HospitalInspections.org

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Based on observation, interview, and document review, the Critical Access Hospital failed to maintain all of the hospital's facility equipment and medical equipment.

Failure to maintain the hospital's preventive maintenance program puts patients at risk from malfunctioning equipment.

Findings included:

1. On 05/03/18 between the hours of 9:30 AM and 11:00 AM, Surveyor #1 interviewed the Director of Maintenance (Staff #104) in regards to the hospital's preventive maintenance program. The Director of Maintenance stated that the current process is that the facility uses a software program called the "Facility Dude" which keeps track of facility equipment. Review of the "Facility Dude" with the director of maintenance showed the ice machine preventive maintenance was due 02/18. Preventive maintenance had not been completed according to the maintenance records. During the same interview, the maintenance director indicated that Providence Sacred Heart did the preventive maintenance for patient care equipment.

2. On 05/03/18 at 2:30 PM, Surveyor #1 observed an ultrasound device (Sonicator 740) in the physical therapy department with no preventative maintenance sticker.

3. On 5/3/18 at 3:00 PM, Surveyor #1 interviewed staff member in charge of medical equipment (Staff #105).
She stated that she was unaware that the facility was using the ultrasound device. Review of the medical equipment list showed the new ultrasound device was not on the list. The facility could not provide documentation to show that the initial preventative maintenance was completed before patient use.
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Based on observation and interview, the Critical Access Hospital failed to secure non-ionizing contrast drugs in computed tomography (CT) department.

Failure to secure medications puts patients at risk from contaminated pharmaceuticals.

Findings included:

On 05/01/18 at 9:45 AM during a tour through the CT department with the Interim Imaging Manager (Staff #102), Surveyor #1 opened a cabinet that held medications used for patients when receiving CT scans. When interviewing the Interim Imaging Manager, Surveyor #1 asked if the double doors to the CT room were left open to the hallway. The manager stated "Yes". The manager also confirmed that the medications in the room were not secured in the cabinets.
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Based on observation, interview and document review, the Critical Access Hospital failed to ensure that pressure relationships were consistent within standard tolerances.

Failure to ensure pressure relationships are properly maintained places patients and staff at risk of infection or an unsafe care environment.

Reference: NFPA 99 Standard references American Society of Heating, refrigerating and Air-conditioning Engineers (ASHRAE 170-2008), Pg. 32 Table 2.1-2 Imaging/ Nuclear medicine hot lab air movement relationship to adjacent areas should be negative with a minimum of 6 air exchange per hour.

Findings included:

On 05/04/2018 at 9:15 AM, Surveyor #1 conducted a string test to check the pressure relationship between the nuclear medicine lab, which contained radioactive diagnostic agents, and the patient examination room. The surveyor was unable to determine the direction of flow using the string test. The Director of Maintenance (Staff #104) used the tissue test and confirmed that the direction of flow was undetermined. The director did not have documentation that the room had negative air flow. The room should be negative to the patient treatment room as stated above.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet all applicable provisions of the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that hospital staff members followed the hospital's restraint policy when caring for patients placed in restraints for 2 of 4 patients reviewed (Patients #701, #702).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. The hospital's policy and procedure titled, "Restraints: Use", revised 08/17, showed that an order written by a physician, physician's assistant, or advance practice nurse practitioner was required for the use of physical restraints. The order for restraints for aggressive or self-destructive behavior would be valid for up to four hours for adult patients. A new order would be required if restraint use was still needed to protect the patient and/or hospital staff members.

2. On 05/02/18 at 1:30 PM, Surveyor #7 reviewed the medical records of four patients who were restrained during their hospital stay. The review revealed the following:

a. Patient #701 was a 49 year-old patient who was admitted to the emergency department (ED) on 01/12/18 and treated for alcohol intoxication. The patient became agitated during his ED encounter and was placed in four-point restraints (all extremities) for "aggressive/self-destructive" behavior. The patient was in restraints from 5:41 PM on 01/12/18 until 7:03 AM on 01/13/18. The patient's medical record included physician orders written at 5:52 PM. The restraints were not re-ordered every four hours as directed by hospital policy.

