HospitalInspections.org

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Based on observation and interview, the critical access hospital failed to maintain walls in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Reference: AORN Guideline for Design and Maintenance, (2019) - "Recommendation XII.a. The integrity of structural surfaces (eg, doors, floors, walls, ceilings, cabinets) should be maintained, and surfaces should be repaired when damaged. ...XII.a.1. ...Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Last Update July 2019) (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee).

Findings included:

1. On 06/14/22 at 1:15 PM Surveyor #4 observed a terminal cleaning in Operating Room 1. During the observation, the surveyor noticed several gouges and missing paint along the lower half of the drywall on both walls adjacent to the door.

2. On 06/15/22 at 1:30 PM Surveyor #4 observed a discharge cleaning in patient room 115. During the observation, the surveyor noticed the laminated surface on the sink edge had chipped off, exposing the particle board underneath.

3. On 06/16/22 at 8:45 AM, Surveyor #4 observed a patient dialysis set up in room 127. During the set-up procedures, the surveyor observed missing paint and drywall gouges along the wall surface adjacent to the sink where the dialysis carts were positioned.

At the time of each observation, Surveyor #4 discussed the surfaces with the Assistant Administrator (Staff #401). Staff #401 confirmed the surfaces were damaged and stated the facility does a quarterly environment of care rounding to look for these types of items and possibly needs to increase the rounding frequency.
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Based on observation, interview and document review, the hospital failed to maintain air pressure relationships consistent with industry standards for ventilation in healthcare facilities.

Failure to maintain the ventilation within industry standard tolerances places patients at risk for inadequate care or infection and staff at risk for infection or occupational exposure to hazardous chemicals.

Reference: Centers for Disease Control and Prevention (CDC): Guidelines for Environmental Infection Control in Healthcare Facilities (2003), updated July 2019. Ventilation Specifications for Health-Care Facilities Table B.2, Pg. 226. In Clean workrooms and Clean linen storage air movement relationship to the adjacent area should be out; in soiled or decontamination rooms air movement relationship to the adjacent area should be in.

Findings included:

1. On 06/14/22 at 2:00 PM, Surveyor #4 inspected the Emergency Department with the Assistant Administrator (Staff #401). During the inspection, the surveyor used a flutter strip to check the air flow at the entrance to the soiled utility room. The air did not appear to be under negative pressure.

2. On 06/16/22 at 4:00 PM, Surveyor #4, Staff #401, and the Director of Maintenance (Staff #406) observed the air flow at the entrance to the soiled utility room in the Emergency Department. Staff #406 confirmed that the vent was not operating and the air was not under negative pressure.

3. On 6/16/22 at 4:15 PM, Staff #406 provided the Negative Pressure Rooms checklist. Surveyor #4 reviewed the 2022 (to date) checklist for the ER Soiled Utility room. Staff #406 stated a belt had gone out and would be replaced by maintenance right away.
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Item #1 Restraint Face to Face Assessment

Based on record review, interview, and review of the hospital policy and procedure, the hospital failed to ensure that patients placed in restraints or seclusion received a face-to-face assessment within one hour by a physician or licensed independent practitioner as directed by hospital policy for 2 of 2 patients in violent restraint reviewed (Patients #503 and #504).

Failure to perform the required face-to-face evaluation to determine whether the patient actually meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," policy number 4671, dated 05/18/21, showed the following:

a. A face-to-face evaluation must occur with in 1 hour of restraint application.

b. A Physician must document face-to-face evaluations to include:

i. The patient's immediate situation.

ii. The patient's reaction to the intervention.

iii. The patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion.

iv. Revises the patient's plan of care for treatment and services as needed.

2. On 06/15/22 at 3:56 PM, Surveyor #5 and the System Director of Quality (Staff #501) reviewed the medical record for Patient #503 who was placed in violent restraints on 11/26/21. The reviewed showed a restraint order set documented as completed on 11/26/21 at 4:47 PM that included:

a. Restraint Initiate Violent 18 years and more

b. Restraint Monitoring Violent

c. Review Restraint Prior to Expiration-Contact Physician

d. Face to Face Assessment

e. Restraint Debriefing

Surveyor #5 found no evidence a Provider completed and documented a Face to Face evaluation as directed by hospital policy and regulation.

