HospitalInspections.org

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

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

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

Findings included:

1. On 07/10/18 at 1:25 PM Surveyor #7 reviewed the observation (OBS), inpatient (ACU), and long-term care "swing-bed" (LTC) services and interviewed the OBS/ACU/LTC nurse manager (Staff #701). During the interview, the manager stated that an MD or DO was not on site twenty-four hours per day, seven days per week to care for patients. During the interview, the manager stated all patients admitted for emergency, outpatient, observation, inpatient, and/or swing bed services are given a written list of patient rights.

2. Review of the list of patient rights revealed it did not include information for patients that an MD or DO was not on site twenty-four hours per day, seven days per week. During the review, the nurse manager confirmed that this information was not on the lists of patient rights. The manager stated there was no process to provide written notice of information to hospital patients that an MD or DO was not on site twenty-four hours per day, seven days per week.

3. On 07/11/18 at 1:30 PM, Surveyor #7 reviewed the hospital's ED services and interviewed the ED nurse manager (Staff #702). During the interview, the manager confirmed that an MD or DO was not on site twenty-four hours per day, seven days per week. The nurse manager stated there was no process to provide written notice of this information to ED patients.
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Based on interview and record review, the Critical Access Hospital failed to assure contracted hospital staff were licensed or certified as required by state law.

Failure to maintain records of licensure or certification on contracted staff puts patients at risk for receiving care from improperly trained and/or qualified individuals.

Findings included:

1. On 07/11/18 at 2:00 PM, Surveyor #1 observed a contractor removing eye surgery equipment from the operating room during a terminal clean procedure. During an interview at the time of the observation, the contractor (a certified surgical technician) (Staff #101), stated that she brings the equipment and assists with the procedures.

2. On 07/12/18 at 12:00 PM, Surveyor #1 reviewed a contracted agreement which stated that the contractor (Sightpath) will ensure the licensure of technician and shall provide facility with evidence of such licensure upon facility's request.

3. On 07/12/18 at 3:00 PM during the human resources record review, Surveyor #1 asked to see the license of the contracted certified surgical technician. The human resource manager (Staff #102) stated that she was unaware of the contract and did not have a record of the certified surgical technician's license. By the end of the survey, the human resource manager was able to obtain the information.
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Based on observation, interview, and review of emergency equipment logs, the Critical Access Hospital failed to ensure supplies and equipment were immediately available to treat patients experiencing medical emergencies.

Failure to routinely verify supplies and equipment for emergency care are immediately available risks patient harm and adverse healthcare outcomes.

THIS IS A REPEAT CITATION - PREVIOUSLY CITED 01/12/17

Findings included:

1. On 07/10/18 at 8:50 AM, Surveyor #7 inspected the emergency supplies and equipment in the hospital's acute care (ACU) unit. During the inspection, the surveyor observed a tank labeled "Oxygen - Full" next to the emergency supply cart. The surveyor opened the regulator valve on the tank and noted that the gauge on the tank showed the tank was empty.

2. During an interview with Surveyor #7 at the time of the observation, the ACU manager (Staff #701) confirmed that the tank was empty and directed a nurse on the unit to replace the tank.

3. During the interview, the manager stated that nursing staff were expected to verify that supplies and equipment were available and in working order each shift and to document this on a log located on top of the emergency supply cart. The manager stated that there was no written policy and procedure for this process.

4. Review of the logs for June and July 2018 showed that the shift checks were not done for 12 of 60 shifts in June and for 3 of 18 shifts in July.



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

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

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

Findings included:

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

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

Cross-reference: Tag C0330.
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Based on record review and review of facility policies and procedures, the facility failed to ensure nursing staff members performed blood transfusion procedures according to facility policy and procedure for 1 of 3 patients reviewed (Patient #701).

Failure to perform blood transfusion procedures according to acceptable standards of practice risks transfusion reactions and complications.

Findings included:

1. Review of the hospital's policy and procedure titled "Blood Transfusion Administration", Policy #4656302 dated 03/18, showed that two nurses would verify the patient's identity and the unit of blood to be transfused at the patient's bedside prior to initiation of a transfusion. This verification process would be documented on the blood requisition slip attached to the blood.

