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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to include patients undergoing endoscopy procedures in its process for verification of the patient's identity and the procedure to be performed prior to performing invasive procedures, as demonstrated by 2 of 2 patient records reviewed (Patients #701, #702).

Failure to systematically verify the patient's identity and the procedure to be performed prior to initiating an invasive procedure risks medical errors and patient harm.

Reference: WAC 246-320-226 Hospitals must: (3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (d) Patient safety measures;

Findings included:

1. On 01/24/18 at 3:25 PM, Surveyor #7 reviewed the medical records of two patients who underwent endoscopy procedures involving procedural sedation that occurred on 11/15/17 and 01/17/18. The records lacked evidence that the procedure team verified the patient's identity and the procedure to be performed immediately before starting the procedure.

2. The hospital's policy and procedure titled "Pre-Procedure Time-Out" (Approved January 2017) showed that all members of a procedure team would perform a "time-out" prior to the start of any invasive or consent-necessary procedure. This "time-out" would include confirming the patient's identity; the procedure to be performed; the applicable pre-procedure medications, equipment, and imaging; and the patient's position. The policy stated that endoscopy procedures were excluded from the "time-out" procedure.

3. During an interview with Surveyor #7 at the time of the record review, the Clinical Services Director (Staff #701) stated that the hospital had excluded endoscopy procedures from their "time-out" process because the surgeon who performed these procedures (Staff #702) stated it was not necessary.
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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a procedure to ensure that nursing staff members labeled syringes of injectable medications that were not immediately administered to patients.

Failure to label syringes of medication with the patient's name, the medication prepared, the dose of the medication, and date and time of preparation risks medication errors and patient harm.

Findings included:

1. On 01/23/18 at 11:50 AM, Surveyor #7 observed a registered nurse (Staff #703) who was working in the hospital's north wing prepare an injection of insulin for Patient #702 in Room 8. The nurse withdrew insulin from a multi-dose vial, then placed the unlabeled syringe on a shelf in the hospital unit's medication storage cupboard.

2. During an interview with Surveyor #7 at the time of the observation above, Staff #703 stated that when she prepared syringes of insulin for multiple patients, she would place the syringe in the box containing the patient's insulin vial. She stated she did not label these syringes.

3. On 01/23/18 at 11:55 AM, Surveyor #7 interviewed the hospital's Clinical Services Director (Staff #701). During the interview, the director stated the hospital did not have a policy and procedure that directed nursing staff to label syringes of medications that were not immediately administered to patients.

4. On 01/24/18 at 10:25 AM, Surveyor #7 interviewed the hospital's clinical pharmacist (Staff #704). During the interview, the pharmacist stated that it was unsafe practice to not label syringes of medication at the time of preparation.
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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, 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: Conduct a risk assessment to identify of growth of waterborne pathogens; Implement ASHRAE or CDC tool kit to include control measures; and 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.

Reference: Manitowoc Ice Machine Operations Manual on page 2-16 specifies installing ice machine with an open trapped and vented drain/ air gap.

Findings included:

1. On 01/24/18 between the hours of 10:00 AM and 11:30 AM, during a tour of the hospital with the hospital's plant manager (Staff #101), Surveyor #1 identified areas that were at risk of growing waterborne pathogens. The surveyor observed the following: Shower heads with hoses not hung properly to allow for drainage; a therapeutic bathtub with hand held hoses not hung properly to allow for drainage; and an ice machine not installed with an air gap with severe signs of growth in the drain line.

2. Review of the water management plan showed that the risk assessment had identified water stagnation risks for showers and ice machines. The plan did not provide direction to staff for mitigation of these risks, including hanging shower hoses to drain after use and installation of ice machines according to the manufacturer's specifications. The therapeutic bathtub had not been identified as a water stagnation hazard.

3. The hospital's plant manager showed documentation of chlorine residual provided by the city water treatment facility but confirmed that they had not identified testing proctocols and acceptable ranges for control measures or corrective actions to take when control limits are not maintained.


ITEM #2 - ENDOSCOPE REPROCESSING

Based on observation and interview, the Critical Access Hospital failed to ensure staff reprocessed endoscopes according to manufacturer's instructions for use.

Failure to follow manufacturer's instructions for use when reprocessing endoscopes places patients at risk of infection and/or illness.

Reference: Cidex OPA manufacturer's instruction for use indicated, "Date the bottle of test strips when opened (expiration at 90 days or the expiration date on the bottle of test strips, whichever comes first)."