3. On 06/15/22 at 4:45 PM, Surveyor #5 and Staff #501 reviewed the medical record for Patient #504 who was placed in violent restraints on 10/25/21. Surveyor #5 found no evidence a Provider completed and documented a Face to Face evaluation as directed by hospital policy and regulation.

4. At the time of the record reviews, Staff #501 verified the providers did not document a face to face assessment as directed by hospital policy.

Item #2 Restraint Orders

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that orders for restraints to manage violent or self-destructive behavior did not exceed four hours for adults for 1 or 2 patients in violent restraints reviewed (Patient #504).

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

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," policy number 4671, dated 05/18/21, showed the following:

a. Restraints are used in accordance with the order of a physician who is responsible for the care of the patient.

b. Violent restraint orders must be renewed every 4 hours for adult patients 18 years and older

2. On 06/15/22 at 4:45 PM, Surveyor #5 and the System Quality Director (Staff #501) reviewed the medical record of Patient #504 who was placed in violent restraints on 10/25/21. The reviewed showed the following:

a. A provider ordered 4-point Violent Restraints on 10/25/21 at 8:45 PM.

b. The patient was placed in 4-point restraints at on 10/25/21 at 9:00 PM.

c. A provider ordered 4-point Violent Restraints on 10/26/21 at 5:12 AM.

d. The restraints were removed on 10/26/21 at 1:00 PM.

Surveyor #5 found no evidence a provider reordered the violent restraints after the initial order on 10/25/21 at 8:45 PM until 10/26/21 at 5:12 AM (a period of 8 hours and 27 minutes).

Surveyor #5 found no evidence a provider reordered the restraint from 10/26/21 at 5:12 AM and then the restraints were removed on 10/26/21 at 1:00 PM (a period of 7 hours and 48 minutes).

3. At the time of the review, Staff #501 verified the missing orders for violent restraints.

Item #3 Restraint Assessments

Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that hospital staff members assessed and monitored patients while in restraints as directed by the hospital's restraint policy, as demonstrated by 2 of 2 patient placed in violent restraints reviewed (Patient #503 and #504).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," policy number 4671, dated 05/18/21, showed the following:

a. The Registered Nurse is responsible for reassessing and monitoring the patient in restraints.

b. A qualified Registered Nurse must assess the patient at established timeframe's.

c. Violent restraint is assessed and documented every 15 minutes for one hour and then every hour and as needed.

d. Violent restraint assessment includes:

i. The reason for the restraint/evaluation of need.

ii. Restraint type

iii. Restraint Site Assessment including signs of injury and circulation.

iv. Orientation/Level of Consciousness

v. Behavior Status

vi. Patient Position

vii. Respirations

viii. Alternative Interventions

ix. Discharge readiness attempts.

Care that can be delegated to qualified staff members is provided at least every 2 hours includes nutrition/hydration, elimination, hygiene, range of motion, activity and vital signs.

2. On 06/15/22 at 3:56 PM, Surveyor #5 and the System Director of Quality (Staff #501) reviewed the medical record for Patient #503 who was placed in violent restraints on 11/26/21 at 4:47 PM and released from restraint on 06/15/22 at 7:45 PM.

Surveyor #5 found no evidence staff completed and documented a violent restraint assessment every 15 minutes for one hour after the application of violent restraint.

Surveyor #5 found no evidence staff completed and documented a violent restraint assessment every hour while the patient was restrained.

3. At the time of the review, Staff #501 verified the missing assessments.

4. On 06/15/22 at 4:45 PM, Surveyor #5 and the System Quality Director (Staff #501) reviewed the medical record of Patient #504 who was placed in violent restraints on 10/25/21 at 9:00 PM and released from restraint on 10/26/21 at 1:00 PM. The reviewed showed the following:

Surveyor #5 found no evidence staff completed and documented a violent restraint assessment every 15 minutes for one hour after the application of violent restraint.

Surveyor #5 found no evidence staff completed and documented a violent restraint assessment each hour from 10/25/21 at 9:00 PM until 10/26/21 at 8:00 AM (a period of 11 hours).

