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Based on observation, interview, review of code cart checklist documentation for 2 of 2 emergency code carts, and policy review, it was determined the hospital failed to document that its emergency code carts were maintained in accordance with its policy and to assure the integrity and availability of the contents of the carts.

Findings include:

1. A policy titled "Emergency Carts/Defibrillators," dated 02/03/2012 was reviewed. The policy reflected "It is the policy of Harney District Hospital to maintain emergency carts and defibrillators in accordance with the following procedure...To ensure a properly stocked emergency cart will be readily available...To ensure a properly functioning defibrillator will be readily available...The Charge Nurse/designee on each shift shall...Be responsible for daily checking the crash cart, oxygen cylinder level, and defibrillator and document compliance on crash cart checklist...Check the integrity of the lock and lock number every shift and record...Perform defibrillator load checks every shift with the defibrillator plugged in and unplugged...Laryngoscopes will be checked prior to placement on the cart and daily..."

2. A tour of the hospital's medical/surgical unit was conducted with the Chief Financial Officer (CFO) present on 05/15/2012 at 1030. The emergency code cart and corresponding code cart checklist were observed during the tour.

3. An interview was conducted with Nurse H, on 05/12/2012 at 1030. He/she reviewed the medical/surgical code cart checklist and revealed that hospital policy was for the charge nurse to complete a code cart checklist every shift. The nurse further revealed that nurses worked 12 hour shifts, and therefore the code cart checklist should be completed twice each 24 hour period.

4. The emergency code cart checklist titled "Harney District Hospital Daily Code Cart Log MedSurg Floor" for 02/2012, 03/2012 and 04/2012 were reviewed. The monthly checklists included areas for "day shift" and "night shift" to document code cart checks each day of the month. Items listed to be checked included medications, emergency care equipment, and defibrillator function. Review of the checklists revealed that many checks were not documented each shift as directed by hospital policy. Only one check per day was documented 12 days out of 29 for the month of 02/2012. For example, no checks were documented for the following shifts/dates: Day shift - 02/09/2012, 02/14/2012, 02/28/2012; Night shift - 02/02/2012, 02/04/2012, 02/07/2012, 02/08/2012, 02/11/2012 and 02/13/2012.

Similar findings were identified for the medical/surgical code cart for the months of 03/2012 and 04/2012.

5. Similar findings were identified during review of the Emergency Department (ED) code cart checklist titled "Harney District Hospital Daily Code Cart Log Emergency Room" for 02/2012, 03/2012, 04/2012 and 05/2012.

Based on documentation in 4 of 4 medical records reviewed of patients who received blood transfusion services (Record #s 27, 28, 29 and 30) and policy review, it was determined the hospital failed to ensure documentation of all of the elements for blood transfusions as required by hospital policy. Vital signs were not documented according to hospital policy.

Findings include:

1. The policy titled "Blood/Blood Components: Transfusion Process," revised 12/2009 was reviewed and reflected "...Vital signs shall be taken prior to infusion, 15 minutes after infusion started and upon completion of an infusion...Procedure...Complete the Blood Transfusion Form in the patient's electronic chart."

2. Patient record #s 27, 28, 29 and 30 were reviewed. A "Blood Transfusion Form" was contained within each of the patient records. The "BLOOD TRANSFUSION DATA" section of the form included areas for documenting "Time Unit [blood transfusion] Started" and "Time [blood] Transfusion Stopped." The form also included areas for documenting vital signs at designated time frames as follows: "VITALS - Pre-Transfusion," "VITALS - 15 Minutes after initiation of Transfusion," and "VITALS - Post-Transfusion." Each of the time frames were followed by columns for documenting temperature, heart rate, respirations, and blood pressure readings.

