HospitalInspections.org

.
ITEM #1 - NOTICE OF DISCHARGE RIGHTS

Based on interview and medical record review, the Critical Access Hospital failed to provide Medicare patients with a notice regarding their right to appeal their discharge from the hospital as required by federal regulations, as demonstrated by 1 of 1 patients reviewed (Patient #1).

Failure to provide such notice limits the patient's ability to contest their discharge and appeal to a Quality Improvement Organization for review of their case.

Reference: 42 CFR 405.1205 - Notifying beneficiaries of hospital discharge appeal rights.
(b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital...

(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge.

Findings included:

1. Review of the records of Patient #1 showed that the patient had been admitted on 10/14/17 and discharged on 10/17/17. The patient's records included an "Important Message from Medicare" information form. The form included the patient's signature and the date 10/14/17. There was no evidence in the patients' record that the patient had received a second notice of their discharge rights within two calendar days of discharge.

2. On 11/15/17 at 11:40 AM during an interview with Surveyor #1, a hospital staff nurse (Staff #10) stated that admission clerks who worked in the the hospital's registration area provided the "Important Message from Medicare" information forms to Medicare patients on admission.

3. On 11/15/17 at 12:30 PM during an interview with Surveyor #1, the hospital's case manager (Staff #11) and Chief Operations Officer (Staff #12) stated there was no process for providing a second notice if a Medicare patient was hospitalized longer than two calendar days.


ITEM #2 - NOTIFICATION OF PHYSICIAN (MD/DO) ON-SITE PRESENCE

Based on interview and review of patient rights information, the Critical Access Hospital failed to provide written notice to patients that a doctor of medicine (MD) or doctor of osteopathy (DO) was not present in the hospital 24 hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. On 11/15/17 at 9:25 AM, Surveyor #1 interviewed the hospital's Chief Operations Officer (Staff #12). During the interview, the CNO stated that an MD or DO was not on site 24 hours per day 7 days per week.

2. On 11/15/17 at 9:25 AM, Surveyor #1 interviewed a emergency department admitting clerk (Staff #13). The clerk stated that all patients seen in the emergency department were given a handout to read entitled "Patient Rights and Responsibilities" (Revised 07/10) when admitted to the hospital for emergency outpatient and inpatient care.

3. Review of the contents of this handout revealed that it did not include written notice to patients that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week. The hospital did not have a process for informing patients how the hospital would meet the medical needs of any patient who develops an emergency medical condition when a physician is not present.
.

.
Based on observation and interview, the hospital failed to maintain preventive maintenance for the Laminar Flow Hood in the laboratory.

Failure to maintain preventive maintenance schedule on equipment puts patients, and staff at risk of infection from malfunctioning equipment.

Findings included:

1. On 11/16/17 at 10:30 AM during a tour of the laboratory, Surveyor #2 observed that the preventive maintenance (PM) sticker on the laminar flow hood in the laboratory specified that the next PM was due 09/17.

2. During an interview with Surveyor #2 at the time of the observation, the laboratory manager (Staff #8), stated that she had called the vendor (Asepsis Air Control) and found that the service had been discontinued. The manager stated that the hospital was searching for other vendors.
.

.
Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that medications were secured and not accessible to unauthorized individuals.

Failure to secure medications risks drug diversion, tampering, and /or unauthorized use which can endanger staff and patients.

Reference: WAC 246-873-070 (4) Physical requirements: Drug storage areas. Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.

Findings included:

1. The hospital's policy and procedure titled "Medication Administration" (approved 01/03/17) showed that medications would be "stored, handled, and accounted for in a safe manner complying with federal/state laws and standards of professional practice." Licensed nurses were to "Ensure safe handling, storage, and security of medications."

2. On 11/16/17 at 8:35 AM, Surveyor #1 inspected the emergency equipment and supplies cart located in the hallway outside of the endoscopy procedure room. The top two drawers contained vials of medication. These drawers were unlocked and accessible to unauthorized individuals. The cart was not in the line of sight of the nursing staff members.

3. During an interview at the time of the observation above, the endoscopy nurse (Staff #14) confirmed that the medications should be secured.

4. On 11/16/17 at 9:35 AM, Surveyor #1 inspected the endoscopy procedure room during the turnover time between two endoscopy cases. The surveyor observed that medications were being stored in an unlocked cabinet located in the endoscopy procedure room. The key to the cabinet was in the lock. The endoscopy nurse (Staff #14) was not in the procedure room, and the medications were not in the nurse's line of sight.