5. At the time of the review, Staff #501 verified the missing documentation.

Item # 4 Safe Use of Equipment

Based on observation, interview, and document review, the hospital failed to implement its policy and procedure for the safe use of blanket warmers.

Failure to implement procedures for patient care equipment places patient at risk for injury.

Findings included:

1. Document review of the hospital's policy titled, "Blanket and Fluid Warmer Policy and Procedure," policy number 559, dated 07/01/20 showed the following:

a. Blanket warmers are not to exceed 54 degrees Celsius or 130 degrees Fahrenheit.

b. Warmers used for blankets and solutions must be monitored daily for temperature and the temperature must be documented.

c. If there is a problem with the temperature, Biomed will be notified.

2. On 02/14/22 at 9:42 AM, Surveyor #5, the System Quality Director, and the Director of the Family Birthing Center (Staff #502), inspected a clean utility room adjacent to the Intensive Care Unit (ICU) bed #B. The review showed the following:

a. A Pedigo P2010S Blanket warmer with a current temperature of 144 degrees Fahrenheit.

b. The daily monitoring form showed missing temperature checks for the current month for 8 of 14 days.

c. The documentation for 06/14/22 showed that the temperature was 140 degrees Fahrenheit and the action taken for a temperature out of range stated, "no change."

3. At the time of the observations, Staff #501 and #502 verified the missing daily temperature checks, verified the documentation of temperature outside of range, and documentation of no action taken by staff.

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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to implement an effective process to ensure that medication incidents and unanticipated outcomes were reported into the hospital's incident reporting system according to hospital procedure for 1 of 1 events identified (Patient #505).

Failure to ensure timely reporting of patient incidents and events limits the hospital's ability to implement measures that prevent or mitigate future patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "medication Error Reporting Policy," policy number 6293, dated 11/30/21, showed the following:

a. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm.

b. Significant Medication Errors are defined as those which require medical intervention and/or result in possible or confirmed morbidity or mortality.

c. When a medication error occurs, any clinical staff who witnessed or was involved with a medication error must report the error in detail in the electronic incident management system (IDinc).

d. The pharmacy director or designee will be notified by email to complete the IDinc report.

2. On 06/16/22, Surveyor #5, the System Director of Quality (Staff #501), and the Director of Medical/Surgical/Intensive Care (Staff #507) reviewed the medical record for Patient #505 who was admitted on 01/03/22 for the treatment of Septic Shock and a Left Lower Lobe Pneumonia. The patient had a history of diabetes and a seizure disorder. The review showed the following:

a. On 01/03/22 at 11:00 PM, documentation on the patient's medication history showed the patient took Lamictal 100 mg's (medications to treat epileptic seizures) twice daily.

b. On 01/03/22 at 11:01 PM, a provider ordered Lamictal 100 mg twice daily by mouth. The order document showed that Lamictal was a non-formulary medication. The order stated to use "Patient Supply." The Lamictal order showed the next dose to start on 01/03/22 at 11:30 PM.

c. The Lamictal order was validated by nursing on 01/03/22 at 11:16 PM.

d. The Lamictal order was validated by Pharmacy on 01/04/22 at 6:47 PM.

e. Nursing documentation on the medication administration record showed the medication was not available and that the patient was not given a dose of the medication until 01/11/22 at 9:43 PM (16 missed doses) including:

i. 03/04/22 at 2:07 AM, "Not given: no med"

ii. 03/04/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

iii. 03/04/22 at 8:55 PM, "Not Given: Other"

iv. 03/05/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

v. 03/05/22 at 9:53 PM, "Not Given: Other"

vi. 03/06/22 at 9:00 AM, "Not Done: Not here"

vii. 03/06/22 at 9:10 PM, "Not Given: Other"

viii. 03/07/22 at 9:00 AM, "Not Done: Not here"

ix. 03/07/22 at 9:58 PM, "Not Given: Other"

x. 03/08/22 at 9:00 AM, "Not Done: Not Available"

xi. 03/08/22 at 9:55 PM, "Not Given: Other"