3. Patient record #29 was reviewed. The "Blood Transfusion Form" reflected that the patient received one unit of blood on 11/30/2011. The "Time Unit Started" was 1500 and "Time Transfusion Stopped" was 1655. Temperature, heart rate, respirations and blood pressure readings were documented on the form after each of the following time frames: "VITALS - Pre-Transfusion," "VITALS - 15 Minutes after initiation of Transfusion," and "VITALS - Post-Transfusion." Review of the record determined it lacked documentation of the actual time the temperature, heart rate, respirations and blood pressure were taken. The record lacked documentation that vital signs were completed in accordance with hospital policy.

4. Patient record #30 was reviewed. The "Blood Transfusion Form" reflected that the patient received one unit of blood on 01/12/2012. The "Time Unit Started" was 1045 and "Time Transfusion Stopped" was 1300. Temperature, heart rate, respirations and blood pressure readings were documented after each of the following time frames: "VITALS - Pre-Transfusion," "VITALS - 15 Minutes after initiation of Transfusion," and "VITALS - Post-Transfusion." Review of the record determined it lacked documentation of the actual time the temperature, heart rate, respirations and blood pressure were taken.

The record reflected Patient #30 received another unit of blood on 01/12/2012 which was started at 1325 and stopped at 1550. Temperature, heart rate, respirations, and blood pressure readings were documented on the "Blood Transfusion Form" following the time frames "VITALS - Pre-Transfusion," "VITALS - 15 Minutes after initiation of Transfusion," and "VITALS - Post-Transfusion." Review of the record determined it lacked documentation of the actual time the temperature, heart rate, respirations and blood pressure were taken.

5. Similar findings were identified during review of Patient record #s 27 and 28.

6. An interview was conducted with the Nurse Manager on 05/17/2012 at 1150. Patient record #s 27, 28, 29 and 30 were reviewed during the interview. He/she acknowledged that although the forms reflected vital signs were documented following the time frames "VITALS - Pre-Transfusion," "VITALS - 15 Minutes after initiation of Transfusion," and "VITALS - Post-Transfusion," there was no documentation of the actual times when the vital signs were taken.

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 were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of hospital patient care policies that have not been reviewed for more than a year:

-Emergency Department, "Assessment of the Emergency Department Patient," last revised 5/17/2007;
-Medical Staff Rules & Regulations, "Emergency Services," effective 11/2007;
-Human Resources, "Employee Vaccinations & TB Testing," last revised, November 28, 2007;
-Medical Staff Rules & Regulations, "General Rules for Admissions, Discharges, & Patient Care," effective 11/2007;
-Nursing Services, "IV - Central Lines," last revised 7/2008;
-Nursing Services, "Mandatory Overtime," last reviewed 1/11;
-Medical Staff Rules & Regulations, "Patient Rights," effective 11/2007;
-Nursing Services, "Patient Care Planning," last reviewed 2/2010;
-Administration, "Patient's right to a complaint resolution process," last reviewed 3/2010;
-Medical Staff Rules & Regulations, "PPD Skin Test Affidavit for Medical Staff," last reviewed 11/2007;
-All Clinical Areas, "Restraints/Seclusion Definitions and Usage," last revised 7/2009;
-Medical Staff Rules & Regulations, "Rules & Regulations Relating to Patient Care," effective 11/2007;
-Nursing Services,"Staffing Plan," last reviewed, 1/11.

2. During an interview with the Chief Operations Officer/Chief Nursing Offier(COO/CNO) on 05/17/2012 at 1430, he/she confirmed that the patient care policies and procedures were not being reviewed annually.

Based on interview, policy review and the review of radiology department documentation, it was determined the hospital failed to fully implement its policy for the inspection of radiation protective equipment in order to ensure staff were not exposed to radiation hazards. Documentation of protective equipment inspections were not completed as directed by hospital policy.

