policies that have not been revised be placed on the Agenda for approval...."

There were no policies placed on the Agenda for approval from 03/23/17-04/05/18.

Director of Compliance and Quality Assurance #26 confirmed in an interview conducted on 04/25/18 (1205-1240), that hospital policies and procedures had not been brought up for review in any committees in the past twelve (12) months.

Based on review of hospital policy, facility documents, observations on tour, Arizona Revised Statutes (A.R.S.) Article 11 Pharmacy Technicians, and staff interviews, it was determined the hospital failed to:

1. ensure outdated drugs were not available for patient use. This deficient practice poses a risk to the health and safety of patients because the safety and efficacy of expired medications cannot be guaranteed; and

2. ensure the pharmacy department maintained policies and procedures in place for the safe handling of medications requiring compounding as evidenced by allowing the compounding procedure for medications to be performed by a Pharmacy Technician Trainee. This deficient practice poses the high potential risk to the health and safety of patients if improper compounding occurs resulting in the high potential risk of contamination and or wrong dosage if the procedure is performed by unqualified staff.

Findings include:

1. Review of hospital policy titled "Code Cart Security," last revised 04/2018, requires: "... the Pharmacy Department will replace all outdated medications...at least monthly...."

Tour of the Pharmacy on 04/25/18 (1115-1140), identified fourteen (14) 500 ml bags of 5% Dextrose injection stocked in the department. All of the bags had an expiration date of 02/2018.

Pharmacist #30 confirmed during the tour 04/25/2018, all 14 bags, had an expiration date 02/2018.

Tour of the Emergency Department (ED) on 04/23/18 (1418-1433), identified one (1) bag of 500 ml 5% Dextrose injection with an expiration date of 02/2018 in the ED code cart.

CNO #25 confirmed the one expired bag listed above, and the expiration date of 2/2018.

Tour of the Medical/Surgical unit on 04/23/18 (1450-1615), revealed one (1) bag of 500 ml 5% Dextrose injection with an expiration date of 02/2018, found in the Medical/Surgical code cart.

RN #10 confirmed the one expired bag identified above, and the expiration date of 02/2018.

Need Confirmation

2. Review of A.R.S. R4-23-1104 titled "Pharmacy Technicians and Pharmacy Technician Trainees" requires: "... A. Permissible activities of a pharmacy technician trainee. Acting in compliance with all
applicable statutes and rules and under the supervision of a pharmacist, a pharmacy
technician trainee may assist a graduate intern, pharmacy intern, or pharmacist with the
following when applicable to the pharmacy practice site:
1. Record on the original prescription order the prescription serial number and date
dispensed;
2. Initiate or accept verbal or electronic refill authorization from a medical practitioner
or medical practitioner's agent and record, on the original prescription order or by an
alternative method approved by the Board or its designee, the medical practitioner's
name, patient name, name and quantity of prescription medication, specific refill
information and name of medical practitioner's agent, if any;
3. Record information in the refill record or patient profile;
4. Type and affix a label for a prescription medication or enter information for a new or
refill prescription medication into a computer, if a pharmacist verifies the accuracy
and initials in handwriting or by another method approved by the Board or its
designee the finished label prepared by the technician before the prescription
medication is dispensed to the patient;
5. Reconstitute a prescription medication, if a pharmacist checks the ingredients and
procedure before reconstitution and verifies the final product after reconstitution;
6. Retrieve, count, or pour a prescription medication, if a pharmacist verifies the
contents of the prescription medication against the original prescription medication
container or by an alternative drug identification method approved by the Board or its
designee;
7. Prepackage drugs in accordance with R4-23-402(A); and
8. Measure, count, pour, or otherwise prepare and package a drug needed for hospital
inpatient dispensing, if a pharmacist verifies the accuracy, measuring, counting,
pouring, preparing, packaging, and safety of the drug before the drug is delivered to a
patient care area...."