xii. 03/09/22 at 9:00 AM, "Not Done: Not Available"

xiii. 03/09/22 at 9:57 PM, "Not Given: not available patient own med"

xiv. 03/10/22 at 9:02 AM, "Not Done: Equipment/Supplies Unavailable"

xv. 03/10/22 at 9:30 PM, "Not Given: Other"

xvi. 03/11/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

e. On 01/10/22 at 5:25 PM, the patient had a seizure and was treated with Ativan IV

f. On 01/11/22 at 9:44 PM a provider note stated, "Discharge was held yesterday because of breakthrough seizures. No further seizure today ...history of seizure disorder. Breakthrough seizures likely secondary to inadequate medication dosing. Need to give her full dose of antiseizure medications today. We have asked the group home to bring in her Lamictal."

3. At the time of the review, Staff #501 stated that the medication omission and resulting seizure event had not been reported through the hospitals error reporting system and staff should have reported the incident

4. At the time of the review, Staff #501 and Staff #507 stated that they were unaware of the incident.

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Based on document review and interview the hospital failed to ensure that staff appropriately completed an admission nutritional screening/risk assessment according to hospital policy for 1 of 1 patients with nutritional deficiencies reviewed (Patient #506).

Failure to ensure that patients receive appropriate nutritional risk assessments on admission risks improper nutrition that could lead to unanticipated patient outcomes.

Findings included:

1. Document review of the hospitals policy and procedure titled, "Nutritional Screening and Assessment by Registered Dietician Policy," policy number 7308, dated 10/25/19, showed the following:

a. The Malnutrition Screening Tool (MST) is a tool used to screen patients to determine if they are at nutrition risk upon admit.

b. Nutrition consults triggered by the nursing admission malnutrition screening tool and consults generated per policy, are evaluated using the same guideline use to determine risk level of High, Moderate or Low.

c. Nutrition consults, screenings, and assessments are completed within the specified timeline (High risk 1-2 days of identification/notification, Moderate risk 2-3 days of identification/notification, low risk 5-7 days of identification/notification).

d. Identifiers for patients at moderate nutritional risk on the Nutritional Risk Screen completed by the Registered Nurse include weight decrease (any amount in the past 1, 3, or 6 months), decreased appetite, decreased food intake the past 7 days, and difficulty chewing or swallowing.

Document review of the hospitals policy and procedure titled, "Parenteral Nutrition Policy," policy number 6375, dated 10/18/18, showed the following:

a. The Registered Dietician will assess patients who have not received nutrition for 3 or more days and make a recommendation to the Physician.

b. Patients who will be unable to eat for more than 7 days, who have not been eating, or who have suffered more than a 10% to 20% weight loss are candidates for parenteral nutrition.

2. On 06/14/22 at 10:10 AM, Surveyor #5 and a Registered Nurse (Staff #509) reviewed the medical record for Patient #506 who was admitted to the hospital on 05/22/22 for the treatment of shortness of breath, pneumonia, and acute respiratory failure. The patient had a history of a recently diagnoses hiliar mass (an abnormality in one or both of the hilar lymph nodes in the lungs. It normally indicates bronchogenic carcinoma (cancer) or bronchial obstructions. The biopsy showed the patient had Tuberculosis. The record review showed the following:

a. On 05/22/22 at 4:56 PM, the nursing MST assessment showed a score of zero (no risk for nutritional deficiency). The documentation showed no weight loss, no decreased appetite, and no changes in nutritional status.

A nutritional consult by a dietician was not triggered in the electronic documentation system.

b. On 05/22/22 at 6:20 PM, the Admission History and Physical stated that the family complained that the patient has been having difficulty swallowing and has a recent 20-pound weight loss. The provider documented that the patient will also receive a swallow evaluation to rule out aspiration.

c. Documentation of nutritional intake showed the following:

i. On 05/22/22 the patient diet order was nothing by mouth (NPO). No intake was recorded.

ii. On 05/23/22, the patient diet order was pureed modified texture that was changed to full liquid regular texture in the evening. For breakfast the patient intake was documented 0-25% and for lunch the patient intake was documented 0-25%. No intake was documented for dinner.