5. On 11/15/17 at 9:40 AM, Surveyor #1 interviewed the endoscopy nurse regarding medication security. During the interview, the nurse confirmed that the medications were not secured between endoscopy cases.

6. On 11/16/17 at 1:15 PM, Surveyor #1 interviewed the pharmacist regarding the observations above. During the interview, the pharmacist confirmed that medications in the endoscopy procedure room and emergency cart must be secured when not in use.
.

.
ITEM #1 - SAFE INJECTION PRACTICES

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that medications were prepared safely in accordance with recommendations from the Centers for Disease Prevention and Control (CDC).

Failure to ensure multi-dose vials of medications accessed in patient care areas are used for only one patient; and that syringes and needles are not reused risks administration of contaminated medications and transmission of infectious diseases from one patient to another.

Reference: "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings - Safe Injection Practices" (Centers for Disease Prevention and Control, 2007)

Findings included:

1. The hospital's policy and procedure titled "Medication Administration" (approved 01/03/17) showed that medications would be "stored, handled, and accounted for in a safe manner complying with federal/state laws and standards of professional practice." Licensed nurses were to "Ensure safe handling, storage, and security of medications."

2. On 11/15/17 at 10:40 AM, Surveyor #1 inspected a suture supply cart in Room 5 of the hospital's emergency department (ED). During the inspection, the surveyor found a multi-dose vial of bupivacaine 0.5% and a multi-dose vial of xylocaine 1% (local anesthetics). The date 11/04/17 had been hand-written on each vial.

a. During an interview with Surveyor #1 at the time of the observation, the registered nurse on duty in the ED (Staff #15) stated that the vials had been dated when opened, were available for use for multiple patients, and were to be discarded after 30 days. He stated the medications were prepared in ED Room 5 and not in the ED medication room.

b. On 11/16/17 at 1:15 PM, Surveyor #1 interviewed the pharmacist (Staff #16) regarding the observations and interview above. During the interview, the pharmacist confirmed that multi-dose vials of medication should be prepared in a clean medication preparation area or used for one patient and then discarded.

3. On 11/16/17 at 10:20 AM, Surveyor #2 observed the endoscopy procedure nurse (Staff #14) prepare intravenous medications for procedural sedation for Patient #2. During this process, the nurse withdrew medication from a single-dose vial into a syringe, then reused the same needle and syringe to access a second single-dose vial of medication.

4. On 11/17/17 at 11:45 AM, Surveyors #1 and #2 interviewed the infection preventionist (IP) (Staff #9) regarding the observations and interviews above. During the interview, the IP stated he was not aware of the CDC's recommendations for safe injection practices.


ITEM #2 - BLOOD GLUCOSE MONITORING DEVICES

Based on observation, interview, and review of the manufacturer's directions for use, the Critical Access Hospital failed to ensure that glucose meters used during patient care had been approved for multiple patient use.

Failure to use glucose meters approved for multiple patient use risks transmission of infectious diseases from one patient to another.

Reference: "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" (Centers for Disease Prevention and Control, 2017)

"Blood Glucose Meters - Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."

Findings included:

1. On 11/15/17 at 10:00 AM, Surveyor #1 observed two "One-Touch UltraMini" glucose meters located on top of an emergency supply cart in the hospital's emergency department (ED).

2. During an interview with Surveyor #1 at the time of the observation above, the registered nurse on duty in the ED (Staff #15) stated that the glucose meters were used for multiple patients and disinfected between uses.

3. On 11/15/17 at 3:30 PM, Surveyor #1 observed a "One-Touch UltraMini" glucose meter located in the hospital's acute care unit.

4. During an interview with Surveyor #1 at the time of the observation above, the registered nurse on duty in the acute care unit (Staff #10) stated that the glucose meter was used for multiple patients.

5. On 11/15/17 at 3:25 PM, Surveyor #1 reviewed a document titled "510(K) Substantial Equivalence Determination Decision Summary Assay Only Template" (not dated) that showed that One-Touch UltraMini glucose meters were for single patient use and were not to be used for multiple patients.



33674

.

ITEM #3 - WATER MANAGEMENT PROGRAM

Based on interview, 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."

Findings included:

On 11/15/17 at 4:00 PM, Surveyor #2 interviewed the facilities manager (Staff #1) regarding the hospital's water management program. The manager stated that the hospital had established a committee to work on the water management plan but had not made any further progress in developing the plan.


ITEM #4 - SINGLE USE CONTAINERS

Based on observation and interview, the Critical Access Hospital failed to prevent contamination of ultrasound transmission gel used during diagnostic testing procedures.

