HospitalInspections.org

.
Based on interview and document review, the Critical Access Hospital failed to provide policies and procedures to demonstrate that it has the capability of making blood products available directly or through arrangements to its emergency patients 24 hours a day.

Failure to have a system in place to provide blood or blood products on an emergency basis, either direct or through arrangements or agreements, places patients at risk of injury and/or death.

Findings included:

On 02/21/18 at 3:30 PM, Surveyor #1 interviewed and reviewed the hospital's policies and procedure with the laboratory manager (Staff #106). During the interview, Surveyor #1 observed that the hospital did not store blood on site. Surveyor #1 asked to see if the hospital had any arrangements or agreements in place for patients in need of emergency blood or blood products. The manager of laboratory stated they did not have a policy in place but if the patient was in need for blood, the patient would be transported out to another hospital.
.

.
Based on interview, document review and observation the Critical Access Hospital failed to maintain a complete inventory list of all of the hospital's medical equipment and facility equipment in its preventive maintenance program.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk from malfunctioning equipment.

Findings included:

On 02/20/18 between the hours of 2:30 PM and 4:00 PM, Surveyor #1 interviewed the Director of Maintenance (Staff #101) in regards to the hospital's preventive maintenance program. The Director of Maintenance stated that the current process is to schedule facility equipment on their email calendar as a reminder for routine maintenance and that medical equipment maintenance was done by a vendor "Trimedx" which sends a report quarterly. During the course of the interview, surveyor #1 and the Director of Maintenance took a tour of the hospital. During the tour, Surveyor #1 observed the following pieces of equipment that were not placed in the hospital's preventive maintenance program:

1) Hospital bed patient room 121 loose foot board (missing bolts)
2) Patient "EZ Lift" equipment
3) Hospital's Oxygen concentrator machine
4) Vital Sign "Phillips" machine
5) Hospital's "Pulmo Aide" Nebulizer

THIS IS A REPEAT DEFICIENCY - PREVIOUSLY CITED DURING A CAH RECERTIFICATION SURVEY IN 2015
.

.
Based on interview, record review, and review of hospital policies and procedures; review of the hospital's quality plan, quality improvement program, and performance data; and review of past hospital survey reports, 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:

1. The Governing Body failed to ensure that the hospital met the requirements for the hospital staff responsibilities

2. The Governing Body failed to ensure that the hospital met the requirements for provision of hospital services,

3. The Governing Body failed to ensure that hospital staff members 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.

4. The Governing Body failed to ensure that hospital staff members corrected and sustained correction of deficiencies identified during hospital surveys conducted in 2015 and 2016.

Due to the cumulative effect of deficiencies detailed under the Conditions of Participation at 42 CFR 485.631 Staffing and Staff Responsibilities, 42 CFR 485.635 Provision of Services, and 42 CFR 485.641 Periodic Evaluation and Quality Monitoring, the Condition of Participation for Organizational Structure was NOT MET.

Cross-reference: Tags C0250, C0270, C0330
.

.
Based on observation, interview, and review of hospital policies, procedures, and documents, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Staffing and Staff Responsibilities.

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

Findings included:

1. The hospital failed to ensure that the hospital's current medical director and medical staff reviewed the hospital's policies and procedures annually and updated them as necessary.

2. The hospital failed to provide evidence that hospital staff members sent patient medical records with all patients who were transferred for emergency care

3. The hospital failed to provide evidence that mid-level healthcare providers notified the hospital's medical director when patients were admitted to the hospital.

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.631 Staffing and Staff Responsibilities was NOT MET.

Cross-reference: Tags C0258, C0267, C0268
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that the hospital's current medical director and medical staff reviewed the the hospital's policies and procedures annually and updated them as necessary.

Failure to review and update hospital policies and procedures risks medical errors and patient harm.

