HospitalInspections.org

40575


Based on observations, it was determined that the CAH failed to ensure that the physical environment was maintained in a safe, clean, and orderly manner for patients and staff. Areas in the CAH were cluttered, disorganized, dirty and in disrepair.

Findings include:

1. During tour of the EVS department supply storage room on 11/14/2019 beginning at 1110 with the EVSM the following observations were made:
* At 1115 the shelving that holds cleaning solutions was observed in disrepair. The metal shelves had both brown and white discoloration that appeared to be peeling and rusted.
* The shelves holding supplies for the commercial carpet cleaning machine had 2 open measuring cups with an unidentified solution/cleaner in it.
* There were 2 large storage bins near a small sink with containers of cleaning solutions and a box of some type of cleaning solution on top of the containers with brown/rusty discoloration on both bin containers.
* At 1135 the concrete flooring in the clean linen supply area was observed to be discolored and peeling.
* At 1139 the dirty linen storage area was cluttered with old unused washing/drying machines, a rack of grey sharps containers, garbage cans, large bins, yellow mop buckets, an old vacuum, clothing, a bicycle and numerous other items.

2. During tour of the Laboratory department on 11/14/2019 beginning at 1145 with the LabM, a portion of the flooring near the entrance was observed in disrepair and had brown and black discoloration with peeling laminate.

3. During a tour of the ED on 11/12/2019 with CAH staff that included the ED NM and QM the following observations were made:
* At 1605, observation of the Peds cart reflected the edge on the top corner of the cart was missing and was in disrepair. This was an uncleanable surface.
* At 1625, the wall near the wall-mounted glove dispenser had an irregular shaped area of white discoloration that was approximately nine inches by eleven inches that appeared to be peeling or otherwise in disrepair.

4. During tour of the L&D unit on 11/13/2019 at 1330 with the OBD and QM, the door between the L&D unit and the "swing area" was observed in disrepair. The door had an area of missing wood laminate along the edge near the bottom hinge. This is an uncleanable surface.

5. During tour of the Med/Surg unit on 11/13/2019 at 1435 with the MS/ICU NM, Room 222 door was observed in disrepair. The door had two areas of missing wood laminate along the edge near the bottom hinge. This is an uncleanable surface.

Based on observations, interviews, review of drug monitoring records, and review of policies and procedures it was determined that the CAH failed to fully develop and implement policies and procedures to ensure appropriate handling and control of drugs:
* Emergency cart drugs were not managed and controlled to ensure availability and integrity, and prevent theft, misuse, and tampering.

Findings include:

1. The policy and procedure titled "Emergency Equipment & Replacement - Code Carts," dated last revised "11/13/2019" was reviewed. It stipulated the following:
* "Policy Summary/Intent: To provide a standardized and effective system of maintaining equipment and medications. To systematically check, restock and clean the code carts. To maintain code cart readiness at all times."
* "Department RN's or designee is responsible for routine code cart checks. In departments where no RN is employed, staff will be oriented to code cart checks and maintenance responsibilities."
* "When a code cart has been opened and contents are confirmed as complete and ready for use a green lock to (sic) be placed on the cart and number documented."
* "Routine checks using the code cart checklist are completed by a department designee:" The policy reflected checks of the following were to be completed:
- "Equipment and supplies on the top, back and sides of the code cart."
- "The numbered breakaway seal is intact on the outer cart."
- "When a new numbered breakaway seal is placed on a cart, document the reason for replacing the seal...Should for any reason the lock number on the outside of the cart be different from day before without documentation; follow through with a complete inventory check..."

2. a. On 11/12/2019 at 1620 in the ED, an emergency code cart where emergency medications and supplies were kept was observed with the ED NM.

A 2-sided "Code Cart Checklist" form for the month of November 2019 was observed. The staff present at the time of the observation indicated that the checklist was used to verify that the contents inside both the adult code cart and the pediatric code cart were stocked and available for use.

The top of the code cart checklist reflected "Check once daily...Completeness of equipment and supplies - top, back, sides...Seals intact on med drawer and code cart - Seal lock in place note number...Portable suction plugged in...Verify every shift...Code cart checked/initialed during past 24-hour period."

For the adult code cart, the code cart checklist had a column for recording the "Seal [number] on Code Cart" (breakaway lock number) each day of the month. On 11/05/2019 the lock (seal) number was recorded as "024150." On 11/06/2019 the lock (seal) number was recorded as "007698." There was no documentation that reflected the reason for the changed lock (seal) number. On 11/09/2019 the lock (seal) number was recorded as "024181 Tag [change]." There was no documentation that reflected the reason for the "tag [lock number]" change. On 11/10/2019 the lock (seal) number column had a written over illegible entry and on 11/11/2019 the lock (seal) number was recorded as "024180." There was no documentation that explained the illegible entry.

A document observed in the ED that staff indicated reflected the contents of the adult code cart was reviewed. It reflected the cart contained numerous emergency medications and supplies including but not limited to: "Drawer 1: Medication Drawer...1 drug tray (in Sealed Tray)...Drawer 2: IV Start, Blood & Procedure Supplies...5 mL syringe...10 mL syringe...Extension set...2 needle free valve ports...16, 18, 20-gauge Angiocath...18- & 21-gauge needle...Valve cap...Alcohol prep pads...Med added labels...Carpoject...Band-Aids...Cholroprep (sic)...Venigards...2 x 2 sponges...Tourniquet (disposable)...1/2 [inch] Tape (Roll)...Infusion set...Secondary set...IV Fluid: 0.9% Normal Saline 500 mL..."