iii. On 05/24/22, for breakfast the patient intake was documented 76-100%. No intake was documented for lunch or dinner.

iv. On 05/25/22, for breakfast the patient intake was documented 76-100%. No intake was documented for lunch. Dinner intake was documented at 0-25%.

v. On 05/26/22, no intake was documented for breakfast, lunch or dinner.

vi. On 05/27/22, no intake was documented for breakfast, lunch or dinner.

vii. On 05/28/22, the patient diet order was NPO. No intake was recorded.

viii. On 05/29/22, a provider ordered intravenous nutrition.

ix. On 05/31/22, the patient diet order was for consistent carbohydrate pureed food (in addition to IV nutrition). No intake was documented for breakfast, lunch or dinner.

x. On 06/01/22 at 4:10 PM, a Nutrition Note showed that the patient as being assessed related to length of stay and poor intake. The patient was currently receiving IV nutrition. The dietician documented that they had not been consulted but learned from chart review. The dietician noted that the MST was zero on admission, but that the patient had significant weight loss since the last admit. The patient's overall nutritional status was assessed at Severe Risk. The nutritional diagnosis was documented as "inadequate protein-energy intake related to suboptimal oral intakes as evidenced by poor PO (by mouth intake) and significant weight loss prior to admission".

3. At the time of the review, Staff #501 verified that the because the admission nutrition risk showed no risk, a nutritional evaluation was not triggered in the electronic system.

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Based on interview and document review, the hospital failed to develop and implement an effective process to ensure that staff administered non-formulary patient medications according to scheduled dosing times and failed to ensure that staff implemented appropriate action when scheduled doses were not administered for 1 of 1 patients reviewed (Patient #505).

Failure to administer medications according to scheduled dosing times may cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect.

Findings included:

1. Document review of the hospital's policy titled, "Medication Administration Schedule Policy," policy number 1589, dated 10/18/18, showed the following:

a. The purpose of the policy is to reduce the incidence of medication errors and to streamline communication between Pharmacy, Nursing, and Physicians.

b. Medications may be administered sixty (60) minutes before or after the scheduled administration time.

c. Deviations from the standardized schedule are permitted with specific written instruction from the physician.

d. Deviations from the standardized schedule are permitted with specific written instruction from the pharmacist.

Document review of the hospital's policy titled, "Personal Medications Policy," policy number 396, dated 06/09/17, showed the following:

a. A non-formulary drug is any drug that has not been reviewed by the committee or has been reviewed and denied inclusion on the formulary.

b. Non-formulary drugs are not stocked by the Pharmaceutical Services Department and are not available for routine use.

c. Non-formulary drugs may be ordered for individual patients when sound pharmaceutical and/or therapeutic considerations dictate.

d. If it is determined that there is a compelling reason to use the patient's own medication, a Physician's order is required. Examples of valid justification for use include non-formulary medications which the Pharmaceutical Services Department has difficulty obtaining.

e. If the Physician orders a non-formulary medication and the patient has their own, it may be administered after the Pharmacists has identified and examined the drugs to ensure acceptable quality for use in the hospital.

f. The nurse will store the authorized medications with the other routine medications. The nurse will administer the medications and record their use on the Medication Administration Record (MAR).

Document review of the hospital's policy and procedure titled, "Ordering Non-Formulary Medications Policy and Procedure," policy number 7129, dated 08/16/21, showed the following:

a. Should a non-formulary emergency drug be required, (only In-Patient Status) the Physician, who determines the situation emergent (No available medications can be used in the situation) will in a timely manner request that Pharmacy obtain this drug locally, either from nearby hospitals or by purchasing from a local pharmacy.

b. The Physician will provide all needed documentation for the Pharmacy to purchase at a local Pharmacy. The Hospital will cover the cost.

c. The pharmacy director or designee will be notified by email to complete the IDinc report.