Review of A.R.S. R4-23-1105 titled "Pharmacy Technician Trainee Training Program, Pharmacy Technician Drug Compounding Training Program and Alternative Pharmacy Technician Training" revealed the following: "...B. Pharmacy technician trainee training program.
1. A pharmacy permittee or pharmacist-in-charge shall develop, implement, review, and
revise in the same manner described in R4-23-653(A) and comply with a pharmacy
technician trainee training program based on the needs of the individual pharmacy...C. Drug Pharmacy technician drug compounding training program. 1. A pharmacy permittee or pharmacist-in-charge shall develop, implement, review, and revise in the same manner described in R4-23-653(A) and comply with a pharmacy technician drug compounding training program based on the needs of the individual pharmacy...ensure that the pharmacy
technician trainee training program includes training guidelines that: a. Define the specific tasks a pharmacy technician trainee is expected to perform, b. Specify how and when the pharmacist-in-charge will access assess the
pharmacy technician trainee's competency, and c. Address the policies and procedures specified in R4-23-1104(F) R4-23-1104(G) and the permissible activities specified in R4-23-1104(A) and (B)...Document a pharmacy technician trainee's progress throughout the training program...4. A pharmacy technician trainee shall perform only those tasks, listed in R4-23-1104(A), for which training and competency has been demonstrated...."

Review of the "PolicyStat Index" of hospital policies and procedures for the pharmacy department identified that no policy or procedure for the development of a pharmacy technician trainee program, as required by Arizona Revised Statutes (A.R.S.) R4-23-11-5(b)(1) was available, and no pharmacy technician compounding training program as required by A.R.S. R4-23-1105(C)(1) was present as well.

Per A.R.S. R4-23-1104 compounding is not listed among the permissible activities of a pharmacy technician trainee.

Review of documents titled "Pharmaceutical Bulk Compounding Worksheet" revealed the following:

On 3/07018, Pharmacy Technician Trainee # 33 compounded eleven (11) "GI Cocktails" (name for the medication preparation created by the hospital pharmacy to identify the combination of medications compounded), consisting of Lidocaine viscous 2%, generic Maalox, and Dicyclomine 10 mg (milligrams)/5 ml (milliliters) liquid. The required form for documenting all compounded medications completed in the pharmacy department was missing a signature and initials of the pharmacist indicating that calculations, formulas, ingredients, weights, and volumes were checked. The area on the form for "Calculations and Proof" was also blank.

On 03/07/18, Pharmacy Technician Trainee # 33 and Pharmacy Technician Trainee # 34 compounded Lidocaine Viscous 2% and generic Maalox for a "GI Cocktail". The pharmacist initials and signature were missing, as well as "Calculations and Proof" on the required area on the form where the compounded medication is documented in the pharmacy department.

On 04/10/18, Pharmacy Technician Trainee # 33 compounded thirteen (13) "Dr. Miles Eye Block" (name for the medication preparation created by the hospital pharmacy to identify the combination of medications compounded) consisting of Hylenex 150 units/ml, Lidocaine 2 % Preservative Free (PF), and Bupivacaine 0.75% PF.

Pharmacist # 30 confirmed in an interview conducted on 04/25/18, that the initials in the "Prepared By" box on the "Pharmaceutical Bulk Compounding Worksheets" were those of Pharmacy Technician Trainee # 33 and Pharmacy Technician # 34.

Based on review of policies and procedures, facility documents, and staff interviews, it was determined, the hospital failed to ensure medication administration errors were reported correctly, and potential corrective actions were identified and implemented. This deficient practice poses a risk to the health and safety of patients when medication administration errors are not properly monitored and corrected.

Findings include:

Review of hospital policy titled "Incident/Occurrence Reporting", last reviewed 03/2016, requires: "...the Compliance/Risk Manager will assure that the incident form is complete; that a complete and thorough investigation is conducted; and appropriate corrective action is taken..."