For the pediatric code cart, the code cart checklist had a "Peds Cart/Bag Seal [number]" column for recording the breakaway lock number each day of the month. On 11/05/2019 the lock (seal) number was recorded as "926496." On 11/06/2019 the lock (seal) number was recorded as "007612." There was no documentation that reflected the reason for the changed lock (seal) number. On 11/09/2019 the lock (seal) number was recorded "024181" with a line drawn through it and "Error" written next to it. There was no further documentation that reflected the reason for the error or what the correct lock (seal) number was on 11/09/2019. On 11/10/2019 the lock (seal) number was recorded "007612" with "007612" recorded a second time directly below it on 11/10/2019. There was no documentation that reflected the reason the lock (seal) number was recorded twice on 11/10/2019.

The bottom of the code cart checklist reflected "Initial in the box corresponding with the day of the month of checking the code cart...If you need to change a numbered seal, please record the date, new number and reason on the back side of the form..."

The back of the code cart checklist had spaces for documenting "Date...New Seal # for Code Cart...New Seal # for Peds Cart/Bag...Reason for new number(s)...Initials...Legible Signature." All of the spaces on the back of the form were blank. There was no documentation that reflected the reason for the lock (seal) number changes.

b. During an interview with the ED NM at the time of the code cart checklist review on 11/12/2019 at 1620 he/she acknowledged that the documentation on the code cart check list was unclear. The ED NM stated that the back of the code cart checklist should be filled out each time the code cart has been opened and the lock number is changed. The ED NM acknowledged that the back of the form had not been filled out and there was no other documentation to explain the reason the lock (seal) numbers were changed.

3. a. On 11/13/2019 at 1350 in the OB unit, the neonatal emergency cart where emergency medications and supplies were kept was observed with the OBD. The cart had a green breakaway lock (seal) on it. The lock (seal) had number "212403" on it. The drawers on the cart were labeled indicating the cart contained "Medications...IV Tray...Airway...Suction Drawer...Needle Aspiration Tray...Umbilical Cutdown Tray...Infant Transport Mattress."

A 2-sided "OB Equipment Checklist" form for the month of November 2019 was observed with the neonatal emergency cart.

The form had a column for recording the lock (seal) number each day. The last recorded lock (seal) number was recorded on 11/13/2019 and it was "926480."

The back of the form had spaces for documenting "Date...New Seal # for Code Cart...New Seal # for Top Box...New Seal # for Peds Cart/Bag...Reason for new number(s)...Initials...Legible Signature." All of the spaces on the back of the form were blank.

There was no documentation that reflected the reason for the discrepancy between the observed lock (seal) number "212403" and the recorded lock (seal) number "926480" on the cart checklist.

b. During an interview with the OBD on 11/13/2019 at the time of the observation at 1350, he/she confirmed the lock (seal) number observed on the cart and the lock (seal) number recorded on the cart checklist were not the same. The OBD stated the neonatal emergency cart was accessed the previous night and a new lock (seal) was put on the cart thereafter. However, he/she acknowledged the cart checklist was not updated to reflect the new (observed) lock (seal) number or the reason for the discrepancy.

4. During tour of the Surgical Services Department on 11/15/2019 at 1100 with CAH staff including the SSD and CNO, the PACU emergency cart was observed. The top drawer contained a bin of emergency medications and a list of the emergency medications that were normally stocked in the bin. The list included "Albuterol...Adenosine...Amiodarone...Atropine...Calcium chloride...Epinephrine...Lidocaine...Naloxone...Saline flushes...Sodium Bicarbonate...50% Dextrose...Potassium chloride...Magnesium Sulfate...Dopamine..." The bin had a lid on it with a breakaway lock (seal). However, the lid was observed to be easily lifted and the bin accessed with the lock (seal) remaining intact. The ability to easily access the drugs without breaking the lock (seal) did not ensure drug availability and created the risk of theft, misuse, and tampering. These observations were confirmed with the SSD on 11/15/2019 at 1105.

Based on observation, interview, review of policies and procedures, and other documentation it was determined that the CAH failed to ensure it fully developed and implemented policies, procedures and systems for infection prevention in the following areas:
* Environmental surfaces were in disrepair and were not cleanable.
* The integrity and cleanliness of patient care supplies was not ensured.
* Processes for cleaning, disinfection and management of instruments/devices on patient units and in SPD were unclear, and had not been fully developed and/or implemented.
* Cleaning and disinfection supplies were expired.
* A waterborne pathogens program was not fully developed and implemented.

Findings included:

1. Environmental surfaces were in disrepair and were not cleanable.

Refer to the findings identified under Tag C225 that reflects environmental surfaces in numerous departments and units were in disrepair and uncleanable.