Failure to discard single use items risks use of contaminated products and transmission of infectious diseases from one patient to another.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012), states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings included:

1. On 11/16/17 at 10:30 AM, Surveyor #2 observed a bottle of ultrasonic transmission gel ("Aqua Sonic Gel") in the physical therapy department.

2. During an interview with Surveyor #2 at the time of the observation, the physical therapist aide (Staff #3) stated that the department staff routinely refill bottles of the ultrasound transmission gel.


ITEM #5 - BIOLOGICAL INCUBATION TIME

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that biological indicators used to verify sterilization of medical instruments were read within the required time frame.

Failure to ensure that biological indicators have met the incubation times risks inaccurate readings and compromise sterility of surgical instruments.

Findings included:

1. On 11/16/17, between 9:30 AM and 10:00 AM, Surveyor #2 reviewed the biological indicator log (3M Attest Incubator). The log provided by the manufacturer included a column to document the "Time In" and "Time Out" to ensure the read times were met. The surveyor noticed that no read times had been documented on the log for 09/12/17; 09/20/17; 09/26/17; 10/03/17; 10/10/17 and 10/17/17.

2. During an interview at the time of the log review, the surveyor asked the central sterile technician (Staff #4) how long the biological indicators were incubated. The technician stated "48 hours". The technician confirmed that they had not documented the read times on the log for the dates above.


ITEM #6 - MONITORING THERAPY POOL WATER FLOW

Based on observation, interview, and document review, the Critical Access Hospital failed to provide a flow meter for the therapy pool.

Failure to provide a flow meter to ensure that pool water circulates through the disinfection system at a minimum rate places patients at risk for infection during therapy.

Reference: CDC 2016 Model Aquatic Health Code
5.7.1.8A Flow Meters
Flow meters in accordance with MAHC 4.7.1.9.1 shall be provided and maintained in proper working order.
5.7.1.9 Flow Rates / Turnovers
5.7.1.9.1 New Construction or Substantially Altered Venues
AQUATIC VENUES constructed or substantially altered after the adoption of this CODE shall be operated at the designed flow rate to provide the required TURNOVER RATE 24-hours per day except as allowed in MAHC 4.7.1.10.

4.7.1.10A Flow Rates / Turnover Times
Table 4.7.1.10: Aquatic Venue Maximum Allowable Turnover Times; Spa, Therapy*, & Exercise Pools Temperature 72-93F (22-34C) Load > 2500 gals/person (9.46 m3)
Turnover Maximum 4 hours or less.

Findings included:

1. On 11/16/17 at 11:00 AM, Surveyor #2 observed that the hospital's therapy pool did not have a flow meter.

2. During an interview at the time of the observation, the facility manager (Staff #1) stated he did not know that the pool needed one.


ITEM #7 - PATIENT ROOM CLEANING

Based on observation, review of hospital policies and procedures, and review of the manufacturer's directions for use, the Critical Access Hospital failed to ensure that 1) housekeeping staff members disinfected high touch areas; and 2) followed manufacturer's instructions for use of disinfection agents when disinfecting patient rooms.

Failure to disinfect high-touch areas when cleaning patient rooms and to follow manufacturer's instructions for use for disinfection agents places patients, staff, and visitors at risk of infection and illness.

THIS IS A REPEAT CITATION - PREVIOUSLY CITED 07/27/16

Findings included:

1. Review of the hospital's policy and procedure titled, "Daily Cleaning of Patient Rooms" (Approved 09/15/16), showed that housekeeping staff members were to clean all patient bedside tables and furniture, including sinks, commodes, floors, toilet seats, and toilet bowls.

2. The product label for Spartan Chemical's "GS Neutral Disinfectant Cleaner" (a quaternary disinfectant cleaner) stated in part, "Apply solution ... so as to wet all surfaces thoroughly. Allow to remain wet for 10 minutes, then remove excess liquid."

3. On 11/17/17 between 9:00 AM and 10:00 AM, Surveyor #2 observed a housekeeper (Staff #5) perform a daily cleaning of patient room 120. During the observation, the housekeeper lightly sprayed GS Neutral Disinfectant Cleaner on a wiping cloth, then proceeded to wipe down the toilet seat. The surveyor observed that the disinfectant solution evaporated within seconds, not meeting the 10 minute contact time specified on the product label. In addition, the housekeeper did not wipe down the following high touch areas in the patient's room: Hand rails, faucet handles, call light buttons, shower handles, and the television remote control.

4. Review of Staff #5's training records revealed that the housekeeper had not received department-specific infection prevention and control training (See Item #10).