Reference: ENZOL (enzymatic detergent) "Add 1 oz of detergent to 1 gallon of water."

Findings included:

1. On 01/23/18 at 10:00 AM in the endoscope reprocessing room, Surveyor #1 observed an open bottle of chemical test strips used to determine the efficacy of the Cidex solution for high-level disinfection. The bottle was marked with an opened date of 12/20/17 but did not have the written 90-day expiration date (from date of opening) as required in the manufacturer's directions for use. During an interview with the reprocessing technician (Staff #102) at the time of the observation, the technician specified that the expiration date on the front of the bottle. The expiration date on the front of the bottle was 04/18, the manufacturer's product expiration date. This would have exceeded the 90 day expiration of 03/21/18 as specified in the instructions for use.

2. On 01/23/18 at 10:20 AM, Surveyor #1 interviewed the reprocessing technician (Staff #102) in regards to processing an colonoscopy scope. The technician stated that the first step was to fill up the sink in the reprocessing area with enough distilled water to submerge the endoscope. She stated the next step was to add one ounce of ENZOL (enzymatic detergent) into the sink. The technician was unable to determine the correct concentration of enzymatic detergent with the corresponding amount of water.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that nursing staff members developed an individualized plan of care for patients at risk for falls that included patient education regarding fall prevention for 5 of 5 patients reviewed (Patients #703, #704, #705, #706, #707)

Failure to educate patients regarding fall prevention risks patient falls and injury.

Findings included:

1. The hospital's policy and procedure titled "Care Plans" (Reviewed/Revised April 2017) showed that nursing staff members would develop an individualized plan of care for each patient and swing bed resident within twenty-four hours of admission. The plan would include "observations to make, what nursing actions to carry out, and what instructions the patient/resident or family members require".

2. The hospital's policy and procedure titled "Fall Risk Assessment" (Reviewed/Revised April 2017) showed that patient's determined to be at high risk for falling would be educated regarding fall prevention.

3. On 01/23/18 between 2:40 PM and 3:10 PM, and on 01/24/18 at 9:15 AM, Surveyor #7 reviewed the records of five long-term care ("swing bed") patients currently receiving care in the hospital. The record review revealed the following:

a. Patient #707 was a 91 year-old resident who had been admitted to the hospital's long-term care unit on 06/25/13. On 01/12/18, the patient fell in her room and fractured two bones in her right leg. The patient's nursing care plan indicated she was at high risk for falling. The patient's record did not include evidence that the patient had been educated regarding fall prevention before nor after her fall.

b. Review of the nursing care plans for four other swing-bed patients (Patients #703, #704, #705, #706) showed these patients were also at high risk for falls. The patients' records did not include evidence that the patient's had been educated regarding fall prevention.

4. On 01/24/18 at 9:15 AM during an interview with Surveyor #7, the hospital's Clinical Services Director (Staff #701) confirmed the findings above.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide evidence that patients who were given anesthesia for procedural sedation were discharged under the care of a responsible adult as directed by hospital policy, as demonstrated by the medical records of 2 of 3 patients reviewed (Patients #701, #702).

Failure to ensure patients who are given anesthesia or procedural sedation are discharged under the care of a responsible adult risks patient injury due to impaired driving and other post-sedation side effects.

Findings included:

1. The hospital's policy and procedure titled "Gastrointestinal Endoscopy Short Stay" (Reviewed/Revised August 2017) showed that patients undergoing outpatient endoscopy procedures would be discharged only if accompanied by a responsible adult to drive them home.

2. On 01/24/18 at 3:25 PM, Surveyor #7 reviewed the medical records of three patients who underwent endoscopy procedures involving procedural sedation that occurred on 11/15/17 and 01/17/18. The records for Patient #701 and #702 lacked evidence that the patient had been discharged under the care of a responsible adult following their procedures.

3. During an interview with Surveyor #7 at the time of the record review, the Clinical Services Director (Staff #701) confirmed the medical record findings above.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop a process for notifying long-term care ("swing bed") patients in writing of an impending transfer or discharge 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 patient 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:

1. On 01/23/18 at 1:40 PM during an interview with Surveyor #7, the hospital's Clinical Services Director (Staff #701) stated that a written list of patient rights was given to all swing bed patients.

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

3. The director stated that swing bed patients did not receive a written notice prior to transfer or discharge.
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Based on interview and record review, the Critical Access Hospital failed to provide social services by a qualified social worker for 5 of 5 long-term care patients reviewed (Patients #703, #704, #705, #706, #707).