Findings included:

1. The hospital's medical staff bylaws (Adopted and Approved 07/02/14) read as follows: "The Medical Staff shall initiate and adopt such clinical and ancillary service policies and procedures as it may deem necessary for the proper conduct of its work and shall every year review and revise its policies and procedures to comply with current staff practice. Recommended changes to the policies and procedures may be submitted to the Medical Staff at any meeting where a majority of the active staff members are present. Following adoption, such policies and procedures shall become effective following the approval of the hospital Administrator.

2. Review of hospital policies and procedures revealed they had not been reviewed since July 2016.

3. On 02/21/18 between 2:25 PM and 5:00 PM, Surveyor #7 interviewed the hospital's Superintendent (Staff #703) and Director of Nursing Services (Staff #704). During the interview, the Superintendent stated that there was no process for ensuring the medical director and other members of the hospital's medical staff reviewed clinical care policies and procedures annually and updated them as needed.

Cross Reference: C0272
.

.
Based on interview and record review, the Critical Access Hospital failed to provide evidence that hospital staff members sent patient medical records with all patients who were transferred for emergency care, as demonstrated by 3 of 5 patients reviewed (Patients #701, #702, #703)

Failure to send information regarding the patient's condition and emergency care when patient's are transferred to another hospital impairs continuity of care and risks adverse patient outcomes.

Findings included:

1. On 02/20/18 between 11:30 AM and 1:00 PM in the hospital's emergency department (ED), Surveyor #7 interviewed the ED nurse manager (Staff #701) regarding the hospital's emergency services and procedures. During the interview, the manager stated that ED staff members completed a form titled "Garfield County Hospital District Authorization for Transfer" when patients were transferred from the ED to another hospital.

2. Review of the transfer form showed the form included an area titled "Medical Records Sent with Patient" with boxes to check to indicate the type of records sent with the patient. These included laboratory and radiology reports, physician findings, medication and treatment records, and nursing assessments. A statement at the bottom of the form read "Keep original document. Send copy to receiving facility."

3. On 02/23/18 between 9:15 AM and 9:45 AM, Surveyor #7 reviewed the records of five patients who were treated in the hospital's ED in January and February 2018 and transferred to another hospital. Transfer forms in two of the five records (Patients #701, #702) lacked evidence that medical records had been sent to the receiving hospital with the patient. The records for Patient #703 did not include a transfer form.

4. During an interview with Surveyor #7 at the time of the record review, the hospital's Health Information and Coder Assistant (Staff #702) confirmed the findings above.
.

.
Based on interview and record review, the Critical Access Hospital failed to provide evidence that mid-level healthcare providers notified the hospital's medical director when patients were admitted to the hospital for 3 of 3 patients reviewed (Patients #704, #705, #706).

Failure to notify a physician when a patient is admitted to the hospital risks adverse patient outcomes if the patient develops a medical problem during their stay that is outside the scope of the admitting practitioner.

Findings included:

1. On 02/21/18 at 10:20 AM, Surveyor #7 reviewed the records of three patients who were admitted to the hospital in February 2018. Patient #704 was admitted on 02/18/18 by a physician's assistant (Staff #705) for treatment of abdominal pain and vomiting. Patient #705 was admitted on 02/10/18 by a physician's assistant (Staff #705) for a possible stroke. Patient #706 was admitted on 02/20/18 by a nurse practitioner (Staff #706) for a possible pulmonary embolism. The records did not include evidence that the mid-level healthcare providers had notified the hospital's medical director when the patients were admitted.

2. During an interview with Surveyor #7 at the time of the record review, the hospital's acute care nurse manager (Staff #701) confirmed the findings above.
.

.
Based on observation, interview, and review of hospital policies, procedures, and documents, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

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

Findings included:

1. The hospital failed to ensure policies and procedures for clinical care of patients were developed and reviewed annually by a professional group that included one or more physicians and one or more physician's assistants on the hospital's staff.

2. The hospital failed to develop and maintain a current description of the services the hospital provided, including those services provided through agreements or arrangements.