2. The integrity and cleanliness of patient care supplies was not ensured.

a. During a tour of SSD and SPD on 11/15/2019 beginning at approximately 1100 with CAH staff that included the CNO, SSD, and AD the following observations were made:
At 1145 eight disposable airway devices were observed in the second drawer of the "Difficult Intubation Cart" in the hallway near SPD. None of the airways were in a package and there was no information that reflected if the airways had been used or were otherwise contaminated. The integrity and cleanliness of the airways could not be ensured. At the time of the observation, the SSD stated the airways were usually contained in a package.

b. Email documentation from DA dated 11/18/2019 at 1626 related to the oral airway observation reflected "Oral airways (OPA) open and out of their original plastic bags...Single-use clean airways are received individually wrapped in plastic at the point of use in surgery...Plastic airway bags are opened (debagged) in the Surgery department and immediately placed in a clean drawer of the difficult intubation cart...Tillamook Infection Prevention policy does not stipulate individual wrapping for oral airways..."

c. Email documentation from DA dated 11/19/2019 at 1229 related to the oral airway observation reflected "The Infection Prevention Plan...describes the frequency of which the anesthesia work surfaces will be wiped down...Additionally, the Infection Control Plan...describes the frequency in which the inside of the code carts are cleaned..." Review of the Infection Control Plan titled "Tillamook Regional Medical Center Infection Prevention Program" reflected in Section VIII "Utilization of disposable equipment, including...Oropharyngeal airways...Anesthesia machine work surfaces will be wiped down with hospital-approved disinfectant after each case or as often as needed and/or soiled..." and in section VI "...The code cart is cleaned by the department staff... Inside the Code Cart to be wiped down monthly, or sooner if necessary."

The email documentation reflected the CAH's IC plan had general information about cleaning carts and work surfaces where patient supplies were maintained. However, no IC policy and procedure was provided that reflected how the single-use oral airways observed were managed to ensure integrity and cleanliness, and prevent use on more than one patient.

3. Processes for cleaning, disinfection and management of instruments/devices on patient units and in SPD were unclear, and had not been fully developed and/or implemented.

On patient units:
a. During a tour of the ED on 11/12/2019 with CAH staff that included the ED NM and QM the following observations were made:
* At 1625, a hinged instrument/device was observed soaking in liquid in a red container in the soiled utility room. Staff present at the time of the observation indicated that the instrument/device was placed in the container after it was used during a procedure or was otherwise contaminated. The staff stated that the liquid the device was soaking in was Endozime, an enzymatic solution. The observation reflected the hinged instrument/device was not in the open position.

b. During tour of the OPS on 11/13/2019 with CAH staff that included the SSD the following observations were made:
* At 1225 a red container with instruments/devices soaking in liquid was observed in the soiled utility room. Staff present at the time of the observation indicated that the instruments were placed in the container after they were used, and the liquid they were soaking in was Endozime, an enzymatic solution. Two of the instrument/devices observed in the container were hinged devices that were not in the open position.

c. During an interview with the IP on 11/15/2019 at 1605 he/she stated that the hinged instruments/devices observed soaking in Endozime in the red containers in the soiled utility rooms should have been in the open position.

d. The following documents were provided in response to a request for policies, procedures and information related to management of contaminated instruments/devices used in patient units:
* The policy and procedure titled "Cleaning Contaminated Items in Patient Care Areas," dated last revised 08/27/2019 was reviewed. It stipulated:
- "Handing Contaminated Equipment within Clinical Departments...Immediately remove equipment and instruments from the patient's room and take to the soiled utility area. Refer to the Transportation of Contaminated Items to Designated Decontamination Area policy."

* The policy and procedure titled "Transportation of Contaminated Items to Designated Decontamination Area," dated last revised 11/14/2019 referenced above, was reviewed. It stipulated:
- "The following objectives are to provide operator of sterilization processes and the end user a standard of care...To ensure items are transported in a manner that contains the bioburden...To assure items are kept moist between end of use and the beginning of the decontamination process..."
- "Procedure For Hospital...hospital staff are required to load puncture proof, leak proof containers with contaminated items...Instrumentation used in procedure will be moistened with Endozime solution intended to pre-cleanse soiled instruments..."
- "The following steps must be followed..."
"Don appropriate PPE"
"Wipe procedure/exam instruments of gross contaminates and place them in the small transport container in the room"
"Remove gloves and perform hand hygiene"'
"Transport container to designated decontamination area for instrument soaking"
"Place instruments in designated container of Endozime solution, for delivery to Central Processing; hinged instruments must be in an open position..."
"Central Processing techs pick up soiled instruments Monday - Friday..."

e. The policies and procedures required that contaminated instruments/devices used in patient areas were to be taken to a designated area, placed in a container of enzymatic solution, and "hinged instruments must be in an open position." However, email documentation received from DA dated 11/19/2019 at 1229 reflected inconsistent information related to hinged instruments as follows: "Used hinged instrument in red enzymatic solution bin in closed hinged position...In regards to precleaning of surgical instruments at the point of use...AORN recommends...treating instruments that cannot be immediately cleaned with an instrument cleaner; and...separating clean and sterile supplies from contaminated instruments before transport to the processing area...AAMI recommends...having cleaning occur as soon as possible...preparing instruments in a way that prevents organic soils from drying; and...using precleaning disinfectants if processing will be delayed...In review, there is no specific recommendation from either organizations for opening all hinged instruments at the point of use in preparation for transport to the cleaning and decontamination area..."

The information in the email documentation was inconsistent with the IC policies and procedures. It was not clear whether the CAH required hinged instruments/devices that had been used in patient units to be in the open position while soaking/pre-cleaning in enzymatic solution prior to being picked up by Central Processing techs and taken to Central Processing.