Review of Pharmacy and Therapeutics Meeting minutes from 06/14/17 revealed medication error rate is one of the Quality Improvement measures for the Pharmacy department.

Review of Medical Staff Executive Committee Meeting minutes from 03/2017-04/2018 revealed no mention of medication administration error reporting, investigation, and/or follow up.

Review of Board of Directors Meeting minutes from 03/2017-04/2018 revealed no mention of medication administration error reporting, investigation, and/or follow up.

Review of Nursing Staff Meeting minutes from 04/2017-01/2018 revealed no mention of medication administration error reporting, investigation, and/or follow up.

Review of Quality Council Meeting minutes from 02/2017-04/2018 revealed no mention of medication administration error reporting, investigation, and/or follow up.

Review of Pharmacy and Therapeutics Meeting minutes from 06/14/17-01/10/18 revealed no further mention of medication administration error reporting, investigation, and/or follow up.

Director of Compliance and Quality Assurance #26 confirmed during an interview conducted on 04/25/18 (1548-1558), medication administration errors are not being monitored or corrected according to hospital policy.

37240

Based on review of policies and procedures, credentialing files, manufacturer's recommendations, hospital documents and staff interviews, it was determined that the Critical Access Hospital (CAH) failed to:

1. provide routine infection control training to 17 of 17 medical staff members (Medical Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17); and

2. failed to require that the masks in the Sleep Lab were soaked in the Cidex OPA disinfectant for the appropriate length of time prior to each patient's use; and failed to maintain temperature of Cidex OPA at maximum temperature reading of (20 C) Celsius (68 F) Fahrenheit, per hospital policy.

3. failed to require that the ultrasound transducers used for vaginal ultrasound procedures, were soaked in the CIDEX OPA disinfectant solution which requires the solution to first be tested with the CIDEX test trip prior to initiating the cleaning of the ultrasound transducers.

These deficient practices pose the high potential risk to the patient's health for transmission of infections, to include the potential of cross contamination of microorganisms, and communicable diseases to patients and staff.

Findings include:

1. Policy and procedure titled "Infection Control Program, #3533653, Revised 03/2016" revealed: "...It is the policy of White Mountain Regional Medical Center to maintain an infection control program for the prevention, early detection, identification, control, education, and investigation of infections and communicable diseases in the facility...The following mechanisms are used to achieve the objective...4. Participate in the facility's education program in an effort to reduce and control the spread of infection...7. Collaboration with all facility departments in policy and procedure development relative to the prevention and control of infection...The Infection Control Committee membership will be multi-disciplinary and will consist of representatives from the Medical Staff, Nursing Department...The Infection Control Committee will be responsible for the following: 1. Monitoring and evaluating the Infection Control program...To assist with Employee Health activities...5. Direct and assist with infection control education...7. Review, revise and develop written policies and procedures relating to the Infection Control Program...."

Policy and procedure titled "Education: Professional Development Policy, #4486304, Revised 03/2018" revealed: "...White Mountain Regional Medical Center recognizes that for professional development purposes, employees need to attend training seminars...an in-service training program will be conducted on a continuing basis...continuing education opportunities and in-service training programs will be made available to eligible employees...In-service training will be conducted on an ongoing basis and may be presented by individuals of varying experiences and varying topics related to department personnel or the general employee population. In-service records will be maintained and will include at least the in-service subject matter, the date of the in-service training and the signature of each individual who participated in the in-service training...Continuing education will be available to eligible facility personnel. Participation will be based on...the impact of the continuing education in meeting the needs of the facility/department and the staff member...."

A review of credentialing records revealed that 17 of 17 medical staff members ( #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) were missing documentation of Infection Control training and/or ongoing education related to Infection Control in their files.

RN # 26, Director of Compliance & Quality Assurance, confirmed during interview on 04/26/18 at 08:40, that the CAH had been utilizing SWANK as their on-line infection control training, and recently converted to Relias. RN # 26 relayed that the CAH's medical staff members do not receive infection control training, upon granting of privileges, nor additional/ongoing refresher training thereafter.