3. The hospital failed to ensure that emergency treatment protocols were current and immediately available for emergency department staff members.

4. The hospital failed to develop and implement pharmacy policies and procedures for safe preparation of intravenous (IV) medications and fluids, and for monitoring medication refrigerator temperatures.

5. The hospital failed to develop and implement infection prevention and control policies and procedures for a water management plan, cleaning point of care devices, sterilizing surgical instruments, daily patient room cleaning, and providing cleanable, non-absorbent furniture in patient common areas and patient rooms.

6. The hospital failed to ensure that nursing staff members developed an individualized plan of care for all inpatients.

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.

Cross-reference: Tags C0272, C0273, C0274, C0276, C0278, C0298
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure policies and procedures for clinical care of patients were developed and reviewed annually by a professional group that included one or more physicians and one or more physician's assistants on the hospital's staff.

Failure to review and update hospital policies and procedures risks medical errors and patient harm.

Reference: 42 CFR 485.635(a) - "The policies include the following:

(3)(iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.

(3)(iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

(3)(v) Procedures for reporting adverse drug reactions and errors in the administration of drugs.

(3)(vi) A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

(3)(vii) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of §483.25(i) of this chapter is met with respect to inpatients receiving post-hospital SNF [skilled nursing facility] care."

Findings included:

1. The hospital's medical staff bylaws (Adopted and Approved 07/02/14) read as follows: "The Medical Staff shall initiate and adopt such clinical and ancillary service policies and procedures as it may deem necessary for the proper conduct of its work and shall every year review and revise its policies and procedures to comply with current staff practice. Recommended changes to the policies and procedures may be submitted to the Medical Staff at any meeting where a majority of the active staff members are present. Following adoption, such policies and procedures shall become effective following the approval of the hospital Administrator.

2. Review of hospital policies and procedures revealed they had not been reviewed since July 2016.

3. On 02/21/18 between 2:25 PM and 5:00 PM, Surveyor #7 interviewed the hospital's Superintendent (Staff #703) and Director of Nursing Services (Staff #704). During the interview, the Superintendent stated that there was no process for ensuring the medical director and other members of the hospital's medical staff reviewed clinical care policies and procedures annually and updated them as needed.

Cross Reference: C0258
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and maintain a current description of the services the hospital provided, including those services provided through agreements or arrangements.

Failure to develop and maintain a current description of services the hospital provides impairs the hospital's ability to develop a hospital-wide quality assessment and performance improvement program.

Findings included:

1. Review of the hospital's policies and procedures and the hospital's Governing Board Bylaws (Approved 02/05/18) revealed the hospital developed and maintained a current description of the services the hospital provided, including those services provided through agreements or arrangements.

2. On 02/21/18 between 2:25 PM and 5:00 PM, Surveyor #7 interviewed the hospital's Superintendent (Staff #703) and Director of Nursing Services (Staff #704). During the interview, Superintendent confirmed that the hospital did not have a current description of services.
.

.
Based on interview and review of hospital emergency department (ED) protocols, the Critical Access Hospital failed to ensure that emergency treatment protocols were current and immediately available for ED staff reference.

Failure to ensure emergency policies, procedures, and protocols are current and immediately available to emergency department staff members risks provision of inadequate, inappropriate, and/or ineffective patient care and adverse patient outcomes.

Findings:

On 02/20/18 between 11:30 AM and 1:00 PM, Surveyor #7 inspected the hospital's emergency department (ED) and interviewed the hospital's ED nurse manager (Staff #701). During the interview, nurse manager stated that the department staff maintained a file of frequently used emergency protocols for staff reference. Review of this file revealed the following:

1. Three of these protocols ("Acute Myocardial Infarction Care (AMI)" (Effective 04/17/06), "Diabetic Management, Hypoglycemic" (No effective date) and "Endotracheal Intubation with Succinylcholine" (No effective date) had not been reviewed in the past year by the hospital's current medical director and medical staff.