In SPD:
a. During a tour of Surgical Services Department and SPD on 11/15/2019 beginning at 1100 with CAH staff that included the CNO, SSD, AD and SPT the following observations were made:
* At 1155, a surgical instrument/device washer was observed between the decontamination area and the "clean" area of SPD with the SPT. Observation of the washer from the "clean" side revealed it contained metal trays with numerous surgical instruments/devices on them that had gone through the wash cycle and were ready to be removed from the washer. One of the trays contained more than twenty surgical instruments/devices stacked on top of each other, and some were hinged or jointed and were not in the open or unlocked position.
* At 1215 a stainless steel triple sink was observed in the Decontam area of SPD with the SPT. The sink had no "fill line" or other visible cue for measuring water in the sink. The SPT stated the sink was used to clean surgical instruments/devices before they were sterilized. The SPT stated he/she cleaned the instruments/devices by soaking/cleaning them in a solution of one gallon of water per one ounce of Endozime enzymatic in the sink. The SPT was asked how he/she measured the water in the sink. The SPT stated "That's a good question." The SPT stated that he/she had a sticker that needed to be put on the sink to be used as a "fill" line to measure the water. However, the SPT stated the sticker had not been placed on the sink. No liquid measuring container was observed in the Decontam area.
* At 1215 a one gallon container of Endozime enzymatic was observed at the triple sink area in the Decontam area. The manufacturer's instructions and information on the side of the container reflected "Endozime is a dual enzymatic cleaner that removes blood, protein, mucous, vomit and fecal matter...Endozime will solve any problem with clogged channels, sticky forceps or clouded lenses and will leave both scopes and instruments free of any unpleasant odors or baked-on blood...Directions For Use...Surgical Instruments and Scopes...Add one (1) ounce of Endozime to one (1) one gallon (8ml/liter) of water...Submerge instruments and scopes to be cleaned...Soak for 2 minutes to remove all organic soils...Rinse thoroughly with tap, distilled or sterile water."

b. During an interview with the IP and SSD on 11/15/2019 at 1610 the IP stated the hinged instruments/devices observed in the SPD instrument/device washer should have been in the open position. The SSD who was present during the observation stated "It's an opportunity on our part."

c. Email documentation from DA dated 11/18/2019 at 1626 reflected "...AORN and AAMI recommend hinged instruments be unlocked/open for the mechanical washer..."

3. Cleaning and disinfection supplies were expired.

a. During tour of the Med/Surg unit on 11/13/2019 beginning at 1435 with the MS/ICU NM the following observations were made:
* At 1500 a container of Clorox Bleach Germicidal Wipes with expiration 05/09/2019 was observed available for use inside the isolation cart in the clean utility room.

b. During tour of the EVS department supply storage room on 11/14/2019 beginning at 1110 with the EVSM, the following observations were made:
* At 1120 a container of HB Quat Disinfectant Cleaner Concentrate with expiration 05/2014 was observed available for use in the dispenser located in the EVS supply room.

4. A water-borne pathogens program was not fully developed and implemented:

a. The policy and procedure provided titled "Corporate Model Policy: Water Management Program Policy," dated revised 09/26/2018 was reviewed. It stipulated:
* "Policy Summary/Intent...To standardize the requirements identified in CMS S&C 17-30 Requirements to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease regarding a water safety program with emphasis on Legionella."
* "As legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization, the WMP will address the following areas: hot and cold water storage tanks, water heaters, water-hammer arrestors, pipes, valves, and fittings, expansion tanks, water filters, electronic and manual faucets, aerators, faucet flow restrictors, showerheads and hoses, centrally-installed misters, atomizers, air washers, and humidifiers, nonsteam aerosol-generating humidifiers, eyewash stations, ice machines, hot tubs/saunas, whirlpools, decorative fountains, cooling towers and medical devices (such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)."
* "...Hazard Risk Assessment and Analysis...Hazard risk assessment and analysis of building water systems is used to evaluate where hazardous conditions may occur in the water systems and to determine where control measures can be applied. Refer to Appendix C..."
* "...Implementation of Plan...WST will develop a corrective action plan, time line for completion, and recommended feasible solutions for each area based on the hazard risk assessment...Recommendations, if required, shall include inspection and maintenance changes, equipment design and upgrades and record-keeping requirements...If necessary, the action plan will specify requirements to develop necessary infrastructure improvement projects..."
* "...Control Measures...Include locations where control measures are applied to stay within established control limits...Examples of control measures are: physical controls, water filters in high risk areas, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens..."
* "...Monitoring and Corrective Actions...WST will ensure that the WMP is followed by...Include procedures for monitoring established control limits and corrective actions to be applied if the system is not operating within established limits..."
* "...Confirmation process...Confirm that the WMP is being implemented as designed (verification) and the WMP effectively controls the potential hazardous conditions; such as in the building water systems (validation)...Document and communicate procedures used for all activities of the WMP."
* "Annual Follow Up...The WMP shall provide...Annual plan review, verification and validation of all plan components..."

b. During an interview with CAH staff that included the CSPS and SD on 11/15/2019 at 1700 they provided "Appendix C Hazard Risk Assessment and Analysis" referenced in the "Corporate Model Policy: Water Management Program Policy" policy and procedure above. The top of the document reflected "Hazard Risk Assessment and Analysis Mark 'X' on identified hazards or risk" and "Mark 'NA' if equipment not present." The document included approximately 38 risks to be identified for: "Hospital Building," "Floor," "Tower," and/or "Wing." The risks included but were not limited to "Shower Heads...Faucets...Ice-Machine...Humidifiers and non-steam aerosol generating humidifiers...Decorative Fountains & Swimming Pools...Potable Water...Non-Potable Water...Water Heating...Humidifiers...Heating...Ventilation...Air-Conditioning...Water Filters...Hot Water Heaters...Steam Boilers...Pipes, Valves and Fittings...Expansion Tanks...Cooling Towers...Dialysis Machine and Accessories...Eye Wash Stations...Medical devices which are continuously wet and can spread contaminated water droplets via aerosolization - example: CPAP machine, hydrotherapy equipment, bronchoscopes, heater-cooler units..." The form was blank and none of the areas or items were checked to indicate they had been evaluated for risk. During the interview the staff present stated the CAH had plans to use the "Appendix C Hazard Risk Assessment and Analysis" document to conduct a water-borne pathogens risk assessment but they stated no forms had been filled out yet.