Findings include:

1. A policy titled "Radiation protective devices/equipment," revised 04/2011 reflected "All employees who use or are around radiation producing equipment are required to wear lead aprons or other protective equipment during exposures...1. All personnel who are in a fluoroscopic room or are in the vicinity of a radiographic procedure (fluoro., or diagnostic x-ray) are required to wear radiation protection...2. Every effort must be made to provide non-occupationally exposed employees/individuals a lead apron or other appropriate protective device when performing X-ray procedures in a mobile capacity. 3. Twice a year all lead aprons, thyroid shields, gloves, etc. will be visually inspected to check for suspicious defects such as cracks or tears. Any suspicious equipment will be [space] and placed back into operation or disposed of as appropriate. Each protective device is numbered and will be marked off on the appropriate inspection sheet as to the appropriate action taken."

2. An interview was conducted with the Interim Imaging Department Lead on 05/17/2012 at 1415. During the interview he/she revealed that aprons used for shielding staff during X-ray procedures were inspected every 6 months for damage. He/she provided a log book which contained a list of 42 protective equipment items and corresponding "visual" checks for each item. The log book had columns to document the visual checks, with the headings "BI-ANNUAL DATE January: 2011" and "BI-ANNUAL DATE July: 2011." The items listed in the log book included 28 aprons, 1 breast shield, 1 CT (computed tomography) shield, 4 gloves, 6 gonad shields, and 2 ED thyroid shields. Review of the documentation reflected the last equipment checks were completed 07/2011, approximately 10 months ago.

This was reviewed with the Imaging Department Lead and he/she said the visual checks were due 01/2012. He/she further acknowledged the log book lacked documentation that the equipment was inspected every 6 months per usual procedure. The department lead checked his/her quality assurance binder and was unable to locate documentation of any equipment checks after 07/2011.

Based on interview, review of documentation in 1 of 2 records of patients who underwent a surgical procedure with general anesthesia (Record #35), and policy review, it was determined the hospital failed to ensure documentation that an examination was performed by a qualified practitioner prior to the surgical procedure to evaluate the risk of anesthetic agents in accordance with hospital policy.

Findings include:

1. The policy titled "Assessment Prior to Induction of Anesthesia/Sedation," revised 06/30/2010 was reviewed and reflected "The purpose of this policy is to provide optimum patient care through a comprehensive preanesthesia evaluation, ensuring that the patient is hemodynamically stable to receive administration of anesthetic agents...The patient will be evaluated by the anesthetist prior to provision of anesthesia services, with the results of the evaluation documented on the pre-anesthesia evaluation record. All patients requiring anesthetic agents will be evaluated immediately prior to induction....It is understood that the term "immediately prior to induction" identifies that time period within one (1) hour prior to provision of anesthetic agents, with baseline vital statistics reassessed immediately prior to physical induction...Any evaluation performed more than one (1) hour prior to the provision of anesthesia to the patient, requires a re-evaluation immediately prior to induction. Documentation of above noted evaluations/re-evaluations is required by the anesthetist providing anesthesia services. A note will be made on the preanesthesia history and physical form..."

2. Patient record #35: Review of the record reflected the patient underwent a laparoscopic cholecystectomy surgical procedure on 03/13/2012 which was started at 0814 and completed at 0923. The physician operative note authenticated 03/14/2012 at 1248 reflected the patient received general anesthesia with oral endotracheal intubation for the procedure. Review of the certified registered nurse anesthetist (CRNA) anesthesia history and physical form reflected a physical examination was completed on 03/13/2012. Review of the CRNA anesthesia perioperative record reflected that a "PRE INDUCTION EVALUATION" vital signs and anesthesia history and physical were checked off [check box with "X"]. However, the record lacked a documented time of the examination in order to determine whether or not it had been conducted prior to the provision of anesthesia services within time frames directed by hospital policy and before surgery as required by this regulation.

3. An interview was conducted with the CRNA on 03/16/2012 at 1530. He/she reviewed Patient record #35 and acknowledged the record lacked a documented time of the pre-anesthesia examination.

Based on interviews with hospital staff and the review of documentation, it was determined that the hospital lacked a periodic evaluation of its total program.

Findings include:

The review of documentation revealed that the last CAH program evaluation was dated December 1, 2010. The hospital lacked documentation of any more recent CAH program evaluations.