b. Patient #702 was a 56 year-old patient who was admitted to the ED on 02/04/18 with an altered level of consciousness. The patient was diagnosed with a blood electrolyte imbalance and a urinary tract infection. The patient became confused and combative during his ED encounter and was placed in three-point restraints (right arm, both legs) at 5:55 PM for "aggressive/self-destructive" behavior. The patient was in three-point restraints from 5:55 PM until 6:30 PM, at which time he was placed in four-point restraints (all extremities). The patient was in four-point restraints from 6:30 PM until 7:00 PM. At 7:00 PM, the patient's record indicated the patient demonstrated "non-aggressive/non-self-destructive behavior" and remained in four-point restraints until 8:00 PM. At 8:00 PM, the patient's legs were released and his arms remained restrained (two-point restraints). The patient remained in two-point restraints until he was transferred to another facility at 2:30 AM on 02/05/18.

The patient's medical record included physician orders written at 6:49 PM on 02/04/18 authorizing use of restraints for aggressive/self-destructive behavior and at 1:31 AM on 02/05/18 authorizing use of restraints for non-aggressive/non-self-destructive behavior. Orders were not written at 7:00 PM when the patient transitioned from one type of restraint category to another.

3. During an interview with Surveyor #7 at the time of the record review, the nurse manager for the acute care and obstetrics departments (Staff #701) confirmed the findings above and stated that orders for restraints had not been written for these patients.
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ITEM #1 - PREPARATION OF INTRAVENOUS MEDICATIONS

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 admixtures.

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

References:

246-873-080 WAC - Drug procurement, distribution and control. (2) Additional pharmaceutical services should include: ... (b) Preparation of all sterile products (e.g., IV admixtures, piggybacks, irrigation solutions), except in emergencies.

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

Findings included:

1. On 05/02/18 at 10:15 AM, Surveyor #7 interviewed the hospital's pharmacy director (Staff Member #704) regarding pharmacy services at the hospital. During the interview, the director stated that pharmacy staff members were on site Monday through Friday from 7:00 AM to 3:30 PM. The director stated that IV medications and admixtures were not prepared by pharmacy staff members. These were prepared by nursing staff members for "immediate use" (administered to patients within one hour of preparation). The pharmacist stated that if more than one medication was added to a bag of IV fluid, nursing supervisors had been instructed to prepare the admixture using the pharmacy's laminar flow hood.

The interview revealed that there nursing staff members had not received structured training regarding preparation of IV medications and admixtures according to USP 797 safe compounding standards. There was no process for assessing competency of nursing staff members when preparing these products.

2. Review of the hospital's policy and procedure titled "Laminar Flow Hood, Use and Care, Infection Control", Policy #4433689 dated 01/18, showed that only personnel trained in the use of aseptic technique would be allowed to use the pharmacy's laminar flow hood.


ITEM #2 - EXPIRED MEDICATIONS

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that medications that exceeded their manufacturer's expiration date were not available for administration to patients.

Failure to ensure medication storage areas do not contain outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, and efficacy.

Findings included:

1. The hospital's policy and procedure titled "Nursing Unit Inspections and Maintenance of Drug Storage Areas", Policy #2449851 dated 05/16, showed that all nursing units and areas where medications were stored would be inspected for outdated medications monthly. The policy showed that the hospital pharmacy was responsible for ensuring medications were free from deterioration and in-date.

2. On 05/01/18 at 1:25 PM, Surveyor #7 inspected a supply cart in the hospital's obstetrical unit that contained medications and supplies used during insertion of epidural anesthesia infusion lines. The top drawer of the cart contained the following medications:

a. 2 ampules of 1% lidocaine hydrochloride:
1) 1 ampule - expiration date 01/18
2) 1 ampule - expiration date 11/17
b. 1 ampule of 1.5% lidocaine hydrochloride - expiration date 08/17
c. 1 vial of phenylephedrine - expiration date 11/17
d. 1 unlabeled 20 cc syringe containing 8 cc of clear fluid - no contents or expiration date
e. 28 ampules of epinephrine 1:1000:
1) 1 ampule - expiration date 03/18
2) 8 ampules - expiration date 01/18
3) 2 ampules - expiration date 12/17
4) 5 ampules - expiration date 11/17
5) 8 ampules - expiration date 10/17
6) 1 ampules - expiration date 04/17
7) 3 ampules - expiration date 10/16

3. During an interview with Surveyor #7 at the time of the observation above, the hospital's pharmacy director (Staff #704) and obstetric unit nurse manager (Staff #701) stated the medication cart was used by the hospital's certified registered nurse anesthetists. The pharmacy director and nurse manager stated they were unaware that the expired medications were in the cart. The nurse manager stated the medications had originally been included in commercially pre-packaged epidural anesthesia kits and should have been discarded when not used. The pharmacy director stated that the cart was not included in the pharmacy's monthly medication storage area inspection process.


