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Based on policy review, observations, code cart documentation for 4 of 4 emergency code carts and staff interview, it was determined that the hospital failed to ensure that emergency code carts were maintained in accordance with its policy to ensure the integrity and availability of the contents of the carts.

Findings include:

1. A policy titled "Defibrillator Operational Checks & Code Cart Security," effective 09/2010 was reviewed. The policy reflected "It is the policy of West Valley Hospital that staff will check defibrillators and code carts for function and security at regularly designated intervals, per the guidelines in this document...Code Cart Security...Code cart security assures availability of life-saving equipment for breathless and/or pulseless events...Code cart security checks are performed according to the hours a unit is in operation...Units open twenty-four hours a day, seven days a week will check code cart security every shift...Units open a single shift document code cart security once daily...Documentation-the code cart checklist is used to document the following...A. Date and time checked...B. All supplies and equipment are present...C. Cart is secure with numbered lock intact...F. Pharmacy label is present on medication drawer with next medication outdate and lock number recorded...Emergency and Med/Surg Department Code cart drawer inventory including outdate checks and equipment function will be done bi monthly and documented on the Code Cart Check list...Emergency medications will be checked by pharmacy every month...The department manager will assign appropriate staff to check code cart supplies every month...This will be recorded on the Code Cart Checklist."

2. During a tour of the hospital's outpatient Infusion and Wound Care department on 02/06/2012 at 1115 with the department's Assistant Nurse Manager, an emergency code cart and a corresponding crash cart checklist were observed. Page 1 of the checklist reflected "Crash Cart will be checked daily when department open by IWCC or Cardiopulmonary Staff." Page 1 of the checklist had a column which identified items on the cart that were to be checked and included "Backboard...Adult Ambu bag w/mask...Ped dosage chart..." Four of the items listed on the checklist were partially "cut off" and therefore it was unclear what items were to be checked. For example, the following items were listed to be checked "...Record," "...and clean," and "...in bottom of Code Cart)" however the preceding words were "cut off" and therefore were not legible. Page 1 of the checklist lacked documentation that checks had been completed on 10/03/2011, 10/04/2011, 10/08/2011, 10/09/2011, 10/15/2011, 10/16/2011, 10/23/2011, 11/12/2011, 11/13/2011 and 01/08/2012.

Review of Pages 2 and 3 of the checklist reflected the cart had drawers which contained airway, oxygen, suction and IV supplies. The top of page 2 reflected "Crash Cart Drawer Contents will be checked Bimonthly for outdates and to assure all equipment is in working order." The checklists for 10/01/2011-10/31/2011 and 11/01/2011-11/30/2011 lacked documentation that checks had been completed.

3. An interview was conducted with the Director of Clinical Operations on 02/07/2012 at 0930. He/she said the outpatient Infusion and Wound Care department was open daily, including most weekends, with the exception of some holidays. He/she provided a list of the dates in which the department was closed and those dates were not included in the findings above.

4. Similar findings were identified during observations of the pediatric code cart on 02/09/2012 at 1415, and code carts in the Emergency and Medical/Surgical departments during observations of those units on 02/09/2012 at 1420.

Based on policy review, the review of documentation in 5 of 5 records of patients who received transfusions of blood or blood products in the hospital's outpatient infusion and wound department (Record #s 1, 2, 3, 4 and 5) and staff interview, it was determined that the hospital failed to ensure documentation of all of the elements required for blood transfusions in accordance with its policy.

Findings include:

1. The policy titled "Blood Administration for Adults (whole blood, packed/frozen red blood cells, white blood cells & plasma)," dated effective 10/2010 was reviewed and reflected "Transfusion Administration...Obtain baseline vital signs and document...blood must be transfused within 4 hours of [leaving] the Blood Bank...Re-check and document vital signs and compare to baseline vitals...After the first 15 minutes...Upon completion of the infusion...KEY POINTS...Documentation in the permanent medical record: chart the following in the Epic Blood Flow and MAR...vital signs before, during and immediately after the transfusion."