c. During an interview with the CSPS on 11/15/2019 at 1730 the following documents were provided in response to a request of the CAHs evidence of a waterborne pathogens program:
* An undated document titled "Flow Diagram of Building Water Systems." The CSPS stated the document reflected the initiation of a risk assessment but he/she stated the risk assessment was not completed.
* An undated diagram titled "Areas Where Legionella Could Grow & Spread." The diagram identified six areas identified as "Conditions for Bacteria Spread" and those were "Cooling Tower," "Decorative Fountain," "Ice Machines Floors 1, 2, & 3," "Hot Tub Floors 2 - OB," "Sinks/Showers Floors B - 2," and "Kitchen Appliances 1st Floor." The CSPS stated the document reflected the initiation of a risk assessment but he/she stated the risk assessment was not completed.
* An undated "Water Safety Maintenance Program Adventist Health Water Management Plan" document.

Review of the documents provided reflected:
* No documentation of a completed hazard risk assessment.
* No documentation of identification of control measures.
* No documentation of monitoring and corrective actions if the system was not operating within established limits.
* No documentation of a confirmation process that the water-borne pathogens program was being implemented as designed.
* No documentation of an annual review of the program.
No further documentation was provided.

d. During an interview with the CSPS on 11/15/2019 at 1730 he/s/she stated the CAH was "testing chlorine but its not being logged."

Based on observation, interview, and review of the list of services furnished under arrangement it was determined that the list of all services furnished under contract, arrangement or agreement was not complete. The list did not include all such services, and it did not include descriptions of the nature and scope of the services provided, to include at a minimum:
* The service(s) being offered;
* The individual(s) or entity providing the service(s);
* Whether the services were offered on-site or off-site;
* Whether there was any limit on the volume or frequency of the services provided; and
* When the service(s) were available.

Findings include:

1. An untitled, undated document provided in response to a request for the CAH's list of patient care services furnished under contract, agreement or arrangement was reviewed. It consisted of a list of four services. Those services were for radiology reading services, Emergency Department medical staff, temporary RN services, and hospitalist services. Four additional services that were not on the list were identified during the survey. Those services were for wound care products, carpet cleaning services, linen/laundry services, and language interpretation services.

The list did not contain descriptions of the nature and scope of services provided. Examples include:
* The first item on the list was identified as "Radiology reading services." The "Expected & Monitored Performance Improvement Elements" reflected "Over reads as assigned by the Radiology Manager...Critical findings verbal report to ordering provider within 30 minutes...After hours Xray within 24 hours." There was no further description of how often the services were provided, and any limits on the volume or frequency of the services provided.
* The second item on the list was identified as "Emergency Department medical staff 24 X 7 X 365." The "Expected & Monitored Performance Improvement Elements" reflected "Other requirements...EMTALA elements completed before patients leave for transport to another acute care facility...Reply to all inquiries within 60 minutes...Patient experience..." There was no further description of what the specific services were. For example, there was no description of whether the emergency department medical staff services were provided by physicians, other LIPs or both. There was no information about any limit on the volume or frequency of the services provided.

The list was not complete as during the survey four additional services provided under contract or agreement were identified that were not on the list as follows:
* During a tour of the Med/Surg unit with CAH staff that included the MS/ICU NM on 11/13/2019 at 1435, it was stated that the CAH had a contract with KCI for wound vac products/services. This contract was not on the list and there was no documentation of the nature and scope of the service.
* During a tour of ORT with the CAH staff that included RD and QM on 11/13/2019 at 1630, it was stated that the CAH had a contract for linen/laundry services and language interpreter services. These contracts were not on the list and there was no documentation of the nature and scope of the services.
* During a tour of the EVS department on 11/14/2019 at 1110 with EVSM, a commercial carpet cleaning machine was observed. The EVSM stated the CAH had a contract for carpet cleaning services through which the machine was used to clean carpets in the CAH. This contract was not on the list and there was no documentation of the nature and scope of the service.

2. During interview with the DA on 11/14/2019 at 1600 he/she confirmed the CAH had a contract for the following services and that those services were not on the CAH's list of contracted services:
* KCI for wound product services;
* Associated Cleaning Services, Inc. for carpet cleaning services; and
* Oregon Corrections Enterprises for laundry services.
No further information was provided.

Based on interview, and review of the list of services furnished under arrangement it was determined that the CAH failed to ensure that services provided under contract, arrangement or agreement were evaluated and furnished in a manner that enabled the CAH to comply with all applicable CoPs.

Findings include:

1. An untitled, undated document provided in response to a request for the CAH's list of patient care services furnished under contract, agreement or arrangement was reviewed with the DA. It consisted of a list of four services. Those services were for radiology reading services, Emergency Department medical staff, temporary RN services, and hospitalist services. The list included a column to document "Expected & Monitored Performance Improvement Elements" for each of the four services. However, there was no documentation that reflected the services were evaluated to ensure they complied with the CAH CoPs.