2. On 07/13/18 at 9:30 AM, Surveyor #7 reviewed the records of 3 patients who received blood transfusions during their hospital stay. This review revealed the following:

a. The transfusion records for Patient #701 dated 04/11/18 did not include evidence that two nurses had verified the patient's identity and the unit of blood prior to transfusion for 2 of 2 units reviewed.

b. The transfusion records for Patient #701 dated 05/25/18 did not include evidence that two nurses had verified the patient's identity and the unit of blood prior to transfusion for 1 of 1 unit reviewed.

3. During an interview at the time of the record review, the acute care unit nurse manager confirmed that the records lacked evidence that nurses had verified the identity of the patient and the units of blood prior to transfusion as directed by hospital policy.
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Based on observation, interview, review of a controlled substances log for Patient #702, and review of policies and procedures, the Critical Access Hospital failed to ensure that controlled substances were counted by two nursing staff members each shift according to pharmacy policy.

Failure to verify that controlled substances are secure and accounted for risks diversion of narcotics and unsafe healthcare.

Findings included:

1. On 07/10/18 at 9:20 AM during inspection of the hospital's acute care unit (ACU) medication room, Surveyor #7 observed a bottle of medication in a locked cupboard labeled with Patient #702's name. The label indicated the medication was hydrocodone 10 mg with acetaminophen 325 mg (an opioid pain medication).

2. During the inspection, Surveyor #7 interviewed the ACU nurse manager (Staff #701) regarding how nursing staff were to monitor controlled substances. The manager stated the medication was to be counted and logged by two nursing staff members at the change of every shift.

3. During the inspection, review of the "Controlled Substances Recording Log" for Patient #1 showed that the medication had not been counted by two nursing staff members since 06/09/18 at 8:20 AM.

4. Review of the telepharmacy contractor's policy and procedure entitled "Controlled Substances Management of Patient Care Units", Policy #3010422 dated 07/08, showed that controlled substances were to be counted according to the controlled substance policy of the remote hospital site.

5. On 07/11/18 at 3:10 PM during an interview with Surveyor #7, the hospital's contracted clinical pharmacist (Staff #703) stated that the hospital did not have a written hospital-specific policy and procedure regarding accountability of controlled substances.
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ITEM #1 HAND HYGIENE

Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy and procedure to ensure that all hospital staff members performed hand hygiene according to acceptable standards of practice, as demonstrated by 2 of 3 nursing staff members observed (Staff #704, #705).

Failure to perform hand hygiene while providing patient care risks transmission of infectious diseases to patients and caregivers.

Reference: "Guidelines for Hand Hygiene in Healthcare Settings" (Centers for Disease Control and Prevention, 2008). "Recommendations: Indications for handwashing and hand anti-sepsis... J. Decontaminate hands after removing gloves".

Findings included:

1. During the survey, Surveyor #7 observed the following:

a. On 07/10/18 at 11:30 AM in Room #124 of the acute care unit, Staff #704 did not perform hand hygiene after removing gloves on three occasions during preparation of insulin for injection for Patient #703.

b. On 07/11/18 at 11:30 AM in the outpatient services unit, Staff #705 did not perform hand hygiene after removing gloves on two occasions during wound care for Patient #704.

3. On 07/12/18 at 9:00 AM during an interview with Surveyor #7, the hospital's infection control program coordinator (Staff #706) stated that hospital staff members were to perform hand hygiene after removing gloves when providing care to patients.

4. Review of the hospital's policy and procedure titled "Hand Hygiene", Policy #3695333 dated 06/17, showed that the policy did not direct staff to perform hand hygiene after removing gloves.


ITEM #2 - COMPLIANCE WITH FOOD SAFETY REGULATIONS

Based on observation and interview, the Critical Access Hospital failed to follow the Washington State Retail Food Code, WAC 246-215.

Failure to follow the Washington State Retail Food Code places patients at risk from food-borne illness.

Findings included:

On 07/12/18 at 9:15 AM, Surveyor #1 observed with the hospital's plant operations manager that 2 ice machines in the cafeteria did not have an air gap (a minimum of 1 inch air space between the drain line and the floor drain to protect ice from contamination).

Reference: Washington State Retail Food Code, WAC 246-215-05215 Design, construction and installation-Backflow prevention, air gap (2009 FDA Food Code 5-202.13).


ITEM #3 - EQUIPMENT TESTING

Based on observation and interview the critical access hospital failed to ensure that testing of the eyewash station in the laboratory met nationally recognized standards.