2. Patient record #1 was reviewed and reflected the patient received one unit of blood on 11/02/2011 which was started at 1204. The electronic record reflected that vital signs were completed at 1222 and 1351. The the blood transfusion was completed at 1356, 5 minutes after the last set of vital signs were completed. This was reviewed with the Infusion and Wound Care Assistant Nurse Manager on 02/06/2012 at 1510. He/she checked Patient #1's record and was unable to locate documentation that vital signs were done upon completion of the blood transfusion as required by the hospital policy.

3. Patient record #2 was reviewed and reflected the patient received one unit of blood on 01/03/2012 which was started at 1006. The electronic record reflected that vital signs were not completed until 1158, over an hour later.

An interview was conducted with the Infusion and Wound Care Assistant Nurse Manager on 02/06/2012 at 1500. He/she checked Patient #2's record and acknowledged that the record lacked documentation that vital signs were completed 15 minutes after the start of the transfusion as directed by the hospital policy.

4. Patient record #3 was reviewed and reflected the patient received one unit of blood on 10/10/2011 which was started at 1340. The electronic record reflected that vital signs were completed at 1400, 20 minutes later.

An interview was conducted with the Infusion and Wound Care Assistant Nurse Manager on 02/06/2012 at 1445. He/she checked Patient #3's record and acknowledged that the record lacked documentation that vital signs were completed 15 minutes after the start of the transfusion as directed by the hospital policy.

5. Patient record #4 was reviewed and contained a "Blood Bank/Transfusion Label." The record reflected the patient received one unit of blood on 10/28/2011 which was "Started" at 1235 and "Stopped" at 1700, over 4 hours later. The record reflected that vital signs were completed at 1255, 20 minutes after the blood transfusion was started. This was reviewed with the Infusion and Wound Care Assistant Nurse Manager on 02/06/2012 at 1430.

6. Patient record #5 was reviewed and reflected the patient received one unit of blood on 08/16/2011 which was started at 1149. The electronic record reflected that vital signs were completed at 1210, more than 20 minutes later.

An interview was conducted with the Infusion and Wound Care Assistant Nurse Manager on 02/06/2012 at 1500. He/she checked Patient #5's record and acknowledged that the record lacked documentation that vital signs were completed 15 minutes after the start of the transfusion as directed by the hospital policy.

Based on observations, documentation review, and interviews with hospital staff, the State Fire Marshal determined that the hospital failed to maintain a current emergency action plan readily available to all staff. Additionally, the hospital failed to continuously maintain, inspect, and test the required automatic sprinkler system which resulted together with the lack of an action plan in a threat to the health and safety of patients and staff.

Findings include:

Refer to the detailed findings listed at K tags:
K 48 and K 62.

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. During the CAH recertification and State relicensure survey, it was determined that many policies had not been reviewed or revised on an annual basis per this regulation. Listed below is a sample of patient care policies that had not been reviewed for more than a year:

WEST VALLEY HOSPITAL POLICY/PROCEDURE, "REFRIGERATION/ DISH MACHINE TEMPERATURES," last reviewed 07/2008;
Salem Health Administrative Housewide Policy and Procedure, "Tuberculosis Control for Healthcare Providers," last reviewed 02/2009;
Salem Health Administrative Housewide Policy and Procedure, "Mandatory Abuse Reporting," last reviewed 03/2009;
Salem Health Administrative Housewide Policy, "Mandatory Abuse Reporting Disclosure of Protected Health Information (PHI)," last revised 08/2009;
Salem Health Administrative Housewide Policy and Procedure, "Prevention & Control of Infection & Disease," last reviewed/revised 09/2009;
Salem Health Clinical Housewide Policy and Procedure, "Fall Risk Assessment, Prevention & Management," last reviewed/revised 11/2009;
Salem Health Administrative Housewide Policy, "Patient Assessment," last reviewed 11/2009;
Salem Health Clinical Housewide Policy and Procedure, "WVH Rapid Response Team," last reviewed/revised 04/2010;
Salem Health Clinical Department Level Policy, "WVH Trauma Care System Overview," last reviewed/revised 07/2010;
Salem Health Administrative Housewide Policy and Procedure, "Tuberculosis Exposure Control Plan," last reviewed 08/2010; and
Salem Health Administrative Department Level Policy and Procedure, "Food Handling," last revised 09/2010.