2. On 06/16/22, Surveyor #5, the System Director of Quality (Staff #501), and the Director of Medical/Surgical/Intensive Care (Staff #507) reviewed the medical record for Patient #505 who was admitted on 01/03/22 for the treatment of Septic Shock and a Left Lower Lobe Pneumonia. The patient had a history of diabetes and a seizure disorder and lived in a group home. The review showed the following:

a. On 01/03/22 at 11:00 PM, documentation on the patients medication history showed the patient took Lamictal 100 mg's (medications to treat epileptic seizures) twice daily.

b. On 01/03/22 at 11:01 PM, a provider ordered Lamictal 100 mg twice daily by mouth. The order document showed that Lamictal was a non-formulary medication. The order stated to use "Patient Supply." The Lamictal order showed the next dose to start on 01/03/22 at 11:30 PM.

c. The Lamictal order was validated by nursing on 01/03/22 at 11:16 PM.

d. The Lamictal order was validated by Pharmacy on 01/04/22 at 6:47 PM.

e. Nursing documentation on the medication administration record showed the medication was not available and that the patient was not given a dose of the medication until 01/11/22 at 9:43 PM (16 missed doses) including:

i. 03/04/22 at 2:07 AM, "Not given: no med"

ii. 03/04/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

iii. 03/04/22 at 8:55 PM, "Not Given: Other"

iv. 03/05/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

v. 03/05/22 at 9:53 PM, "Not Given: Other"

vi. 03/06/22 at 9:00 AM, "Not Done: Not here"

vii. 03/06/22 at 9:10 PM, "Not Given: Other"

viii. 03/07/22 at 9:00 AM, "Not Done: Not here"

ix. 03/07/22 at 9:58 PM, "Not Given: Other"

x. 03/08/22 at 9:00 AM, "Not Done: Not Available"

xi. 03/08/22 at 9:55 PM, "Not Given: Other"

xii. 03/09/22 at 9:00 AM, "Not Done: Not Available"

xiii. 03/09/22 at 9:57 PM, "Not Given: not available patient own med"

xiv. 03/10/22 at 9:02 AM, "Not Done: Equipment/Supplies Unavailable"

xv. 03/10/22 at 9:30 PM, "Not Given: Other"

xvi. 03/11/22 at 9:00 AM, "Not Done: Equipment/Supplies Unavailable"

e. On 01/10/22 at 5:25 PM, the patient had a seizure and was treated with Ativan IV 0.5 mg intravenously.

f. On 01/11/22 at 6:36 AM, a nursing note stated, "Patient did not have a seizure on night shift. Patient was able to ambulate to the bathroom with moderate assistance. Patient took medications in pudding whole. Need to call group home about home seizure medication Lamictal."

g. On 01/11/22 at 9:44 PM a provider note stated, "Discharge was held yesterday because of breakthrough seizures. No further seizure today ...history of seizure disorder. Breakthrough seizures likely secondary to inadequate medication dosing. Need to give her full dose of antiseizure medications today. We have asked the group home to bring in her Lamictal."

h. On 03/11/22 at 9:43 PM, the patient was given the first dose of the Lamictal.

Surveyor #5 found no evidence staff contacted the patients group home to obtain the antiseizure medication.

Surveyor #5 found no evidence staff contacted the pharmacy or the patient's provider related to the unavailable medication.

Surveyor #5 found no evidence staff contacted the provider related to the missed doses of the Lamictal.

3. At the time of the review, Staff #501 and #507 verified the finding including the medication omissions, documentation of the seizure, and the provider orders. At this time, Staff #501 called to the pharmacy to verify the procedure for medications from home. Staff #501 stated that the pharmacist (Staff #508) stated that it was the nurse's responsibility to call and have the medications brought to the hospital and then pharmacy would review the medication.

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Based on interview, medical record review, and review of the hospital's policy and procedures, the hospital failed to ensure that providers completed a pre-sedation evaluation for 2 of 2 patients receiving procedural sedation (Patient #501 and #502).