Failure to provide social services by a qualified social worker risks a patient's ability to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Findings included:

On 01/23/18 at 1:10 PM, Surveyor #7 interviewed the Clinial Services Director (Staff #701) regarding how social services were provided to the hospital's long-term care ("swing-bed") patients, including five patients included in the survey sample. The director stated that social services were provided by a registered nurse with an associate degree (Staff #705) and a licensed practical nurse (Staff #706).
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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 included measurable objectives, interventions, and timetables for meeting treatment goals, as demonstrated by 5 of 5 swing bed patients reviewed (Patients #703, #704, #705, #706, #707).

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. The hospital's policy and procedure titled "Care Plans" (Reviewed/Revised April 2017) showed that nursing staff members would develop an individualized plan of care for each patient and swing bed resident within twenty-four hours of admission. The plan would include "observations to make, what nursing actions to carry out, and what instructions the patient/resident or family members require". The policy stated that goals would be patient-oriented and measurable with a time frame for achievement.

2. On 01/23/18 between 2:40 PM and 3:10 PM, and on 01/24/18 at 9:15 AM, Surveyor #7 reviewed the records of five long-term care ("swing bed") patients currently receiving care in the hospital. The record review revealed that the nursing plans for care did not include measurable objectives, interventions, and timetables for meeting treatment goals.

3. During an interview with Surveyor #7 at the time of the record review above, the hospital's Chief Nursing Officer (Staff #701) confirmed the findings above.
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Based on interview and document review the Critical Access Hospital failed to include internal risk factors in the "All Hazards" risk assessment of the hospital's emergency preparedness plan.

Failure to include internal risk factors such as but not limited to care-related emergencies; equipment and power failures; interruptions in communications, including cyber-attacks; loss of portions or all of the facility; and interruptions in the normal supply of essentials, such as water and food into the scope of the hospitals all hazard risk assessment, places patients, staff and visitors at risk of internal disasters which could result in injury and/or death.

Findings Included:

On 01/24/18 between the hours of 9:00 and 10:00 AM, Surveyor #1 interviewed the emergency preparedness program manager (Staff #101) regarding the hospital's all hazard risk assessment. During the interview the manager provided documentation of the all hazards risk assessment which only contained items of external hazards and did not include internal hazards as described above.
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Based upon record review and staff interview, the Critical Access Hospital failed to develop policies and procedures that addressed alternate energy sources necessary to maintain heat, emergency lighting and the building's fire alarm system during an emergency situation.

Failure to provide adequate alternate energy sources places residents, staff and/or visitors within the facility at risk of injury or death if these systems were to fail.

Findings included:

On 1/23/18 between the hours of 8:45 AM and 10:30 AM during an interview with hospital's emergency preparedness program manager (Staff #101), Fire Marshal #1 discovered that the facility did not have policies in place to address how the hospital would provide heating and emergency lighting in the event of a power outage. The facility had no documentation indicating how many hours of fuel they had on-site for their Level 2 emergency generator. This was discussed with and acknowledged by the emergency program manager, who said he was unaware the hospital needed these policies.
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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 01/24/18 between the hours of 9:00 AM and 10:00 AM, Surveyor #1 interviewed the hospital's emergency preparedness program manager (Staff #101) regarding the communication plan during emergencies. The interview 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 hospital's plant manager.
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Based on interview and record review, 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:

1. On 0124/18, Surveyor #1 reviewed the hospital's emergency preparedness plan. The plan did not address training requirements for all staff.

2. On 01/24/18 at 9:00 AM, Surveyor #1 interviewed the facility's emergency preparedness program manager (Staff #101) regarding the process for training staff in emergency preparedness. The manager provided documentation that indicated hospital department managers had received emergency preparedness training but was unaware that all new and existing staff also needed to be trained. The manager did not have a process in place to ensure all staff were trained.
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Based upon record review and staff interview, the Critical Access Hospital failed to test the emergency generator fuel in accordance with NFPA 110.

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

Finding included:

On 01/23/18 between the hours of 8:45 AM and 10:30 AM during an interview with Fire Marshal #1, the emergency preparedness program manager (Staff #101) was unable to provide documentation showing that a fuel quality test had been performed per NFPA 110-8.3.8 within the past 12 months. The above was discussed and acknowledged by the manager who stated the he believed the fuel had been tested within the past 12 months but was unable to provide the documentation.
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