2. The "Endotracheal Intubation with Succinylcholine" protocol referred to performing a crichothyroidotomy (a surgical procedure for cutting the trachea to create an airway). However, inspection of the ED equipment at the time of the protocol review revealed the ED did not have the surgical instruments to perform a crichothyroidotomy.

3. The ED nurse manager stated the hospital followed a region-wide standardized heart attack treatment protocol for treatment of ST-segment elevation myocardial infarction (STEMI). She stated the protocol was located on her computer hard drive. The protocol was not available for staff in the ED.
.

.
ITEM #1 - COMPOUNDED INTRAVENOUS FLUIDS

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement policies and procedures for safe preparation of intravenous (IV) medications and fluids, and to ensure staff who prepared IV fluids were trained and competent.

Failure to comply with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.

Reference: United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016)

Findings included:

On 02/20/18 at 2:15 PM, Surveyor #7 interviewed the hospital's Director of Pharmacy (Staff Member #707) regarding pharmacy services at the hospital. During the interview, the director stated that a pharmacist was not on site at all times, and that IV medications were prepared by nursing staff members for "immediate use" (administered to patients within one hour of preparation). The interview revealed that there were no policies and procedures to direct staff on how to prepare IV according to USP 797 safe compounding standards, and no process for training nursing staff members and assessing competency in IV preparation and administration


ITEM #2 - MEDICATION STORAGE

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to develop and implement a policy and procedure for monitoring and maintaining medication refrigerator temperatures.

Failure to store medication within a safe temperature range risks deterioration of the medication and decreased effectiveness.

Findings included:

1. On 02/20/18 at 2:25 PM, Surveyor #7 inspected a medication refrigerator attached to the automated drug dispensing device in the hospital's emergency department (ED). The surveyor was assisted by the emergency department nurse manager (Staff #701), the Director of Pharmacy (Staff #707) and an Information Technology staff member (Staff #708). The inspection revealed the refrigerator alarm parameters were set at 0 degrees Centigrade and 10 degrees Centigrade.

2. During an interview with Surveyor #7 at the time of the inspection, the Director of Pharmacy stated the refrigerator temperature alarms should be set at 36 degrees Fahrenheit (2 degrees Centigrade) for a low temperature and 46 degrees Fahrenheit (8 degrees Centigrade) for a high temperature.

3. On 02/21/18 at 8:45 AM, Surveyor #7 reviewed a computerized log dated 01/01/17 to 12/31/17 of the temperatures of the medication refrigerators in the ED and the acute care unit. The review revealed that the refrigerator in the ED exceeded 46 degrees Fahrenheit on 11 of 365 days in 2017, and that the refrigerator in the acute care unit exceeded 46 degrees on 83 of 365 days in 2017.

4. On 02/20/18 during an interview with Surveyor #7, the Director of Pharmacy stated the pharmacy policies were in draft and had not been finalized for staff reference. There was no current policy and procedure for monitoring medication refrigerator temperatures.
.

.
ITEM #1 WATER MANAGEMENT PLAN

Based on observation, interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a) Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system;

b) Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;

c) Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained."

Findings included:

On 02/20/18 between the hours of 10:30 AM and 12: 15 PM, Surveyor #1 interviewed the Director of Maintenance (Staff #101) regarding the water management plan. The Director of Maintenance stated that he was unaware of the CMS requirements and did not have a plan.

ITEM #2 BLOOD GLUCOSE METER

Based on interview and document review the Critical Access Hospital failed to develop policies and procedures and to follow manufacturer's directions when disinfecting the glucose meter.

Failure to develop policies and procedures and to follow manufacturer's directions places patients, and staff at risk for infections and illness.

Reference: "Breeze 2 User Guide", Page 23 Subtitled, "Cleaning Your Meter:" Stated, your Breeze2 meter can be cleaned using a moist lint free tissue with mild detergent or disinfecting solution (1 part bleach mixed with 9 parts water). Do not use alcohol."