Failure to perform a pre-sedation evaluation puts patients at risk of harm or injury due to physical conditions that would not be identified or recorded and readily accessible to all providers caring for the patient and risks patients not receiving treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Moderate (Procedural) Sedation Policy and Procedure," policy number 240, dated 03/01/18, showed the following:

a. The physician will complete a focused history and physical examination.

b. Supportive documentation must be in the record prior to the procedure on all patients receiving moderate sedation; to include documentation of:

i. Assessment of risk; ASA Classification

ii. Airway Assessment

iii. The plan for sedation

iv. Evaluation of the patient immediately before administering moderate sedation

2. On 06/16/22 at 10:35 AM, Surveyor #5 and the System Director of Quality (Staff #501) reviewed the medical records for Patient #501 who had received procedural sedation on 05/04/22. Surveyor #5 found no evidence the provider completed and documented an assessment of risk (ASA Classification), an airway assessment, a plan for sedation, or an evaluation of the patient immediately before administering moderate sedation.

3. On 06/16/22 at 11:00 AM, Surveyor #5 and the System Director of Quality (Staff #501) reviewed the medical records for Patient #502 who had received procedural sedation on 02/16/22. Surveyor #5 found no evidence the provider completed and documented an assessment of risk (ASA Classification), an airway assessment, a plan for sedation, or an evaluation of the patient immediately before administering moderate sedation.

4. At the time of the review, Staff #501 verified the missing assessments and documentation.

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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the infection control professional was appointed by the governing body, and that the appointment is based on recommendation from the medical staff leadership and nursing leadership.

Failure to follow infection control program organizational policies could result in an unqualified infection control professional overseeing the program which could place patients at increased risk of infection and/or illness.

Findings included:

1. Document review of hospital policies titled, "Corporate Bylaws of Sunnyside Healthcare (a Washington nonprofit corporation)," no policy number, adopted 09/15/16, and "Amended and Restated Bylaws of Sunnyside Community Hospital Association (a Washington nonprofit corporation)," no policy number, effective 03/23/17, showed an overview of the governing body responsibilities including to ensure governance structure and operation are appropriate and statutes are followed. No provision for infection control professional appointment was included.

2. On 06/16/22 at 2:30 PM, Surveyor #4 held an infection control meeting to discuss the hospital infection control program. During the meeting the surveyor interviewed the Infection Preventionist (Staff #402) about the qualifications and appointment process. Staff #402 indicated that she was not appointed through the governing body (board).
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Item 1 - CAPR/PAPR maintenance

Based on observation, interview, and document review, the hospital failed to ensure it had an effective process in place to ensure that Controlled Air Purifying Respirators (CAPR)/ Powered Air-Purifying Respirators (PAPR) filters were changed as directed by the manufacturer.

Failure to maintain CAPR/PAPR's puts staff and patients at risk of contracting infectious disease.

Reference:

MAXAIR® Systems CAPR and PAPR manufacturer Frequently Asked Questions, "How often does the filter need to be changed?" no date, showed that filter changes depend upon the application, the environment where used, the frequency and duration of use, and the organization's protocol for the prevention of cross contamination. In addition, due to its self-monitoring system, the yellow LED will illuminate when airflow intake nears the threshold of 6 cfm (170 liters per minute), allowing the user ample time to exit the working environment, and change out a heavily loaded filter. Otherwise, filter change-out a minimum of every six-to-twelve months is recommended.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Max Air Powered Air Purifying Respirator," policy number 1978, dates 03/01/20 showed the following:

a. The filter should be replaced upon patient discharge regardless of its condition.

b. Filters should be changed when breathing resistance increases or the filter becomes damaged or exposed to blood or body fluids.

2. On 06/15/22 at 1:30 PM, Surveyor #5, the System Quality Director (Staff #501), the Chief Nursing Officer (Staff #505), and the Emergency Department Director (Staff #506) inspected the hospital's Emergency Department. Surveyor #5 observed the following:

a. 1-Max Air Powered Air Purifying Respirator (CAPR), number B-31046 with a filter dated 12/20.

b. 1-Max Air Powered Air Purifying Respirator (CAPR), number B-31060 with a filter dated 03/21.

c. 1-Max Air Powered Air Purifying Respirator (CAPR), number B-24493 with a filter dated 09/21.

3. At the time of the observation, Staff #505 verified the dates on the CAPR's. Staff #506 stated that the filters were changed when the indicator light showed the filter needed changed. Surveyor #5 and Staff #501 verified the manufacturer's recommendations for filter changes.