ITEM #3 - PHARMACY OVERSIGHT OF RADIOPHARMACEUTICALS

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that the hospital's pharmacy provided oversight of the procurement, preparation, storage, distribution and control of radiopharmaceuticals used in the hospital's nuclear medicine department as required by Washington State Board of Pharmacy hospital standards.

Failure to provide such oversight risks improper preparation of such drugs, which can result in inaccurate diagnostic testing.

Reference: 246-873-080 WAC - Drug procurement, distribution and control.
(1) General. Pharmaceutical service shall include: (a) Procurement, preparation, storage, distribution and control of all drugs throughout the hospital... (2) Additional pharmaceutical services should include: (c) Distribution and control of all radiopharmaceuticals... (3) The director shall be responsible for establishing specifications for procurement, distribution and the maintenance of a system of accountability for drugs, IV solutions, chemicals, and biologicals related to the practice of pharmacy.

Findings included:

1. The hospital's policy and procedure titled "Nursing Unit Inspections and Maintenance of Drug Storage Areas", Policy #2449851 dated 05/16, showed that all nursing units and areas where medications were stored would be inspected for outdated medications monthly. The policy showed that the hospital pharmacy was responsible for ensuring medications were free from deterioration and in-date.

2. On 05/03/18 at 8:45 AM, Surveyors #1 and #7 inspected the hospital's nuclear medicine procedure area. The area included a room where radiopharmaceuticals were prepared for intravenous injection into patients during diagnostic procedures. During the inspection, Surveyor #7 found 14 vials of generator eluant (a saline product used during medication preparation) with the following expiration dates:
a. 3 vials - expiration date 04/18
b. 3 vials - expiration date 01/18
c. 3 vials - expiration date 07/17
d. 2 vials - expiration date 03/17
e. 3 vials - expiration date 11/16

3. During an interview with Surveyor #7 at the time of the observation, the hospital's Director of Patient Care Services (Staff #702) confirmed that the eluant had expired

4. On 05/03/18 at 9:50 AM during an interview with Surveyor #7, the hospital's pharmacy director stated he was not involved in the procurement, storage, and preparation of radiopharmaceuticals used in the nuclear medicine department.

Cross Reference: C0283
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ITEM #1 - SAFE INJECTION PRACTICES

Based on observation and interview, the Critical Access Hospital failed to develop and implement policies and procedures that reflected safe injection practices for use of multidose vials of medications and intravenous fluids.

Failure to develop such policies and procedures risks transmission of infectious diseases to patients during medication administration.

Reference: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee)

"IV.H. Safe Injection Practices:

IV.H.3. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set."

IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable."

Findings included:

1. Staff interviews and policy review regarding preparation of medication contained in multidose vials showed the following:

a. The hospital's policy and procedure titled "Medication: Multi-dose Vials", Policy #3746010 dated 07/17, showed that once opened, multi-dose vials of medications would be stored in an enclosed clean area.

b. On 05/01/18 at 8:45 AM during an interview with Surveyor #7, the nurse manager for the acute care and obstetrics departments (Staff #701) stated that nurses took multidose vials of insulin into patients' rooms when preparing the medication for injection.

c. On 05/02/18 at 10:05 AM during an interview with Surveyor #7, the nurse manager for the emergency department (ED) (Staff #703) stated that nurses took multidose vials of insulin into ED examination rooms when preparing the medication for injection.