RN # 27, Infection Control, Employee Health, and Education nurse, confirmed during interview on 04/26/18 at 13:20, that the CAH's medical staff does not receive infection control training, upon granting of privileges, nor additional/ongoing refresher training thereafter.

2. Hospital policy titled "Cidex OPA Solution" requires: "...will be tested using manufacturers test strips...temperature recorded...label date opened...expiration date...14 days...submersible thermometer...temperature documented in ...Log book...."

Hospital document titled "Cidex Instrument Processing Log" revealed 9 columns with the following information:
Month/day/year/; Cidex pass/fail; temperature; time in/time out; item/ CPAP/ leak test; Employee/User; Technician.

Review of the above document dated 4/12/18 revealed: concentration pass; temperature 33.7; time in 0630, out time 0640; item CPAP-mask; technician initials.

Review of the above document dated 4/17/18 revealed: concentration pass; temperature 33.7; time in 1625, out time 1630; item flow sensor; technician initials.

Review of the above document dated 4/19/18 revealed: concentration pass; temperature 33.7; time in 0505, out time 0520; item CPAP-mask; technician initials.

Review of the above document dated 4/19/18 revealed: concentration pass; temperature 33.7; time in 1645, out time 1657; item CPAP-mask; technician initials.

Review of the above document dated 4/25/18 revealed: concentration pass; temperature 33.7; time in 0300, out time 0305; item CPAP-mask; technician initials.

Hospital document shared by the Director of Respiratory and Sleep Lab with the surveyor revealed per "Respironics Mask" exposure time for Cidex OPA is 12 minutes per manufacturer's instruction.

The Director of Respiratory and Sleep Lab confirmed during an interview conducted on 04/26/18, that the facility failed to follow hospital policy and manufacturer's recommendation regarding decontamination of the Sleep Lab's mask/equipment.

3. Review of Manufacturer Guidelines, CIDEX OPA, requires the high-level disinfectant, should be tested with the appropriate CIDEX test strip prior to each usage. Additionally, the Manufacturer's recommendations require that CIDEX test strips be discarded after ninety (90) days after the the bottle is originally opened.

Review of the hospital policy titled: Ultrasound Transducer Cleaning, #3755493, last approved 07/2011, requires "...ultrasound transducers and transvaginal probes will be cleaned and disinfected before each patient...before soaking a transducer the OPA must be tested...using the CIDEX OPA test strips...."

Review of the hospital policy titled: Ultrasound Protocol - CIDEX OPA Test Strips, #3755432, last approved 05/2015, requires "...disinfectant is to be used on all transvaginal probes per manufacture's guidelines...disinfectant CIDEX OPA will be tested each duty day the endocavity probe is used...CIDEX OPA will be tested using manufacture's test strips...prior to cleaning probe in CIDEX, with the manufacture's recommended testing procedure...documented in the Test Log Book...submerge the test strip pad into the CIDEX OPA...soak container for one (1) minute...remove excess solution by standing the test strip on its end...after ninety (90) seconds read the results...comparing the test strip to its color chart on the test strip bottle...record the results...if the CIDEX OPA test fails, discard the solution...repeat the test strip test...record temperature of CIDEX prior to cleaning probe for each endocavity patient examination...temperatures should be 15-30 (C) or 59-86 (F)...."

Review of the hospital document titled: White Mountain Regional Medical Center, CIDEX Activation-Indicator Log revealed the following entries: 03/23/18 - Time 1720 - Pass - Temp: 23.8 - Comment: N/A; 04/06/18 - Time 1608 - Pass - Temp: 24.6; 04/20/2018 - Time 1836 - Pass - Temp: 23.9 - Comment: N/A; 04/21/18 - Time 1240 - Pass - Temp: 22.1 (C) - Comment: N/A.