In an interview with the CFO on 05/15/2012 at approximately 1500, he/she confirmed there has not been a CAH program evaluation completed since 2010.

Based on the review of documentation contained in 2 of 2 records of patients who expired at the hospital (Record #s 31 and 32), policy review, and medical staff rules and regulations, it was determined that the hospital failed to ensure documentation of timely notification of the Organ Procurement Organization (OPO) as required and OPO notification was not documented in all cases in accordance with hospital policy.

Findings include:

1. A policy titled "Organ and Tissue Donation," revised 11/30/2009 was reviewed and reflected "The [Conditions of Participation] require hospitals and donation agencies to work in collaboration to increase the organs and tissues available for transplant. To that end, hospitals [shall] refer all deaths to the donor agency via the donor referral line...A. Procedure for Referring Death: 1. Patients, age newborn through 75 years, who are supported by a ventilator and display an [sic] Glascow Coma Score (GCS) of 3...will be referred to the donor agency. 2. Patients, age newborn through 75 years, who are NOT on ventilators must be referred to the donor referral line at the time of cardiac death or when death is imminent. 3. Patients over 75 years should be referred to the donor referral line as they may be potential eye donors."

The policy did not include a clear definition of a timely referral of all patients to the OPO to ensure the OPO was contacted as soon as possible after a patient had died, had been placed on a ventilator due to a severe brain injury, or had been declared brain dead.

2. Review of hospital medical staff rules and regulations, titled "Organ/Tissue Donation," effective 11/2007 reflected "All deaths in the hospital should be considered for possible organ/tissue donations according to the established criteria. All deaths will be reported to the hospital's administrator on-call, with all organ and tissue donation performed in accordance with state and federal laws..."

3. Patient record #31: Review of the record reflected the patient was admitted to the hospital on 03/02/2012 at 1311. The "RELEASE OF DECEASED PATIENT AND INFORMATION FORM" reflected the patient expired at the hospital on 03/13/2012 at 0400. The "RECORD OF REQUEST FOR ANATOMICAL DONATION" form had not been completed and failed to include documentation that the death was referred to the OPO in accordance with hospital policy.

4. Patient record #32: Review of the record reflected the patient was admitted to the hospital on 11/07/2011 at 2207. The "RELEASE OF DECEASED PATIENT AND INFORMATION FORM" reflected the patient expired at the hospital on 11/07/2011 at 2342. The "RECORD OF REQUEST FOR ANATOMICAL DONATION" form was signed/dated by an RN on 11/08/2011 at 0200, more than 2 hours after the patient had expired. Review of the record determined it lacked documentation that Patient #32's death was referred to the OPO in a timely manner as required.

Based on the review of documentation contained in 4 of 4 Swing-bed records of patients who were discharged from the hospital (Record #s 23, 24, 25, and 26), the review of Swing-bed documentation, and interviews with hospital staff, it was determined that the hospital failed to ensure the provision of a written notice before discharge with all of the elements required by this regulation.

Findings include:

1. The review of the hospital's Swing-bed patient information revealed that the hospital had developed a 2-page form titled "Notice of Transfer or Discharge." The form lacked a specified mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals and the appropriate protection and advocacy agency for Swing-bed patients with mental illness or mental retardation.

2. Swing-bed Patient record #23: Review of the record reflected the patient was admitted to a hospital Swing-bed on 03/19/2012 at 1919 and discharged on 03/23/2012. The record lacked documentation that a written discharge notice with all of the required elements had been provided to the patient prior to discharge.

These findings were reviewed with the Swing-bed Coordinator on 05/17/2012 at 1700. The coordinator reviewed Patient record #23 and was unable to locate documentation that the patient had been notified of the discharge and the reasons for the move in writing as required by this regulation.