Four additional services that were not on the list were identified during the survey. Those services were for wound care products, carpet cleaning services, linen/laundry services, and language interpretation services. There was no documentation of an evaluation of those services, including an evaluation to ensure they complied with CAH CoPs.

2. During interview with the DA on 11/14/2019 at 1600, he/she confirmed the CAH had contracts for KCI for wound product services; Associated Cleaning Services, Inc. for carpet cleaning services; and Oregon Corrections Enterprises for laundry services. The DA confirmed the CAH had not developed a system for evaluation of contracted services to ensure they complied with CAH CoPs. No further information was provided.

Based on interview, review of documentation in 3 of 3 inpatient medical records of CAH patients (Patients 3, 13 and 14) who received nursing services, and review of policies and procedures, it was determined that the CAH failed to ensure that the RN supervised and evaluated the patient's care in accordance with clearly written and fully developed and implemented CAH policies, procedures and physician orders in the following areas:
* Conformance with physician orders;
* Physician notification and assessments of patient symptoms and condition changes;
* Vital signs and pulse oximetry monitoring;
* Oral/dental assessments of Swing Bed patients; and
* Medication administration.

Findings include:

1. The policy and procedure titled "Nursing Process," dated last revised 09/22/2017 was reviewed. It stipulated:
* "...Nursing assessment is the basis for planning nursing care....A Registered Nurse (RN) performs and documents the assessment for each patient...The Assessment Content and Time Frames for completion are determined by the anticipated length of stay and the complexity/dynamics of nursing care needs. It includes consideration of biophysical, psychosocial, environmental, self-care deficits, nutritional, functional, education, and discharge planning factors. Timing of assessments are coordinated with interventions/therapies, and nursing judgment is used to adjust times when determined to be in the best interest of the patient."
* "Reassessments are primarily focused/risk assessments which are limited to system(s) and degree of detail based on...admitting current diagnosis...prescribed treatment/test...patient's response to treatment...complication(s)/significant event...physician order...nursing judgment..."
* "Time frames for ongoing shift reassessments...patient status reassessments are focused assessments documented as often as the nurse determines, physician prescribes..."
* "Nursing Interventions--are provided/delegated by the Registered Nurse and based on...Standards of Patient Care...Plans of Care including physician orders...Supportive therapy...Professional judgment..."
* "Ongoing Evaluations are patient responses as related to interventions, and are documented throughout the shift in progress notes/shift charting with documentation of...treatments...activities..."

2. The Swing Bed policy and procedure titled "Oral Assessment/Dental Care," dated revised 06/27/2018 was reviewed. It stipulated:
* "Oral assessment may be performed at any time along the continuum of patient care, but it is done at least upon Admission and with a change in status from Acute to Swing Bed status."
* "Procedure...Admitting Nurse...Assess and document the patient's dental and oral condition."
* "Admission Oral Assessment includes...Appliance assessment of presence, comfort, visual fit abnormal gums, and any complaints offered...Visual inspection documentation of gums, lips, teeth, tongue, tonsils, and descriptions available for each, such as bleeding, cyanotic, inflamed, lesions, painful, pink, etc..."
* "Document in the Clinical notes: assessment result, any interventions and how the patient responded or tolerated."

3. a. The Swing Bed record for Patient 3 was reviewed. The record reflected the patient was admitted to Swing Bed status on 11/02/2019 with diagnoses of fever, chest pain, and right sided endocarditis.

The record reflected physician orders were not followed by the RN related to physician notification of temperature and pulse oximetry; and changes in the patient's conditions were not assessed/documented by the RN or were not assessed/documented timely. Examples included but were not limited to the following:

* Physician orders dated 11/02/2019 at 1735 reflected orders to notify the physician: If SBP greater than 180 mmHg; if SBP less than 90 mmHg; if oxygen saturation (pulse oximetry) less than 92%; or if temperature greater than 100.4 degrees F.

* Flowsheet documentation dated 11/03/2019 at 2252 reflected the patient's temperature was 101.7 F. There was no documentation that reflected the RN notified the physician of the elevated temperature in accordance with physician orders, and the next temperature was not documented until 11/04/2019 at 0821, more than nine hours later.

* Flowsheet documentation dated 11/10/2019 at 0013 reflected the patient's pulse rate was "[High]" 121, and pulse oximetry was 91% on room air. There was no documentation that the RN notified the physician of the pulse oximetry below 92% in accordance with physician orders, or that the RN notified the physician of the "[High]" pulse rate.

* Flowsheet documentation reflected the next pulse rate and pulse oximetry were not checked until 11/10/2019 at 0823, eight hours later. At 0823, the patient's pulse rate was "[High]" 118 and pulse oximetry was 91% on room air at rest. There was no documentation that reflected the physician was notified of the patient's elevated pulse rate and pulse oximetry that was below 92%. The only documentation of physician communication related to the patient's condition was at 1054, and that reflected only "...Team Rounds...addressed change in mental and physical condition, since Friday, patient again denies any illicit drug use."

* Flowsheet documentation dated 11/12/2019 at 0812 reflected the patient's pulse rate was "[High]" 116 and pulse oximetry was "[Critical]" 89% on room air at rest. There was no documentation that the RN notified the physician of the patient's high pulse rate and pulse oximetry that was below 92%.