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Item 2 - Hydrocollator cleaning frequency

Based on observation, interview and document review, the facility failed to maintain its hydrocollator according to the manufacturer's scheduled cleaning frequency.

Failure to keep the hydrocollator clean and maintained puts patients at risk of infection.

Findings included:

1. Document review of the manufacturer's instructions for use for the Chattanooga E-2 hydrocollator showed that it is essential that water be added daily and that the tank should also be drained and cleaned systematically, at minimum intervals of every two weeks.

Document review of the Outpatient Aide Duties checklist for the Astria Therapy Services facility showed that the hydrocollator is to be cleaned once per month, and water/temperature checks done daily.

2. On 06/14/22 at 2:45 PM, Surveyor #4 observed the facility's hydrocollator. The surveyor interviewed the Director of Audiology and Therapy (Staff #403) regarding the maintenance of the hydrocollator. Staff #403 stated the hydrocollator is drained and cleaned monthly, and the water level and temperature are checked daily.

3. On 06/15/22 at 8:30 AM, the Assistant Administrator stated that the physical therapy hydrocollator cleaning procedure had been updated and provided Surveyor #4 with a copy of the amended checklist indicating the cleaning frequency would be every 2 weeks.

Item #3 Surgical Attire

Based on observation, interview and review of hospital policy and procedure, the hospital failed to ensure staff followed standard infection control practices for surgical attire in 2 of 6 surgical staff observed.

Failure to ensure staff members follow hospital policy for procedural attire places patients and staff at risk for developing infections.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Surgical Attire," policy number 553, dated 10/25/19, showed the following:

a. Surgical Attire consists of hospital issued top and bottom, and a surgical hat or hood, or a bunny suit, and shoe covers for non-dedicated OR (Operating Room) shoes.

b. All persons who enter semi-restricted areas within the hospital will be in surgical attire.

c. All reusable attire shall be laundered after each use in a laundry facility approved and monitored by the hospital.

d. All head and facial hair is to be covered will in the restricted areas.

2. On 06/15/22 from 9:50 AM until 11:25 AM, Surveyor #5 and the System Quality Director (Staff #501) observed a surgical case set up, patient prep, and surgery start, in the hospital's Operating Room #1. The observations showed the following:

a. A circulating Nurse (Staff #502) wearing a cloth surgical cap.

b. The surgeon with a full beard, with no beard cover and wearing a cloth surgical cap.

3. At the time of the observation, Surveyor #5 asked Staff #502 about the hospital's policy related to reusable cloth caps and the cleaning process. Staff #502 stated that she washed her caps at home and used a clean one each day.

4. On 06/15/22 at 11:23 AM, Staff #501 verified that the observation and stated that the surgeon should have worn a beard cover and that she would need to review the hospital's policy for reusable head coverings.
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Based on interview and document review, the hospital failed to ensure that medical accommodation requests complied with the Federal COVID-19 vaccine mandate for 1 of 4 staff requests reviewed.

Failure to fully develop and implement policies and procedures to ensure that the hospital has a standardized method for evaluating and documenting accommodations for COVID-19 vaccination, places patients, visitors, staff, and the community at risk.

Findings included:

1. Review of the hospital policy titled, "Implementing Proclamation 21-14 COVID-19 Vaccination Requirement August 2021," policy number 7904, approved 02/03/22, showed that exemptions from vaccination requirements would be allowed for disability related reasonable accommodations and reasonable accommodations for a sincerely held religious belief. Individuals requesting disability accommodation fill out the Astria Health Request for Accommodation: Medical Exemption form and are to submit the form with documentation from an appropriate health care or rehabilitation professional authorized to practice in Washington state.

2. Review of the 4 requested medical exemptions showed that all were signed by a medical provider, but 1 of 4 were missing the specific vaccine contraindication and clinical reason for the exemption (Staff #407).

3. On 06/15/22 at 2:50 PM, Surveyor #4 interviewed the Director of Human Resources (Staff #404) about the process for COVID-19 vaccine exemption, the facility's policy and documentation process. Staff #404 confirmed that the request for medical exemption documentation was missing vaccine contraindication and clinical reason for 1 of the 4 medical exempted staff reviewed (Staff #407).
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