2. Observations and interviews during inspection of the hospital's nuclear medicine procedure area showed the following:

a. On 05/03/18 at 8:45 AM, Surveyors #7 inspected a room where radiopharmaceuticals were prepared for intravenous injection during diagnostic procedures. During the inspection, Surveyor #7 found a 250 ml bag of 0.9% saline hanging from a hook under a counter in the radiopharmaceutical preparation area.

b. During an interview with Surveyor #7 at the time of the observation, a nuclear medicine technician (Staff #707) stated the bag of saline was accessed multiple times during the day during preparation of radiopharmaceuticals for injection. The bag of saline did not contain preservatives and was for single-patient use.

c. During an interview with Surveyor #7 at the time of the observation, the hospital's infection prevention program coordinator (Staff #702) confirmed that staff should not use a single-patient bag of saline to prepare medications for multiple patients.


ITEM #2 - TRANSMISSION-BASED PRECAUTIONS

Based on observation, interview, and review of policy and procedures, the facility failed to develop and implement policies and procedures to ensure that hospital staff members used appropriate barrier and transmission precautions during patient care, as demonstrated by 1 of 1 staff member observed (Staff #706).

Failure to use transmission-based isolation precautions correctly and appropriately risks transmission of infectious diseases to patients and caregivers.

Reference: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee)

Findings included:

1. The hospital's policy and procedure titled "Isolation Precaution", Policy #4402926 dated 12/17, showed that nursing staff members would wear cover gowns and gloves when caring for patients using contact precautions. Caregivers would remove their gloves and perform hand hygiene after touching contaminated items and prior to touching clean surfaces.

2. On 05/01/17 at 9:15 AM, Surveyor #7 observed a registered nurse (Staff 706) administer medication to Patient #703 in Room #104. The patient was being cared for using contact precautions due to a history of methicillin-resistant Staphylococcus aureus. On two occasions during the medication administration process, the nurse reached underneath her cover gown and obtained items from her pocket. The nurse did not remove her gloves and perform hand hygiene prior to doing so.


ITEM #3 - COMPLIANCE WITH FOOD SAFETY REGULATIONS

Based on observation and interview, the Critical Access Hospital failed to fully implement the requirements of the 2009 Food and Drug Administration Food Code (FDA).

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk of acquiring food borne illnesses.

Findings included:

1. On 05/01/18 at 10:30 AM, Surveyor #1 observed whole pieces of cooked roast (greater than 4 inches thick) in the walk-in refrigerator. The Interim Dietary Manager (Staff #101) stated that the meats were sliced and reheated to 165 degrees Fahrenheit when needed but did not have a temperature cooling log to ensure that meats greater than 4 inches were cooled within the required time frame as stated per FDA food code.

Reference: 2009 Food and Drug Administration Food Code (FDA) 3-501.14) Washington State Retail Food Code, WAC 246-215-03515


2. On 05/01/18 between 10:45 AM, Surveyor #1 interviewed the Interim Dietary Manager (Staff #101) regarding the hospital's ill food worker reporting policy. Review of the hospital's policy titled "Infection Control Dietary" dated 02/18 showed the policy was missing key elements that directed food workers to notify the person in charge about their health as it related to diseases transmissible through food.

Reference: Washington State Retail Food Code, WAC 246-215-02205; WAC 246-215-02215; WAC 246-215-02220; WAC 246-215-02225


3 On 05/01/18 at 10:50 AM, Surveyor #1 observed scoops without handles stored in 4 food bulk containers (pudding, sugar, Jell-O, and salt). At the time of the observation, the surveyor informed the Interim Dietary Manager (Staff #101) that in order to prevent contamination of bulk foods, scoops used in bulk food storage must have handles and stored with handles up and away from product as required in the FDA Food Code.

Reference: Preventing contamination from equipment, utensils, and linens - In-use utensils, between use storage (2009 FDA Food Code 3-304.12(2)


4. On 05/01/18 at 11:15 AM, Surveyor #1 observed that the ice machine in the cafeteria and 1 out of 2 prep sinks in the kitchen did not have an air gap (a minimum of 1 inch air space between the drain line and the floor drain to protect foods/or ice from contamination). During the observation, the surveyor showed the Interim Dietary Manager (Staff #101) the difference between the 2 prep sinks. The prep sink that did not have an air gap was fixed during survey and a work order was placed for the ice machine.

Reference: Washington State Retail Food Code, WAC 246-215-05215 Design, construction and installation-Backflow prevention, air gap (2009 FDA Food Code 5-202.13).