3. Swing-bed Patient record #24: Review of the record reflected the patient was admitted to a hospital Swing-bed on 04/12/2012 at 1119 and discharged on 04/19/2012. The record contained a discharge notice titled "Notice of Transfer or Discharge." Review of the notice reflected "You have the right to appeal this decision as explained on the second page of this form." The record failed to contain the second page of the "Notice of Transfer or Discharge" form. Additionally, page 1 of the "Notice of Transfer or Discharge" form did not include the name, address and telephone number of the State long term care ombudsman
or a statement specifying that the patient had the right to appeal the action to the State as required.

Similar findings were identified in Swing-bed Patient record #s 25 and 26.

These findings were reviewed during an interview with the Swing-bed Coordinator on 05/17/2012 at 1615. The coordinator revealed that the second page of the "Notice of Transfer or Discharge" form, which included a patient's right to appeal the action to the State and the State long term care ombudsman contact information had not been scanned into the computer for Swing-bed Patient #s 24, 25 and 26. He/she further acknowledged that the hospital's "Notice of Transfer or Discharge" form did not include contact information for the agency responsible for the protection and advocacy of developmentally disabled individuals and individuals with mental illness or mental retardation. He/she was provided an opportunity to locate additional documentation and none was received for the duration of the survey which was completed on 05/18/2012 at 0830.

Based on interview, the review of documentation in 4 of 4 records of patients who received hospital Swing-bed services (Record #s 23, 24, 25, and 26), review of Swing-bed program documentation, and Swing-bed policy review, it was determined the hospital failed to provide an on-going program of activities that was directed by a qualified individual or designated staff person who meets the requirements of this regulation. Activities care plans were not completed within time frames in accordance with hospital policy. The hospital failed to ensure activities were encouraged and documented to reflect the assessed interests and needs of each Swing-bed patient in accordance with hospital policy and as required.

Findings include:

1. An interview was conducted with the Swing-bed Coordinator on 05/17/2012 at 1345. He/she stated the hospital's Swing-bed program was not directed by a qualified individual or designated staff person.

2. A hospital Swing-bed policy titled "Activity Program," origination date 12/21/2011 was reviewed and reflected "Activities will be encouraged and suited to meet the patient's unique physical, social, intellectual, spiritual, and creative needs and capabilities...Collaboratively the nursing staff and patient will determine activities of interest and appropriateness, taking into consideration the patient's interests, skills, medical limitations, cognitive ability, and emotional functioning...Each patient will be encouraged to participate in activities...Nursing staff will assess patient's restrictions and assess patient's interests, capabilities, and needs pertaining to activities...The nursing staff will assist the patient in determining activities of interest and benefit; the patient's input and desire is vital to a successful activities plan...The nursing staff will evaluate the patient's ability, interest, and participation with activities...Care Plans are to be initiated upon admission, completed within 4 days, and updated every 2 weeks and as needed...Each patient's individualized care plan will address activities, including patient outcomes/goals, interventions/activities,and evaluation of outcomes...Progress notes should reflect the type of activity performed and the patient's participation."

The policy lacked documentation that Swing-bed patient activities would be directed either by a qualified professional or by an individual on the facility staff who was designated as the activities director and who served in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy.

3. A document titled "HARNEY DISTRICT HOSPITAL SKILLED NURSING CARE/SWING BED PROGRAM A note to Patients," dated 05/2010 was reviewed and reflected "...Upon admission, you will receive a visit from the Swing Bed Coordinator/designee. He/she will assist you in providing supplies for a hobby of your choice or provide some type of activity that you enjoy. From time to time, your activities program will be adjusted to reflect your changing interests."

4. Swing-bed record #23: Review of the record reflected the patient was admitted to a hospital Swing-bed on 03/19/2012 at 1919 and discharged on 03/23/2012 at 1017. A document titled "Harney District Hospital Activity Assessment for Swing Bed Program" listed the following activity preferences: Board games, crafts/art, music (oldies, and rhythm and blues), reading, and visiting with family/friends. The assessment lacked a signature and date of completion in order to determine when the patient's activities needs were assessed and whether or not nursing staff had assisted the patient in determining activities of interest in accordance with hospital policy.