Failure to follow nationally recognized standards when testing eyewash stations places staff, patients and/or visitors at risk of infection during emergency eye flushing procedures.

Reference: (American National Standard Institute) ANSI Z358-2009 standard under Maintenance & Testing.
"Proper maintenance and weekly testing is necessary to ensure that Emergency Drench Showers and Eyewash Stations are functioning safely and properly. Weekly testing helps clear the supply lines of sediment and bacteria build-up that is caused by stagnant water. The ANSI standard states that plumbed flushing equipment shall be activated weekly for a period long enough to verify operation and ensure that flushing fluid is available."


Findings included:

On 07/11/18 at 11:30 AM during a tour of the laboratory department, Surveyor #1 observed that the logs attached to the eyewash station and shower station showed monthly testing. In an interview with the Laboratory Manager (Staff #104), the laboratory manager showed the surveyor that it was set up in the computer system as monthly testing. The monthly testing did not meet nationally recognized standards.
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Based on observation, interview, and review of hospital policies and procedures and the manufacturer's directions for use, the Critical Access Hospital failed to ensure that hospital staff members dated blood glucose meter control testing solutions after opening the bottles.

Failure to date and discard blood glucose meter control testing solutions as directed by the manufacturer risks patient harm due to errors in calibration of the meter and provision of care based on inaccurate test results.

Findings included:

1. Review of the hospital's policy and procedure titled "Accu-Chek/Blood Glucose Monitoring", Policy #3638643 dated 05/17, showed that hospital staff members would date bottles of control solution when opened and discard the solution within three months of opening.

2. On 07/10/18 at 9:30 AM, Surveyor #7 inspected the blood glucose meter and control testing solutions stored at the nurses station of the hospital's acute care unit. One bottle of control solution labeled "Control #1" for low-range testing and two bottles of control solutions labeled "Control #2" for high-range testing were open and undated.

3. Review of the manufacturer's directions for use on the label of the bottles showed that the control solutions were to be discarded within three months of opening.

4. During an interview with Surveyor #7 at the time of the observation, the hospital's acute care unit manager (Staff #701) confirmed that the bottles were undated and discarded the solutions.
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Based on observation, and interview, the Critical Access Hospital failed to ensure that lead shielding aprons used to protect patients during radiological procedures were maintained and routinely inspected by the hospital staff.

Failure to have a system in place to ensure that shielding is routinely inspected places patients and staff at risk of unnecessary radiation exposure.

Findings included:

On 07/10/18 at 12:20 PM during a tour of the coaxial tomography room, Surveyor #1 inspected the integrity of five lead shield aprons in the room. Surveyor #1 found one of the lead shield aprons had a tear in the arm area of the apron. This was confirmed by the Radiology Manager (Staff #105) at the time of the observation. The surveyor asked the manager if the aprons were routinely inspected. The manager stated that department staff members routinely clean the aprons, but that the department did not have polices or procedures in place for routinely inspecting the aprons.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that nursing staff members developed an individualized plan of care for pain management for 3 of 3 patients reviewed (Patients #705, #706, #707)

Failure to develop an individualized pain management plan risks uncoordinated care and ineffective pain relief.

Findings included:

1. Review of the hospital's policy and procedure titled "Nursing Documentation", Policy #2962391 dated 11/14, showed that nursing staff members would develop a care plan for each patient at the time of admission. The plan would be individualized, updated as changes occurred, and documented every shift.

2. On 07/10/18, Surveyor #7 reviewed the medical records of two patients currently receiving care at the hospital who were experiencing and being treated for pain (Patients #705, #706). The review revealed that the nursing care plans for these patients did not include a plan for pain management. The surveyor found similar findings on 07/12/18 during review of the records of Patient #707, who was hospitalized from 06/03/18 to 06/07/18.

3. On 07/11/18 at 3:55 PM during an interview with Surveyor #7 at the time of the record review, the hospital's acute care unit manager (Staff #701) confirmed the records did not include nursing care plans for pain management.
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Based on interview and review of the hospital's process for granting surgical privileges, the Critical Access Hospital failed to ensure information regarding the types of surgical procedures surgeons could perform at the hospital was available to staff members working in the surgical services department.

Failure to ensure information regarding surgical privileges is available to all surgical staff members risks medical errors and patient harm.