Findings included:

1. On 02/20/18 at 4:25 PM, Surveyor #7 interviewed the hospital's nurse manager (Staff #701) regarding the process for measuring a patient's blood glucose. The nurse stated the hospital used a "Breeze" blood glucose meter. The nurse stated that nursing staff members cleaned the meter using either an alcohol swab or a "Micro-kill" sanitizing wipe. The nurse stated there was no written hospital policy and procedure for cleaning the meter.

2. On 02/22/18 at 1:00 PM, Surveyor #1 interviewed a registered nurse (RN) (Staff #102) regarding the process for disinfecting the hospital's blood glucose meter in the emergency department. The RN stated she used the "Micro-kill" sanitizing wipes to disinfect the meter after each patient. In review of the active ingredients in the sanitizer wipes, it showed the wipes active ingredients contained 41 % alcohol, thereby not making it suitable for cleaning the glucometer.

ITEM #3: STERILIZATION FUNCTION

Based on observation, interview and document review, the Critical Access Hospital failed to ensure chemical indicators were used appropriately in the process of sterilizing surgical instruments.

Failure to implement standards of practice based on national organizations such CDC Center for Disease Control, places patients at risk for infection.

Reference: Titled, "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008" states on page 59, "Portable (table-top) steam sterilizers are used in outpatient, dental, and rural clinics. These sterilizers are designed for small instruments, such as hypodermic syringes and needles and dental instruments. The ability of the sterilizer to reach physical parameters necessary to achieve sterilization should be monitored by mechanical, chemical, and biological indicators. . . Typically, chemical indicators are affixed to the outside and incorporated into the pack to monitor the temperature or time and temperature."

Findings included:

1. In review of hospital policy and procedure titled, "Cleaning, Disinfecting and Sterilization" (No review date) showed that on page 4 part (b) "Chemical monitors (internal and external) should be used with every load."

2. On 02/21/18 at 11:00 AM, Surveyor #1 interviewed the central supply staff member who does the reprocessing of surgical instruments (Staff #103) on the process of sterilizing surgical instruments. During the interview, the staff member indicated that the chemical indicator is placed on the tray along with the daily air removal test (DART) and the biological indicator. During the observation it was discovered that the hospital did not follow standard of practice for placement of the chemical indicator, which should have been placed in the sterile packet. In addition, the hospital used two different types of sterile packets. The sterile packet "Agent" came with an internal/external chemical indicator affixed on the packet thereby not needing a chemical indicator. The other sterile packet "Medline" only had an external chemical indicator thereby needing a chemical indicator inside the packet.

ITEM # 4 DAILY PATIENT ROOM CLEANING

Based on observation, and review of hospital's policies and procedures, the Critical Access Hospital failed to disinfect high-touch areas when cleaning a patient room.

Failure to disinfect high-touch areas when cleaning patient rooms places patients, staff, and visitors at risk for illness and infections.

Findings included:

1. The hospital policy titled, "Room Cleaning Checklist" (No review date) stated, "Waste Basket part (1): Wash wastebasket inside and outside ...," "Furniture part (1) Wash all furniture including, TV and over bed light fixtures with germicidal solution ..." "Windows part (1): Clean windows with proper window cleaner..." "Bed part (1): Strip soiled linens; raise bed; clean all surfaces of beds; make bed..."

2. On 02/21/18 at 9:00 AM, Surveyor #1 observed a housekeeper (Staff #104) cleaning patient room #115. During the cleaning process, the housekeeper did not wipe down the door knob handle and call button, which is a high-touch surface area. Surveyor #1 asked the housekeeper if the hospital provided a checklist to follow. The housekeeper showed a checklist titled, "Care Center" which only identified the completion of the patient rooms; dining area etc... It did not identify items to be cleaned in the patient room.