Ultrasound Technician #13, Diagnostic Imaging Manager #33, and CNO #25 all confirmed during the ultrasound room tour conducted 04/24/2018 (0914), that the CIDEX Test Strip container expired 03/28/2018, and that according to the White Mountain Regional Medical Center, CIDEX Activation-Indicator Log, that three (3) patients had an ultrasound transvaginal test performed, when the CIDEX OPA Solution was tested with expired CIDEX Test Strips.













37879

Based on review of the facility's policies, and procedures, documents, medical records, and staff interviews, it was determined that the facility failed to require that staff obtain authentication by the responsible practitioner for all verbal telephone orders written for four (4) out of eight (8) patients, as per facility policy, and Medical Staff Rules and Regulations. This deficient practice poses the risk to the health, and safety of patients, when the medical provider fails to authenticate a verbal order within twenty-four (24) hours, ensuring that the medical order was correct. (Patients # 22, # 23, #24, and # 25)

Findings include:

Review of the hospital's policy titled: Orders: Verbal, #4051686, last revised 03/2016 requires: "...verbal orders (including telephone or other oral orders) shall be processed in accordance with medical staff rules, and regulations...use of verbal orders shall be minimized...orders that are not written by a prescriber shall be subsequently authenticated (verified), and countersigned by the prescribing practitioner...within the time period specified by medical staff rules, and regulations...."

Review of White Mountain Regional Medical Center, Medical Staff, Rules and Regulations, last approved 04/06/2016, requires: "...Order Guidelines...verbal orders must be reduced to writing immediately including the time, and date...authenticated by the responsible practitioner at that practitioner's next visit...within twenty-four (24) hours after issuance of the order...whichever time is shorter...."

Electronic medical record review of four (4) of eight (8) patient's #22, #23, #24, and #25, revealed that all patients had telephone orders that were not authenticated within the required twenty-four (24) hours as follows:

Patient #22: Telephone order written 01/13/2018 (1618), provider signature pending
Patient #23: Telephone order written 03/12/2018 (0857), provider authenticated order on 04/08/2018 (0803)
Patient #24: Telephone order written 03/31/2018 (1624), provider signature pending
Patient #25: Telephone order written 02/15/2018 (1825), provider signature pending

HIM Supervisor #36 confirmed during the electronic medical record review conducted 04/26/2018 (0900), that the telephone orders for Patient's #22, #23, #24, and #25 had not been authenticated, and all dates were beyond the required twenty-four (24) hours.

Based on review of hospital documents, and staff interview, it was determined the facility CAH failed to require that the Infection Prevention Committee submitted a quarterly written report to the Quality Council Committee. This deficient practice poses a high risk to the health, and safety of patients, medical staff, and hospital personnel, when the facility fails to provide an infection control report to the Quality Council Committee identifying the following: infection control data, opportunities for improvement, a facility risk assessment, and education; allowing the Quality Council Committee an opportunity to review, and provide oversight of the Infection Prevention program.

Findings include:

Review of the White Mountain Regional Medical Center, Infection Prevention and Control Plan, January 2018 - January 2019, revealed: "...The Infection Prevention Program functions under the direction of the Infection Preventionist, the Medical Director, and the Quality Council Committee...incorporates involvement of other hospital leaders...is an integral part of the organization-wide program to assess, and improve quality patient care, and patient safety...."

Review of the White Mountain Regional Medical Center, Infection Prevention Meeting minutes dated: 09/12/2017, 10/24/2017, and 03/06/2018 showed no documented evidence of a review or an approval of a quarterly report submitted to the Quality Council.

Review of the White Mountain Regional Medical Center, Quality Council Meeting minutes dated: 04/06/2017, 05/11/2017, 06/08/2017, 07/06/2017, 09/07/2017, 10/10/2017, 11/09/2017, 12/12/2017, 02/01/2018, 03/01/2018, and 04/05/2018 showed no documented evidence of a receipt or a review of a quarterly report submitted by the Infection Prevention Committee.