2. During an interview with the Director of Clinical Operations on 02/10/2012 at 0940, he/she confirmed that there was confusion regarding which policies had to be reviewed annually with the professional group. He/she discussed plans to correct the current practice.

Based on the review of documentation in 3 of 4 records of patients who underwent a surgical procedure (Record #s 14, 16 and 17), policy review, and staff interview, it was determined that the hospital lacked documentation that all patients were discharged in the company of a responsible adult following their procedure in accordance with hospital policy.

Findings include:

1. The policy titled "Patient Safety Guidelines," effective 11/2010 was reviewed and reflected "Guidelines to provide a safe environment in which staff and patients can remain safe...Patients who have CNS depressants should not be discharged unless accompanied by a responsible adult."

2. A document titled "Standards of Care: Endoscopy Lab," last approved 12/16/2011 was reviewed and reflected "The Salem & West Valley Hospital's Administrative and Clinical Policies, Procedures/Protocols, and the Standards will guide the practice of nursing...Safety...8. Ensure patient has a ride home and will not be driving."

3. Patient record #14 was reviewed and reflected that the patient underwent a colonoscopy procedure on 10/12/2011. An RN note dated 10/12/2011 at 0625, prior to Patient #14's procedure reflected "Outpatient ride home confirmed?..Yes." The "Colonoscopy Report" signed 10/12/2011 at 0754 reflected "...After the procedure, the patient was sent to recovery. After recovery, the patient was sent home...Sedation medication(s) administered: fentanyl IV, midazolam IV, propanol IV. Level of sedation: Deep sedation." The RN "Patient Discharge Note" dated 10/12/2011 at 0822 reflected "Data: [Patient #14] has been discharged home at 0843 via ambulatory accompanied by Registered Nurse." The record lacked documentation that reflected whether or not the patient was accompanied by a responsible adult at discharge as directed by the hospital policy.

4. Patient record #16 was reviewed and reflected that the patient underwent an umbilical hernia repair on 11/15/2011. An RN note dated 11/15/2011 at 0805, prior to Patient #16's procedure reflected "Outpatient ride home confirmed?..Yes." The "WEST VALLEY HOSPITAL OPERATIVE/INVASIVE PROCEDURE NOTE," signed 11/17/2011 at 0938 reflected the patient was induced with general endotracheal anesthesia. The RN "Patient Discharge Note" dated 11/15/2011 at 1029 reflected "Data: [Patient #16] has been discharged home at 1210 via wheel chair accompanied by Registered Nurse." The record lacked documentation that reflected whether or not the patient was accompanied by a responsible adult at discharge as directed by the hospital policy.

5. Patient record #17 was reviewed and reflected that the patient underwent a colonoscopy procedure on 12/21/2011. An RN note dated 12/21/2011 at 0712, prior to Patient #17's procedure reflected "Outpatient ride home confirmed?..Yes." The "Colonoscopy Report" signed 12/21/2011 at 0816 reflected "...After the procedure, the patient was sent to recovery. After recovery, the patient was sent home...Sedation medication(s) administered: fentanyl IV, midazolam IV, propanol IV. Level of sedation: Deep sedation." The RN "Patient Discharge Note" dated 12/21/2011 at 0930 reflected "Data: [Patient #17] has been discharged home at 0930 via ambulatory accompanied by Registered Nurse." The record lacked documentation that reflected whether or not the patient was accompanied by a responsible adult at discharge as directed by the hospital policy.