Findings included:

1. On 07/11/18 at 9:35 AM during an interview with Surveyor #7, a surgical services nurse (Staff #707) stated that information regarding the types of surgical procedures surgeons could perform at the hospital was not available to staff members working in the surgical services department.

2. On 07/12/18 at 1:00 PM, Surveyor #1 interviewed the Human Resources Manager (Staff #102) and reviewed health care provider credentialing files. Surveyor #1 confirmed that the hospital did not have a mechanism for informing surgery staff members of the types of surgical procedures that individual surgeons were allowed to perform.
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Based on interview and review of the hospital's quality assurance plan and quality program documentation, the Critical Access Hospital (CAH) failed to implement its plan to monitor, evaluate, and improve the quality of patient care services through routine data collection and analysis.

Failure to systematically collect and analyze facility performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

References:

§485.641(a) Standard: Periodic Evaluation. (1) The CAH carries out or arranges for a periodic evaluation of its total program. The evaluation is done at least once a year and includes review of ... The CAH'S health care policies.

42 CFR 485.641(b) The program requires that: (1) All patient care services and other services affecting patient health and safety are evaluated; (2) Nosocomial infections and medication therapy are evaluated... (5)(i) The CAH staff considers the findings of the evaluations, including findings or recommendations of the QIO; and takes corrective action if necessary; (5)(ii) The CAH also takes appropriate remedial action to address deficiencies found through the quality assurance program; (5)(iii) The CAH documents the outcome of all remedial action.

Findings included:

1. Review of the "Coulee Medical Center 2017 Quality Improvement Plan" and "Coulee Medical Center 2018 Quality Improvement Plan" showed both plans identified the following goal: "To have all departments within the organization create tiered metrics that are linked to the strategic and operation goals of the organization and improvement of patient care."

2. On 07/12/18 between 9:30 AM and 11:30 AM, Surveyor #7 interviewed the hospital's Chief Executive Officer (Staff #708), the hospital's Compliance Officer (Staff #709), and interim quality program coordinator (Staff #706) regarding the hospital's quality program. This review showed the following:

a. The hospital's quality program was based on collecting data for state and federal mandatory reporting requirements. This data was reported to the hospital's governing body and quality committee but was not used for quality improvement activities.

b. The program did not include and assess performance metrics for all hospital services and departments.

c. There was no process for evaluating performance of contracted patient care services that were not reviewed through the medical staff credentialing process (i.e. teleradiology, reference laboratory, telepharmacy, and biomedical equipment maintenance services).

d. Adverse occurrences such as falls, medication errors, and healthcare acquired infections were analyzed individually by department managers but not aggregated for patterns and trends.

e. The hospital had quality improvement projects but no method for developing and tracking action plans.

f. The hospital did not review all patient care related policies and procedures annually. The emergency department policies and procedures had not been reviewed since 2010. The acute care unit and radiology department policies and procedures had not been reviewed since 2014. The sterile processing and semi-critical disinfection policies and procedures had not been reviewed since 2012.

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring was NOT MET.
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Based on interview and review of patient rights information, the Critical Access Hospital failed to notify long-term care ("swing bed") patients in writing of an impending transfer or discharge.

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

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

Findings included:

1. On 07/10/18 at 2:25 PM during an interview with Surveyor #7, the swing bed program manager (Staff #701) stated that all swing bed patients received a document titled "Swing Bed Patient Rights" when admitted to the hospital's long-term care unit.

2. Review of this list of rights showed that the hospital informed swing bed patients that they had the right to be notified before they were transferred to another facility or discharged from the hospital. This notice would be documented in the patient's medical record.

3. During the interview above, the manager stated this notification was done verbally and not in writing. Patients were not informed that they had the right to appeal their discharge to the State long term care ombudsman and were not provided with the ombudsman's name, address, and telephone number.

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Based on interview, review of patient rights information, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a policy and procedure regarding the visitation rights of patients, and parameters and clinical rationale for restriction of visitors.

Failure to develop and implement an unbiased procedure for allowing and restricting visitors risks violation of the patient's right to choose and receive visitors.

Findings included:

1. On 07/10/18 at 1:25 PM Surveyor #7 reviewed the observation (OBS), inpatient (ACU), and long-term care "swing-bed" (LTC) services and interviewed the OBS/ACU/LTC nurse manager (Staff #701). During the interview, the manager stated all patients admitted for emergency, outpatient, observation, inpatient, and/or swing bed services are given written lists of patient rights.