ITEM #4 - ENVIRONMENTAL CLEANING PROCEDURES

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that staff members used disinfectants according to manufacturer's instructions.

Failure to properly use disinfectants places patients at risk of infection.

Findings included:

On 05/02/18 at 3:00 PM, Surveyor #1 observed a terminal (end of day) cleaning of a surgical suite room #1. During the observation the surveyor observed a housekeeper (Staff # 103) applying disinfectant to glass surfaces and immediately wiping off the disinfectant using a dry lint cloth. The surveyor interviewed the housekeeper regarding the types of products used to disinfect surfaces in the surgical suite. The housekeeper stated that she used hdqC2 (Spartan). The housekeeper and surveyor reviewed the manufacturer's instructions for use. The manufacturer's instructions for use stated that the contact time is 10 minutes.

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


ITEM #5 - WATER MANAGEMENT PLAN

Based on 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:

1. On 05/02/18 between the hours of 9:00 AM and 11:30 AM, Surveyor #1 interviewed Director of Maintenance (Staff #104) and Director of Patient Care Services (Staff #106) in regards to the hospitals water management plan. The staff handed the surveyor a water management plan titled "Hospital Acquired Legionnaires and Other Waterborne Diseases (Management Plan for the Prevention of)", Policy #4894881 dated 05/18.

2. On 05/02/18 at 4:00 PM, Surveyor #1 reviewed the hospital's water management plan. The following key elements were missing from the plan:

a) The hospital did not identify an organization such as CDC or ASHRAE when implementing a water management plan.

b) The facility has not conducted a complete risk assessment to identify risks in the hospital, such as plumbing, dead end legs; water pressure; medical equipment such as CPAP machines, and ventilators.

c) The hospital has not provided control measures such as temperature management or disinfection level controls.

d) The hospital did not specify protocols and acceptable ranges for control measures.
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ITEM #1 - PREPARATION OF RADIOPHARMACEUTICALS

Based on observation and interview, the Critical Access Hospital failed to ensure that solutions used to prepare radiopharmaceuticals in the hospital's nuclear medicine department were discarded after exceeding the manufacturer's expiration date.

Failure to ensure solutions used to prepare radiopharmaceuticals for diagnostic imaging have not exceeded the manufacturer's expiration date risks diagnostic errors, which can result in misdiagnosis and patient harm.

Findings included:

1. On 05/03/18 at 8:45 AM, Surveyors #1 and #7 inspected the hospital's nuclear medicine procedure area. The area included a room where radiopharmaceuticals were prepared for intravenous injection into patients during diagnostic procedures. During the inspection, Surveyor #7 found 14 vials of generator eluant (a saline product used during medication preparation) with the following expiration dates:
a. 3 vials - expiration date 04/18
b. 3 vials - expiration date 01/18
c. 3 vials - expiration date 07/17
d. 2 vials - expiration date 03/17
e. 3 vials - expiration date 11/16

2. During an interview with Surveyor #7 at the time of the observation, the hospital's Director of Patient Care Services (Staff #702) confirmed that the eluant had expired.


ITEM #2 - RADIATION SIGNAGE

Based on observation and interview the Critical Access Hospital failed to provide signage identifying hazardous radiation areas.

Failure to provide signage identifying hazardous radiation areas places patients, staff and visitors at risk of potential radiation exposure.

Reference: 42 CFR 485.635(b)(3) Clear signage identifying hazardous radiation areas;

Findings included:

On 05/01/18 at 9:00 AM during a tour of the imaging department with the Interim Imaging Manager (Staff #102), Surveyor #1 observed that the hospital did not have signage identifying hazardous radiation areas, specifically the CT (Computed Tomography) room and Nuclear Medicine lab. During an interview at the time of the observation, the manager confirmed that the CT room and the nuclear medicine lab did not have signage identifying hazardous radiation in these areas.


ITEM #3 - LEAD APRON SHIELDING SAFETY

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that lead shielding aprons used to protect patients during radiological procedures were maintained and routinely inspected by the hospital staff.

Failure to have a system in place to ensure that shielding is routinely inspected places patients and staff at risk of unnecessary radiation exposure.