* Flowsheet documentation dated 11/13/2019 between 0040 and 0810 reflected the patient's temperature was "[Critical]" 94.5 F and "[Critical]" 95.6 F, There was no documentation that the RN notified the physician of the condition change to critical low temperature readings.

* Flowsheet documentation dated 11/14/2019 at 0451 reflected the patient's temperature was 101.6 F. There was no documentation that the RN notified the physician of the elevated temperature reading in accordance with physician orders, and the next temperature was not documented until 11/14/2019 at 0746.

* The record contained no documentation of an oral assessment including no appliance assessment for presence, comfort, visual fit, abnormal gums, any complaints, visual inspection, documentation of gums, lips, teeth, tongue, tonsils, and descriptions such as bleeding, cyanotic, inflamed, lesions, painful, pink, etc; assessment result, any interventions, and how the patient responded or tolerated as required by CAH policy.

b. During an interview with the AD on 11/14/2019 at 1320 the medical record of Swing Bed Patient 3 was reviewed. The AD confirmed the findings above.

4. a. The record for Patient 13 was reviewed. The record reflected the patient was admitted on 11/12/2019 with diagnoses of syncope, hypoglycemia, COPD and atrial fibrillation.

* Physician orders dated 11/12/2019 at 1308 and 1400 reflected:
- "Order information for: diltiazem"
- "Hold...if HR [pulse rate] less than 50 or SBP less than 90 or DBP less than 50. Notify provider per site policy..."
- "diltiazem 30 mg, oral, Q6H-Interval"
The physician orders did not give a timeframe for checking the SBP, DBP and HR relative to the time of administering the medication.

Review of medication records and flowsheets that were provided in response to a request for documentation of vital signs and the MAR reflected the following:
* Vital signs including SBP, DBP and HR were checked on 11/12/2019 at 1105.

* The MAR reflected the patient was administered diltiazem 30 mg on 11/12/2019 at 1430, more than 3 hours after the SBP, DBP and HR were checked at 1105.

* The next vital signs checked on 11/12/2019 at 1519 were "Pulse rate [High] 128...Respiratory rate [High] 22...Systolic BP 129...Diastolic BP 73...Pulse Oximetry [Critical] 81..." The next vital signs were checked on 11/12/2019 at 1547 and those reflected "Pulse rate [High] 110...Respiratory rate [High] 22...Pulse Oximetry 92..." Although the record reflected the patient's pulse oximetry was "[Critical] 81" at 1519, and pulse rate and respiratory rate were high at 1519 and 1547, the next vital signs were not checked until 1948, 4 hours later and those reflected "Pulse rate [High] 116...Pulse Oximetry 91..."

* The next vital signs including SBP, DBP and HR checked on 11/12/2019 at 2012 were "Pulse rate [High] 144...Systolic BP 108...Diastolic BP 69...Pulse Oximetry 90..."

* The MAR reflected the patient was administered diltiazem 30 mg on 11/12/2019 at 2028, less than 20 minutes after SBP, DBP and HR were checked at 2012.

* The MAR reflected the patient was administered diltiazem 30 mg on 11/13/2019 at 0255, almost seven hours after the SBP, DBP and HR were checked on 11/12/2019 at 2012.

* The next vital signs including SBP, DBP and HR were checked on 11/13/2019 at 0257 and those reflected "Pulse rate [High] 111...Systolic BP 129...Diastolic BP 74...Pulse Oximetry [Critical] 89..." The documentation reflected the SBP, DBP and HR at 0257 were after the diltiazem was administered at 0255.

* The next vital signs checked on 11/13/2019 at 0315 reflected "Pulse Oximetry 95." Although the patient's pulse rate at 0257 was "[High] 111," no pulse rate or other vital signs were checked at 0315.

* The next vital signs checked on 11/13/2019 at 0704 reflected "Pulse rate 84...Pulse Oximetry 93..." This was four hours after the patient's pulse rate was "[High] 111" at 0257.

* The next vital signs including SBP, DBP and HR were checked on 11/13/2019 at 0752.

* The MAR reflected the patient was administered diltiazem 30 mg on 11/13/2019 at 0859, more than an hour after the last SBP, DBP and HR were checked at 0752.

* The next vital signs including SBP, DBP and HR were checked on 11/13/2019 at 1100.

* The MAR reflected the patient was administered diltiazem 30 mg on 11/13/2019 at 1348, 2 hours and 48 minutes after the last SBP, DBP and HR were checked at 1100.

b. During interview with the MS/ICU NM, other CAH RN staff and the Pharmacist present at or around the time of the record review on 11/13/2019 at 1515, those individuals were asked what the CAH policy and procedure was regarding the timeframe for when SBP, DBP and HR should be checked relative to the time of the diltiazem administration to ensure conformance with the physician orders for holding the medication. No definitive response was provided. It was stated that the nurse has an hour to administer the medication so it may be okay to check the patient's SBP, DBP and HR an hour before administering the diltiazem.

c. Email documentation from the DA dated 11/18/2019 at 1626 reflected the following information that reflected the CAH's lack of development and implementation of a policy and procedure that identified an acceptable timeframe for RN assessment of patient vital signs prior to administering medications in accordance with physician orders, and to ensure appropriate RN monitoring and conformance with physician orders. The email reflected "Diltiazem PO Q6hours (sic) ordered...Our medication administration policy...nor any other policy mentions vital signs in relation to medication administration; and, guides use of Lippincott Oral Drug Administration Procedure...Lippincott oral drug administration procedure...does mention blood pressure and pulse rate in relation to oral medication administration, however there is no mention of time frame...The Adventist Health Tillamook Pharmacist professional opinion is Diltiazem PO dose is acceptable as long as vital signs are taken at least 60-90 minutes after the previous dose, which represents the patient's response, at which time subsequent doses may be administered as ordered."