2. Review of the list of rights given to patients and an additional list of rights given to swing-bed patients showed that the lists did not inform patients that they had the right to choose their own visitors and that hospital staff members could not restrict visitors based on racial and/or gender bias.

3. Review of hospital policies and procedures showed the hospital did not have a policy and procedure regarding patient visitation.
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Based on interview and review of patient rights information, the Critical Access Hospital failed to develop a process for informing each patient or support person of the patient's visitation rights, including any restrictions or limitations on such rights; and the patient's right to receive visitors whom he or she chooses.

Failure to develop and implement a process for informing patients of their visitation rights risks violation of the patient's right to choose their own visitors.

Findings included:

1. On 07/10/18 at 1:25 PM Surveyor #7 reviewed the observation (OBS), inpatient (ACU), and long-term care "swing-bed" (LTC) services and interviewed the OBS/ACU/LTC nurse manager (Staff #701). During the interview, the manager stated all patients admitted for emergency, outpatient, observation, inpatient, and/or swing bed services are given written lists of patient rights.

2. Review of the list of rights given to patients and an additional list of rights given to swing-bed patients showed that the lists did not inform patients that they had the right to choose their own visitors and that hospital staff members could not restrict visitors based on racial and/or gender bias.
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Based on interview and document review, the Critical Access Hospital failed to conduct a facility-based risk assessment using an all-hazards approach.

Failure to conduct a facility-based risk assessment using an all-hazards approach prevents the facility from preparing a coordinated and meaningful response to emergencies, hazards, and disasters most likely to occur, thus placing patients and staff at risk for serious harm, including death.

Findings included:

On 07/12/18 at 9:00 AM during an interview with the hospital's plant operations manager (Staff #103) regarding the hospital's emergency preparedness plan, Surveyor #1 asked to see the hospital's facility-based risk assessment. The manager provided the hospital's emergency preparedness plan which showed a risk assessment based on external factors such as fire and bomb threats but did not utilize an all-hazard approach to include internal factors such as interruptions in communication and utility failures.


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Based on interview and review of the Critical Access Hospital's emergency preparedness plan, the Critical Access Hospital failed to develop policies and procedures defining how the facility will preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records in the event of an emergency.

Failure to develop policies and procedures for management of medical documentation in emergency situations places patients at risk of harm due to inconsistent continuity of care and breach of confidentiality of medical information.

Findings included:

On 07/12/18 at 10:30 AM during an interview with the hospital's plant operations manager (Staff #103) regarding the hospital's emergency preparedness plan, Surveyor #1 asked to see the hospital's policies and procedures for handling and maintaining medical records during emergencies and disasters. The plant operations manager stated that they had not developed policies and procedures to meet the above criteria.
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Based on interview and review of the hospital's emergency preparedness plan, the Critical Access Hospital failed to develop a communication plan that included a method for sharing information and medical documentation for patients with other health care providers, a means to release patient information in the event of an evacuation, and a means of providing information about the general condition and location of patients.

Failure to develop a method for sharing information and medical documentation for patients with other health care providers places patients at risk for unmet healthcare needs and delay in treatment.

Findings included:

On 07/12/18 at 10:45 AM Surveyor #1 interviewed the Plant Operations Manager (Staff #103) regarding the hospital emergency preparedness plan. The surveyor asked to review the communication plan within the emergency preparedness plan. Review of this plan showed that the hospital did not have a method in place for sharing information and medical documentation for patients with other health care providers in the event of an emergency.
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Based on interview and review of the hospital's emergency preparedness plan, the Critical Access Hospital failed to analyze table top exercises and full scale drills to identify gaps and address needs for improvement of the plan.

Failure to analyze drills and exercises risks implementation of an ineffective emergency preparedness plan, which can result in harm to patients, staff, and visitors during emergencies and disasters.

Findings included:

On 07/12/18 at 11:00 AM during an interview with the Plant Operations Manager (Staff #103) regarding the hospital's emergency preparedness plan, Surveyor #1 asked to see documenation of any action plans for improvement. The manager stated that they were involved with a full scale drill with the region 9 and had one table top exercise but was unable to provide any documentation of analysis of these exercises.
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