3. On 02/21/18 at 9:20 AM Surveyor #1 asked the lead housekeeper (Staff #105) to see if the hospital had any policies and procedures for daily cleaning of a patient room. The lead housekeeper pointed to the housekeeper's closet wall where a checklist for discharge cleaning was posted. The surveyor asked if the process for discharge cleaning was the same as daily clean for the patient rooms. The lead housekeeper stated, that the discharge is different from the daily cleaning of a patient room and did not have a policy or procedure for daily clean of patient rooms.

4. In review of the infection control binder on 02/23/18 at 9:00 AM, Surveyor #1 found a room cleaning checklist with no review date that indicated areas of cleaning that were missed by the housekeeper:

a) Wash wastebasket inside and outside with germicidal solution
b) Wash all furniture including, TV and over bed light fixtures with germicidal solution
c) Clean Windows
d) Strip soiled linens; raise bed; clean all surfaces of beds; make bed

THIS IS A REPEAT DEFICIENCY - PREVIOUSLY CITED DURING STATE SURVEY IN 2016

ITEM #5 PATIENT FURNITURE

Based on observation, and interview the hospital failed to provide patient furniture that was easily cleanable and non-absorbent.

Failure to provide surfaces that are easily cleanable and non-absorbent places patients at risk of infections.

Findings included:

On 02/21/18 between the hours 2:30 PM and 3:00 PM, Surveyor #1 and the Director of Maintenance (Staff #101) identified 5 hospital issued recliner chairs in the common areas; 1 recliner chair in the observation patient room, room #102 and one couch in patient room #121 that were made of non-absorbent material that was not easily cleanable. The couch in patient room #121 and the recliner chair in the observation room #102 were heavily stained and in poor condition.
.

.
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 all inpatients, as demonstrated by 2 of 2 inpatient records reviewed (Patients #705, #709)

Failure to assess the patient's healthcare needs and develop an individualized plan of care can result in the inappropriate, inconsistent, and delayed treatment.

Findings included:

1. The hospital's policy and procedure titled "Nursing Care Plan" showed that nursing staff members would develop a nursing care plan for each patient at the time of admission based on assessment of the patient's nursing care needs. Appropriate nursing interventions would be developed in response to those needs and documented in the patient's medical record.

2. On 02/20/18 at 3:45 PM, Surveyor #7 reviewed the medical records for Patient #705, 77 year-old patient who was hospitalized from 02/10/18 to 02/14/18 for treatment of ketoacidosis. During his stay, the patient was diagnosed with diabetes mellitus. Review of the patient's plan of care revealed the plan addressed only the patient's high risk for falling. The plan did not include interventions for treatment of his diabetes, including educating the patient for care of his diabetes when he was discharged from the hospital.

3. During an interview with Surveyor #7 at the time of the record review, the acute care nurse manager (Staff #701) confirmed the findings above.

4. On 02/23/18 at 10:00 AM, Surveyor #7 reviewed the medical records for Patient #709, a 58 year-old patient who was hospitalized from 12/17/17 to 12/21/17 for treatment of hypertension and chronic obstructive pulmonary disease. The problem list in the patient's record identified the following medical problems: Shortness of breath, gastro-esophageal reflux disease, abnormal breathing, pain, nausea and vomiting, fever, hypertension, hypoxia, cough, and risk for deep vein thrombosis. The plan of care did not include nursing interventions to address these problems.

5. During an interview with Surveyor #7 at the time of the record review, the hospital's Health Information and Coder Assistant (Staff #702) confirmed the findings above.
.

.
Based on interview and review of the hospital's quality assurance plan and quality program documentation and 2016 state licensing and 2015 Medicare Critical Access Hospital recertification surveys, 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:

42 CFR 485.641 (a) 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: (1)(i) The utilization of CAH services, including at least the number of patients served and the volume of services; (ii) A representative sample of both active and closed clinical records; and (iii) 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 hospital's policy titled "Organizational Performance Improvement Plan" (Approved May 2017) showed that the hospital's quality improvement program would involve all departments and services within the organization. Activities would be collaborative and interdisciplinary. The program would include a "continuous and systematic plan to design, measure, assess, and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/healthcare errors."