5. a. The record for Patient 14 was reviewed. The record reflected the patient presented to the CAH on 11/12/2019 with "SOB x several days with bilateral lower leg edema, went to PCP today and was told to come to ER due to Spo2 (sic) in the 80's..."

The patient's condition including pulse oximetry and BP were not assessed by the RN or were not reassessed timely and the physician was not notified of changes in accordance with physician orders. Examples included but were not limited to the following:

* Physician orders dated 11/12/2019 at 1945 reflected "
- "Start oxygen via nasal cannula at 2 L/min Titrate by 1 L/min. increments, each 5 minutes, to keep O2 Sat [pulse oximetry] greater than or equal to 92%. Maximum limit = 6 L/min. Call physician if further titration needed."

* Flowsheet documentation dated 11/12/2019 reflected the patient's pulse oximetry at 2230 was "[Critical] 87[%]," at 2239 "[Critical] 87[%]," and at 2340 "90[%]."

* RN notes at 2359 reflected "Notified of: Other: Patient refused ABG and asked [physician] if [he/she] wanted to set a new O2 goal, [he/she] did not. [Physician] stated that if [patient] becomes symptomatic please call back."

* Flowsheet documentation dated 11/13/2019 at 0013 reflected the patient's systolic BP was "[High]" 152 and pulse oximetry was "[Critical] 88 [%]" and the patient was "on oxygen 5 L/min At rest." There was no documentation that reflected the RN assessed the patient for symptoms secondary to the critical pulse oximetry reading of 88% and high SBP, and there was no documentation the physician was notified of those.

* The next vital signs, including BP were not documented until 0150, one hour and 37 minutes later, and those did not include pulse oximetry. There was no documentation that the RN reevaluated the critical pulse oximetry of 88% recorded at 0013.

* The next RN note at 0151 reflected "...Patient was (sic) stated that we (sic) was having some chest discomfort or heaviness that went through to [his/her] back...[Physician] requested EKG stat..."

* The next RN note at 0211 reflected "...patients (sic) have exertional shortness of breath with saturation [pulse oximetry] dropping in the low 80s, crackles in the lower base of the lungs, and elevated BMP. [Physician] is coming out to see the patient." Although the RN note reflected the patient's pulse oximetry was "dropping in the low 80s," there was no information that included the time the pulse oximetry was checked and the specific pulse oximetry reading.

b. The findings related to Patient 14 were confirmed during review of the medical record with the MS/ICU NM on 11/13/2019 at 1615.

Based on interview, documentation in 1 of 2 medical records reviewed for a pre-anesthesia evaluation (Patient 1) and review of policies and procedures, it was determined that the CAH failed to ensure that a pre-anesthesia evaluation was completed and documented by a qualified practitioner in accordance with CAH policies and procedures.

Findings included:

1. The policy and procedure titled "Anesthesia Documentation," dated last revised "12/18" was reviewed. It stipulated:
* "Anesthesia records are of value to the patient, anesthetist, surgeon and nursing staff. A good anesthesia record will be complete, legible, accurate..."
* "Information pertinent to the conduction of a safe anesthetic is divided into three basic categories: preoperative, intraoperative, and postoperative."
* The policy reflected that the "Preanesthesia Assessment" included "...Review of Systems: Cardiovascular; Respiratory; CNS; Hepato-GI; Renal-Endocrine; Musculoskeletal; Hematological problems; Obstetric history...Current diagnosis...Scheduled Procedure...Pertinent lab data...General state of health...Allergies...Airway Assessment...Surgical/anesthesia history...Medical history...Social history...Family problems with anesthesia...Current drug use...Other..."
* "Pre-anesthesia assessment is the same for all patients."

2. Review of the record for Patient 1 reflected the patient underwent a right shoulder arthroscopy surgical procedure with general and regional anesthesia on 11/14/2019 at 1119. The record reflected the CAH's policies and procedures related to a pre-anesthesia assessment were not carried out as follows:
* The "Preop Examination" signed by the CRNA and dated 11/14/2019 at 0906 did not include an assessment of the patient's endocrine system, obstetric history and pertinent lab data. The spaces on the form for documenting "GU/OB," "Endocrine," "Diagnostics:," "CXR:," "EKG:," "ECHO/StressT/Cath:," and "Other:" were blank. There was no documentation of an assessment of "Family problems with anesthesia." In addition, the space on the form for documenting "Anticipated Difficulty:" and "Potential Problems" was blank.
* The CRNA "Post Anesthesia Exam" dated 11/14/2019 at 1315 reflected the patient experienced stridor after the surgical procedure and was administered the following medications to treat his/her symptoms: "...1400 [medicated nebulizer] for stridor - resolved quickly...1408 Benadryl 10mg IVP..Decadron 8mg IVP..."

3. The medical record for Patient 1 was reviewed with the SSD on 11/15/2019 at 1220. During an interview with the SSD at the time of the record review, he/she confirmed the pre-anesthesia evaluation lacked an assessment of the patient's endocrine system and obstetric history, and the pertinent lab data section was blank. He/she confirmed the record reflected the patient developed stridor after the surgical procedure and required medications to treat it.