Findings included:

On 05/01/18 at 9:20 AM during a tour of the CT room, Surveyor #1 inspected the integrity of five lead shield aprons in the room. Surveyor #1 found two of the lead shield aprons had small holes. This was confirmed by the Interim Imaging Manager (Staff #102) at the time of the observation. The surveyor asked the manager if the aprons were routinely inspected. The manager stated that department staff members cleaned and disinfected the aprons once a week, but that the department did not have polices or procedures in place for routinely inspecting the aprons.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a process to ensure that an individualized discharge plan was developed for all patients based on a discharge needs assessment, as demonstrated by 3 of 5 patient records reviewed (Patients #706, #707, #708).

Failure to assess the patient's healthcare needs and develop an individualized discharge plan can result in an unsafe discharge and readmission to the hospital.

Findings included:

1. The hospital's policy and procedure titled "Discharge Planning" showed that discharge planning would begin when the patient was admitted to the hospital. A multidisciplinary team would assess the patient's needs and develop a plan for care following the patient's discharge. Referrals to internal services such as Case Management would be documented in the nursing notes.

2. On 05/01/18 at 10:15 AM, Surveyor #7 interviewed Patient #706, a 61 year-old patient who had been admitted to the hospital on 04/30/18 for treatment of weakness and headache related to hypertension and hyperglycemia. During the interview, the patient stated she had been unable to refill her medication for two weeks because she had been unable to contact her pharmacy. She stated she was from another town, had no running water at home, and had been trying to find low-income housing in Omak.

3. On 05/01/18 at 3:00 PM, Surveyor #7 reviewed Patient #706's medical record. The record showed that the patient had a blood glucose of 731 on admission and had been diagnosed with new-onset type 2 diabetes. Review of the patient's nursing admission assessment showed the admission nurse had determined the patient had no discharge planning needs. Review of the patient's care plan showed that discharge planning had not been identified as a current problem. The patient had not been referred to the hospital's case manager/discharge planner for further evaluation of need for community resources.

4. At the time of the record review above, Surveyor #7 interviewed the hospital's case manager/discharge planner (Staff #705). The case manager/discharge planner stated she screened all inpatients for discharge needs by viewing the nursing admission assessment. Since the assessment had not identified any discharge planning needs, she had not assessed the patient for the need for community resources.

5. On 05/02/18 at 3:25 PM, Surveyor #7 reviewed the medical records for Patient #707, a 56 year-old patient who had been treated at the hospital from 02/08/18 to 02/14/18 for nausea, vomiting and hypokalemia. The patient also had inactive melanoma (cancer) The patient's nursing admission assessment did not identify any discharge planning needs. During an interview on 05/02/18 at 3:25 PM, the hospital's acute care nurse manager (Staff #701) stated the patient had been a "difficult discharge". She stated discharge planning had been done but had not been documented in the patient's medical record.

6. On 05/02/18 at 3:30 PM, Surveyor #7 reviewed the medical records for Patient #708, a 66 year-old patient who had been treated at the hospital from 03/29/18 to 04/02/18 for alcohol withdrawal, seizures, and pancreatitis. The patient's records showed that the patient had been referred to case management/discharge planning for chemical dependency evaluation and treatment, patient education for alcoholism and treatment options, and financial assistance for housing and shelter. There was no evidence in the patient's record that these discharge needs had been addressed.
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Based on interview and review of the hospital's process for granting surgical privileges, the Critical Access Hospital failed to ensure information regarding the types of surgical procedures surgeons could perform at the hospital was available to staff members working in the surgical services department.

Failure to ensure information regarding surgical privileges is available to all surgical staff members risks medical errors and patient harm.

Findings included:

1. On 05/02/17 at 7:55 AM during an interview with Surveyor #1, the hospital's surgical services nurse manager (Staff #708) stated that information regarding the types of surgical procedures surgeons could perform at the hospital was not available to staff members working in the surgical services department.

2. On 05/03/18 at 10:00 AM, Surveyor #1 interviewed Human Resource Manager (Staff #107) and reviewed health care provider credentialing files. Surveyor #1 confirmed that the hospital had an effective process for granting surgical privileges. This process did not include a mechanism for informing surgery staff members of the types of surgical procedures that individual surgeons were allowed to perform.
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ITEM #1 - QUALITY INDICATORS

Based on interview and review of the hospital's quality and performance improvement program, the hospital failed to ensure that performance measures for all patient care services and departments were systematically reported to and evaluated by the hospital's quality program.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings:

1. The hospital's policy entitled "Performance Improvement (Improving Organizational Performance)", Policy #4233396 dated 02/18, showed that department-specific data regarding important processes or outcomes related to patient care would be systematically collected and analyzed.