Further review of the record including the patient kardex and care plan history reports dated 03/19/2012 at 1740 and 1743 determined the record lacked documentation that an activities care plan had been initiated on admission as directed by hospital policy.

5. Swing-bed Patient record #24: Review of the record reflected the patient was admitted to a hospital Swing-bed on 04/12/2012 at 1119 and discharged on 04/19/2012, 7 days later. The Swing-bed activity assessment was reviewed and included the following activity preferences: Cards, board games, crafts/art, exercise/sports, country/western/easy listening music, reading and writing. The assessment lacked a signature and date of completion.

Review of the record including the "COMPREHENSIVE CARE PLAN" dated 04/19/2012 at 0756 and 0757 determined it lacked documentation that an activities care plan had been initiated on admission and completed in 4 days as directed by hospital policy.

6. Swing-bed Patient record #25: Review of the record reflected the patient was admitted to a hospital Swing-bed on 01/13/2012 at 1419 and discharged 01/25/2012 at 1458. The Swing-bed activity assessment was reviewed and included the following activity preferences: Cards, board games, crafts/art, puzzles, exercise/sports, country/western/easy listening music, reading and writing. The assessment lacked a signature and date of completion.

Review of the record lacked documentation that the patient was encouraged to engage in activities suited to meet his/her unique physical, social, intellectual, spiritual, and creative needs and capabilities in accordance with hospital policy. For example, progress notes reflected the patient was watching television 01/14/2012 at 1755, 01/16/2012 at 2051, and "TV on" 01/19/2012 at 1500. However, review of the activity assessment revealed the patient did not identify television as an "activity preference." Review of progress notes dated 01/20/2012 at 1630 reflected "[Patient] resting at [the][edge of the bed] reading [a] book upon entering [the] room." Although the patient identified "reading" as a preferred activity, the 01/20/2012 progress note was the only documentation that the patient engaged in any "activity preference" during his/her entire 12 day Swing-bed hospitalization. Additionally, the record lacked documentation that the Swing-bed Coordinator or designee had assisted or provided the patient with supplies for a hobby or activity that he/she enjoyed as indicated in the "HARNEY DISTRICT HOSPITAL SKILLED NURSING CARE/SWING BED PROGRAM A note to Patients."

An interview was conducted with the Swing-bed Coordinator on 05/17/2012 at 1615. He/she was informed that Patient record #25 lacked documentation that the patient was provided assistance and encouragement to engage in activities based on his/her interests. He/she said patients were provided an activities assessment and completed it themselves which was why the assessments were not signed or dated. He/she said Certified Nursing Assistants and the Swing-bed Coordinator were responsible for assisting patients with activities and documenting activities performed in the medical record progress notes.

Review of the record including the care plan history reports dated 01/13/2012 at 1636 and 2345; and 01/18/2012 at 0936 determined the record lacked documentation that an activities care plan had been initiated on admission and completed within 4 days as directed by hospital policy.

7. Swing-bed Patient record #26: Review of the record reflected the patient was admitted to a hospital Swing-bed on 04/07/2012 at 1641 and discharged 04/13/2012. The Swing-bed activity assessment was reviewed and included the following activity preferences: country and Christian music, television (news, Christian, westerns, drama and action), "Spiritual/Religious," and visiting with family. The assessment lacked a signature and date of completion.

Review of the record lacked documentation that the patient was encouraged to engage in activities suited to meet his/her unique physical, social, intellectual, spiritual, and creative needs and capabilities in accordance with hospital policy. For example, progress notes reflected the patient was watching television 04/08/2012 at 1000 and 1339; 04/09/2012 at 1500; and 04/12/2012 at 1621 and 1840. None of the documentation included whether or not the patient was assisted or encouraged to engage in watching news, Christian, westerns, drama or action television programs which he/she had identified as preferences.

Review of the record including the "COMPREHENSIVE CARE PLAN" dated 04/13/2012 at 0728 determined it lacked documentation that an activities care plan had been initiated on admission and completed within 4 days as directed by hospital policy.