RN, Infection Control & Employee Health #27 confirmed during an interview conducted 04/24/2018 (1412-1435), that currently an Infection Prevention quality report is not submitted to the hospital's Quality Council on a quarterly basis.

Based on review of facility medical records, and staff interviews, the Department determined that the facility CAH failed to require that a comprehensive care plan was completed within the required seven (7) days for two (2) residents (patients # 24 and # 26), ordered in a swing bed status. This deficient practice poses a risk to the health, and safety of the resident, when an interdisciplinary comprehensive plan of care (IPOC) is not establish, to aid in the overall health, and well-being of the resident, ensuring that the resident is progressing.

Findings include:

Review of the hospital's policy titled: Initial Assessment Resident, #3112426, last revised 03/2016, requires: "...conduct initially...periodically a comprehensive, accurate, standardized, reproducible assessment of each resident...physical factors...cognitive...psychosocial functioning...personal information...financial...the purpose of obtaining this data is to identify information to help staff develop a personalized plan of care that will utilize the individual's existing strengths...optimize function...quality of life...data obtained from the assessment shall be used to develop all relevant portions of the care plan (interdisciplinary team members)...."

RN #19 confirmed during an interview conducted 04/25/2018 (1435-1450), that resident's in swing bed status are required to have an IPOC, and that the Swing Bed Manager is the person who is in charge of getting the IPOC completed.

RN #31 confirmed during an interview conducted 04/25/2018 (1500-1519), that resident's in swing bed status are required to have an IPOC. It was revealed, that the care plan is pre-determined, but the nurse can customize the care plan. Additionally, it was confirmed that the Swing Bed Manager does the care plan, but is not certain how it is done.

Electronic medical record review conducted 04/26/2018 (0800), revealed no IPOC for resident's #24, and #26.

HIM Supervisor #36, confirmed that there was no IPOC for resident's #24, and #26.

04/26/2018 (0930), the surveyor requested the IPOC for resident's #24, and #26. RN, Swing Bed Manager #24 revealed on 4/26/2018 (1130), that there was no IPOC available for resident's #24, and #26.

RN, Swing Bed Manager #24 confirmed during an interview conducted 04/26/2018 (0800), that s/he has been in this position effective 01/2018, and that a registered nurse can customize a pre-populated care plan in the computer. After the initial care plan is established, RN, Swing Bed Manager #24 revealed that s/he develops the IPOC, and that it must be completed within seven (7) days. It was confirmed that the medical provider, the resident, the resident's nurse, the Swing Bed Manager, and any other staff involved in the care of the resident attends the IPOC meeting. Additionally, the resident's family representative is encouraged to attend the IPOC meeting. The IPOC meetings are held weekly, while the resident is in swing bed status.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to have documentation of new and existing staff trained in the Emergency Preparedness Plan. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Safety Disaster Coordinator and the Director of Compliance and Quality Assurance reviewed the facility's Emergency Plan (EP) on April 24-25, 2018 with the Life Safety Code surveyor. The plan did not include annual facility based training and testing for staff based on the Emergency Plan.

The Chief Executive Officer, Director of Compliance and Quality Assurance, Plant Services Manager confirmed during an interview on April 26, 2018, the EP plan did not include annual facility based training and testing for staff based on the Emergency Plan.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to perform a Community-Based full scale exercise. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Safety Disaster Coordinator and the Director of Compliance and Quality Assurance reviewed the facility's Emergency Plan (EP) on April 24-25, 2018, with the Life Safety Code surveyor. The plan did not have a documented Community-Based full scale exercise for staff based on the Emergency Plan.

The Chief Executive Officer, Director of Compliance and Quality Assurance, and the Plant Services Manager confirmed during an interview on April 26, 2018, the EP plan did not include annual facility based training and testing for staff based on the Emergency Plan.