2. On 05/03/18 between 11:30 AM and 12:45 PM, Surveyor #7 interviewed the hospital's quality program manager (Staff #702) and reviewed the hospital's quality and performance improvement program. During the interview, the manager stated that the hospital did not have a process for centralizing departmental quality indicators. Each department monitored their quality indicators but did not systematically report performance data to the hospital's Quality Council.


ITEM #2 - REPEAT DEFICIENT PRACTICE

Based on observation, interview, document review, and review of the hospital's 2016 state licensing survey, the Critical Access Hospital failed to implement effective action plans to correct deficient practice.

Failure to systematically identify problems, implement corrective action plans, and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings:

1. During the hospital's state licensing inspection in December 2016, the hospital was cited for deficient practice for failing to ensure that staff members used disinfectants according to manufacturer's instructions. The hospital developed and submitted an action plan for correction of this deficiency to the Department of Health.

2. On 05/02/18 at 3:00 PM, Surveyor #1 found that the hospital had not corrected this deficiency. through observation, interview, and document review during a terminal cleaning procedure in the surgery department.

Cross Reference: C0278, Item #4
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to provide social services under the supervision of a qualified social worker.

Failure to develop and implement a social services program supervised by a qualified social worker risks not meeting the patient's psychosocial needs.

Findings included:

1. On 05/01/18 at 3:00 PM, Surveyor #7 interviewed the hospital's case manager/discharge planner (Staff #705) regarding how social services were provided to the hospital's long-term care ("swing-bed") patients. The case manager/discharge planner stated that she provided these services. She stated she had an associate degree in nursing.

2. Review of the hospital's swing bed policies and procedures revealed the procedures did not require that social services were to be provided under the supervision of a qualified social worker.
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Based on 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 2 of 2 swing bed patients reviewed (Patient #704, #705)

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 05/01/18 at 3:35 PM, Surveyor #7 reviewed the medical records of Patient #704, a swing bed patient who had been treated at the hospital from 02/02/18 to 03/23/18 for a sacral decubitus ulcer. Review of these records showed that the patient's care plan did not include time frames to meet goals for care. Similar findings were found on 05/02/18 at 1:30 PM during review of the records of swing bed Patient #705.

2. Review of the hospital's policy and procedure titled "Swing Bed Policies: Purpose, Plan of Care, Abuse/Neglect; Patient Rights, Standards of Care", Policy #257760 dated 06/16, showed that a care plan would be developed for each swing bed patient based on a comprehensive assessment. The procedure did not specify that the care plan was to include measurable objectives, interventions, and timetables for meeting treatment goals.
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Based on record review and staff interviews the Critical Access Hospital failed to ensure emergency preparedness policies and procedures addressed adequate alternate energy sources necessary to maintain heat, emergency lighting and the building's fire alarm system.

Failure to have policies and procedures that address alternate energy sources, heating, lighting and fire alarm systems places patients, staff and visitors at risk of injury and/or death during disasters and other emergency situations.

Findings included:

1. On 05/02/18 between the hours of 8:30 and 10:00 AM, the state Deputy Fire Marshal (DFM) reviewed the facility's emergency preparedness plan. During the review, the DFM discovered that the facility did not have any policies in place to address how they would provide emergency power for lighting, heating and cooling for staff, patients and visitors within the facility in the event of a power outage. In addition, no policy was found for the emergency provision of sewage services.

2. The above was discussed and acknowledged by the Facilities Director at the time of the review, who said he was unaware that the hospital did not have these specific policies in place.
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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 05/02/18 between the hours of 9:00 AM and 10:00 AM, Surveyor #1 interviewed the hospital's Director of Patient Care Services (Staff #106) regarding the communication plan during emergencies. The surveyor asked how the hospital would ensure the preservation of patient information and have it readily available in the event of an emergency. The director stated that hospital staff members would prepare paper copies of medical records that would go with the patient but was unable to provide documentation of policies and procedures that directed staff on how to do so.
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