Quality indicators and performance measures would assess processes and outcomes of care and would focus on processes that are high-risk and problem-prone. Data would be analyzed to determine if performance goals were met. The hospital would take action to correct identified problem areas to improve performance, and evaluate and document the effectiveness of these actions. The performance improvement program would be evaluated for effectiveness at least annually, including the identification of the number of distinct performance improvement projects, and revised as necessary.

2. On 02/21/18 between 2:25 PM and 5:00 PM, Surveyor #7 interviewed the hospital's Superintendent (Staff #703) and Director of Nursing Services (Staff #704) regarding the hospital's quality program. The interview and review of year-end quality program data for 2017 revealed the "Organizational Performance Improvement Plan" had been approved in May 2017 but had not been implemented, as demonstrated by the following:

a. Quality indicators had not been identified for all hospital departments and services that focused on outcomes of care related to processes that were high risk and problem prone.

b. Quality indicators did not include assessment of medication therapy.

c. Nosocomial infections and other adverse healthcare events were counted but not analyzed for patterns and trends.

d. There was no evidence the hospital's quality committee developed and implemented action plans when quality indicators did not meet performance goals.

e. Medical care quality as assessed through internal and external peer review did not interface with the hospital's quality program.

f. 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, and telepharmacy services).

g. The CAH had not performed a CAH program evaluation since 2014.

3. Surveyors #1 and #7 determined that quality program deficiencies found at C-330(2)(a), (b), (c), and (d) and C-278(4) were repeat citations from the hospital's state licensing survey in 2016; and that the deficiencies found at C-222 were repeat citations from the hospital's federal Medicare Critical Access Hospital survey in 2015.

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.
.

.
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 as stated in the list of swing bed rights and in accordance with 42 CFR 483 Subpart B Requirements for Long Term Care Facilities.

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 02/21/18 at 10:45 PM during an interview with Surveyor #7, the hospital's social worker (Staff #709) stated that all swing bed patients received a booklet titled "Resident Admission Agreement". The booklet contained information for swing bed patients including a list of the swing bed patient's rights.

2. Review of this list of rights showed that the hospital informed swing bed patients that they had the right to be notified in writing before they were transferred to another facility or discharged from the hospital.

3. On 02/22/18 at 11:05 AM during an interview with Surveyor #7, the hospital's social worker stated that patients were given a written notice three days prior to the end of their Medicare benefits but no written notice when the patient was transferred or discharged.
.

.
Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed a care plan for each long-term care ("swing bed") patient that include individualized interventions and timetables for meeting treatment goals, as demonstrated by 3 of 3 swing bed patients reviewed (Patients #708, #709, #710).

Failure to develop and implement a comprehensive plan for care that includes measurable objectives, interventions, and timetables for meeting treatment goals risks deterioration of the patient's condition and health status.

Findings included:

1. On 02/22/18 between 4:15 PM and 4:40 PM, Surveyor #7 reviewed of the medical records of three long-term care ("swing bed") patients. The record review revealed the following:

a. Patient #708 was a 68 year-old patient with terminal cancer who resided at the hospital from 06/05/17 to 08/06/17. The problem list in the patient's record included the following medical problems: Anxiety and fear, anxiousness, chronic intractable pain, chronic pain due to malignancy, and dry mouth. The patient's plan of care did not include nursing interventions to address these problems. The patient expired on 08/06/17.

b. Patient #709 was a 79 year-old patient with congestive heart failure and lower leg skin ulcers who resided at the hospital from 12/18/17 to 12/28/17. The problem list in the patient's record included the following medical problems: Acute respiratory failure, anxiety, hypoxia, acute pain, and nausea. The patient's plan of care did not include nursing interventions to address these problems. The patient expired on 12/28/17.

c. Patient #710 was a 93 year-old patient with myasthenia gravis who resided at the hospital from 11/05/15 to 01/24/18. The problem list in the patient's record included the following medical problems: Pain, anxiety, and candidiasis of the mouth. The patient's plan of care did not include nursing interventions to address these problems. The patient expired on 01/24/18.