6. An interview and review of Patient record #s 14, 16 and 17 were conducted with the Surgical Services Assistant Nurse Manager on 02/08/2012 at 1345. During the interview it was revealed that the "Data" section of the "Patient Discharge Note" had a drop down menu whereby various options such as "Registered Nurse," "wife" and/or a customized option could be selected in order to document who accompanied the patient at discharge. During the interview, the assistant manager acknowledged that although these options were available for Patient record #s 14, 16 and 17, the "Patient Discharge Note" lacked documentation of whether or not the patients were accompanied by a responsible person at the time of discharge. No further documentation that the patients were discharged with a responsible adult was received for the duration of the survey which was completed on 02/10/2012 at 1530.

Based on the review of hospital policy and the review of documentation contained in 1 of 3 medical records of patients who expired in the hospital (Record #6) , it was determined that the hospital failed to ensure documentation of the notification of the Donor Referral organization within the timeframe directed by hospital policy.

Findings include:

1. The policy titled "Organ and Tissue Donation Request," effective 12/2010 reflected "Staff will call the Donor Referral Line...within one hour of cardiac death or within one hour when a patient meets a clinical trigger to determine medical suitability for donation and to give sufficient time for the family to be contacted regarding a donation option...Nursing staff shall complete the Call Center Referral and Post-Mortem Care Checklist."

2. The medical record for Patient #6 was reviewed. The "Call Center Referral and POST-MORTEM Care" form reflected the date/time of death was 09/11/2011 at 0321. Although the record reflected a referral had been made to the "Donor Referral Hot line," the record lacked a documented time of the referral in order to determine whether or not staff had called within one hour as directed by the hospital policy.

The "POS-MORTEM Care Check list" reflected
"0630...Call Center Referral...
0620...Consent for Tissue and Organ Donation faxed by donor agency..."
The record lacked documentation that the Donor Referral line was contacted within one hour as directed by the hospital policy.

3. These findings and a review of Patient record #6 were conducted with the Emergency Department Manager on 02/07/2012 at 1400. These findings were also reviewed with the Director of Clinical Operations on 02/07/2012 at 1430. No further documentation was provided for the duration of the survey which was completed on 02/10/2012 at 1530.

Based on the review of medical records, hospital Swing-bed policies and staff interview it was determined that the hospital failed to ensure the provision of a written notice which included all of the required elements before transfer or discharge in 4 of 5 medical records of individuals who were discharged from the hospital following the provision of Swing-bed services (Patient record #s 9, 11, 12 and 13).

Findings include:

1. An interview and review of Swing-bed Patient records was conducted with the Med Surg/ED Manager on 02/07/2012 at 1110. Documentation of the hospital's Swing-bed Discharge and Transfer notice was requested. He/she provided a document titled "An Important Message From Medicare About Your Rights." No further documentation of a Swing-bed discharge notice utilized by the hospital which included all of the required elements was received for the duration of the survey which was completed on 02/10/2012 at 1530.

2. Swing-bed Patient record #9: Review of the record revealed the patient was admitted to a hospital Swing Bed on 10/28/2011 and discharged on 11/09/2011.

Swing-bed Patient record #11: Review of the record revealed the patient was admitted to a hospital Swing Bed on 10/15/2011 and discharged on 10/19/2011.

Swing-bed Patient record #12: Review of the record revealed the patient was admitted to a hospital Swing Bed on 11/30/2011 and discharged on 12/09/2011.

Swing-bed Patient record #13: Review of the record revealed the patient was admitted to a hospital Swing-bed on 10/15/2011 and discharged on 10/17/2011.

Swing-bed Patient record #s 9, 11, 12, and 13 listed above lacked documentation that the individuals were provided a discharge notice which included all of the required elements per 483.12(a)(6).

3. Swing-bed policies were reviewed and included provisions for issuing a "Swing Bed Notice of Non-Coverage" and a "Discharge Planning" procedure, however the documentation lacked a process for providing a Swing-bed patient with a discharge notice prior to transferring or discharging the patient.