2. During an interview with Surveyor #7 at the time of the record review, the hospital's acute care nurse manager (Staff #701) confirmed the findings above.

3. Review of the hospital's policy and procedure titled "Admission/Care Center" (Effective 08/22/12) showed that nursing staff would develop a nursing care plan for the patient within one week of admission. The procedure did not identify how nursing care plans would be updated as the patient's condition changed or how nursing interventions that addressed the patient's healthcare needs would be identified, implemented, and documented.
.

.
Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that healthcare providers completed a discharge summary for each long-term care ("swing bed") patient, as demonstrated by 2 of 5 swing bed patients reviewed (Patients #711, #712).

Failure to complete a discharge summary that includes a recapitulation of the patient's stay and a post-discharge plan of care impairs continuity of care in the outpatient setting.

Findings include:

1. On 02/23/18 at 10:00 AM, Surveyor #7 reviewed the records of five swing bed patients who had been discharged from the hospital between 10/24/17 and 01/04/18. Two of the five records did not include a discharge summary.

2. On 02/23/18 at 10:15 AM, Surveyor #7 interviewed the hospital's Health Information and Coder Assistant (Staff #702). During the interview, the staff member confirmed that the records did not include a discharge summary. The staff member stated a discharge summary was required for swing bed patients.

3. Review of hospital policies and procedures revealed the hospital did not have a policy and procedure for completion of a discharge summary for all swing bed patients.
.

Based on document review and interviews with administration and maintenance staff, the Critical Access Hospital failed to provide a written policy for alternate power sources.

Failure to provide written policies for alternate power sources places patient, staff and visitors at risk of injury and/or death from power failures.

Findings included:

Document review on 02/22/2018 between the hours of 1130 and 1430 revealed that there was not an established policy to have the generator maintain the following:

1. Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
2. Emergency lighting.
3. Fire detection, extinguishing, and alarm systems.

The above was discussed and acknowledged by the Director of Maintenance (Staff #101).
.

.
Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures to ensure that patient records are secure and readily available to support continuity of care during an emergency.

Failure to have policy and procedures in place to ensure patient information is secure and readily available in an event of an emergency, places patients at risk of injury and/or death.

Findings included:

On 02/20/18 between the hours of 1:30 PM and 2:00 PM, Surveyor #1 interviewed the Director of Maintenance (Staff #101) and reviewed the hospital's emergency preparedness plan. The interview and review of the documents revealed that the plan was missing policies and procedures that would ensure preservation of patient information; protect confidentiality of patient information; and secure and maintain the availability of patient records in the event of an emergency. This was confirmed by the Director of Maintenance.

Based on document review and interview, the Critical Access Hospital failed to provide initial emergency preparedness training to all new and existing staff.

Failure to train staff on how to respond during emergencies places patients and staff at risk of injury and/or death in the event of a man-made and/or natural disaster.

Findings included:

On 02/20/18 between the hours of 1:00 PM and 2:00 PM, Surveyor #1 interviewed the Director of Maintenance (Staff #101) and reviewed the hospital's emergency preparedness plan. The interview and review of the plan revealed that the Director of Maintenance was unable to provide documentation of training for all new and existing staff.

.
Based on interview and record review, the facility failed to meet the generator requirements of Emergency Preparedness. The facility failed to maintain and test the emergency generator in accordance with NFPA 110.

This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff and/or visitors within the facility.

Findings included:

On 02/11/18 at 12:00 PM, the deputy fire marshal interviewed the hospital's Director of Maintenance (Staff #101) and reviewed generator service records. The review revealed there was no documentation of a current annual fuel quality test.

The above was discussed with and acknowledged by the Director of Maintenance.