ITEM #8 - HAND HYGIENE

Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to ensure all staff members performed hand hygiene when providing patient care.

Failure to comply with the hospital's policy for hand hygiene risks transmission of infectious diseases between patients.

Findings included:

1. The hospital's policy and procedure titled "Hand Hygiene" (Approved 08/31/16) read in part, "Healthcare workers must wash their hands and use an alcohol based hand rub: ...Before and after contact with all patients; Before performing invasive procedures, whether or not sterile gloves are worn.; .. After contact with a source that is likely to be contaminated with microorganisms..."

2. On 11/16/17 at 10:22 AM, Surveyor #1 observed a registered nurse (Staff #14) start an intravenous (IV) fluid infusion for Patient #2. The nurse did not perform hand hygiene prior to donning gloves and inserting the IV needle into the patient's arm.

3. On 11/17/17 at 10:55 AM, Surveyor #2 observed a certified nurses aide (CNA) (Staff #6) enter patient room 114 to provide patient care. The CNA exited the room with wet gloves, picked up clean linens at the nurses station, then went back into the patient room. The nurse did not remove her gloves and perform hand hygiene prior to touching clean linens.


ITEM #9 - PERSONAL PROTECTIVE EQUIPMENT

Based on observation and review of hospital policies and procedures, the Critical Access Hospital staff failed to develop policies and procedures in accordance with health and safety guidelines for use of personal protective equipment (PPE) when performing patient care.

Failure to wear and remove PPE appropriately risks transmission of infectious diseases between patients.

Reference: Center for Disease Control (CDC): "Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings." read in part: "How to Don a Gown: Select appropriate type and size, opening is in the back, secure at neck and waist....Remove [PPE] and discard carefully, either at the doorway or immediately outside the patient's room... immediately perform hand hygiene."

Findings included:

1. On 11/16/17 at 9:00 AM, Surveyor #2 observed a medical assistant (MA) (Staff #7) reprocess an endoscope in the decontamination room. During the observation, the MA's gown was not secured at the waist allowing the gown to cover only the front of the MA's attire.

2. On 11/16/17 at 9:15 AM, Surveyor #1 observed a registered nurse (Staff #14) transport a patient from the endoscopy procedure room to patient room #4 in the acute care unit. The nurse did not remove her gown and gloves after assisting with the endoscopy procedure and prior to transporting the patient to the acute care area.

3. During an interview with Surveyor #1 at the time of the observation above, the nurse confirmed she should have removed her gown and gloves after assisting with the endoscopy procedure.

4. Review of the hospital's policy and procedure titled "Infection Control - Standard Precautions" (Approved 08/11/17) showed that the policy did not include directions for staff when wearing and removing PPE.


ITEM #10 - INFECTION PREVENTION AND CONTROL TRAINING

Based on interview and review of staff training records and orientation checklists, the Critical Access Hospital failed to provide infection prevention and control training for all patient care staff members.

Failure to provide infection prevention and control training to all patient care staff members places patients, staff and visitors at risk for infection and illness.

Findings included:

1. On 11/16/17 at 3:30 PM, Surveyor #2 reviewed the training records for a hospital housekeeper (Staff #5). The records did not include evidence that the housekeeper had received department-specific infection prevention and control training.

2. Review of the hospital's new-hire orientation checklist revealed that environmental services (housekeeping) does not receive infection control training. In addition, the surveyor reviewed a department orientation check list. The check list did not include department-specific infection control training.

3. On 11/17/17 at 11:30 AM during an interview with Surveyors #1 and #2, the infection preventionist (Staff #9) stated that training was provided for nurses but was not aware of training provided for other departments. The hospital did not have a written infection prevention and control staff training plan for all patient care staff members.
.

.
Based on interview, medical record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that medical records of patients treated in the emergency department were accurately documented for 5 of 5 records reviewed (Patients #3, #4, #5, #6, #7)

Failure to ensure medical records are complete and accurately documented risks medical errors and patient harm.

Findings included:

1. The hospital's policy and procedure titled "Medical Records" (Approved 06/26/17) showed that medical records were to be accurate, created in the sequence of events as they occurred, and would be sufficiently comprehensive to support the diagnoses, course of treatment, and outcome of care. Care was to be documented as close to the time of the actual event as feasible.

2. On 11/16/17 from 1:50 PM to 2:45 PM, Surveyor #1 and the hospital's clinical informatics specialist (CIS) (Staff #9) reviewed the medical records of five patients who had been treated in the hospital's emergency department (ED). This review showed the following:

a. Patient #3 was a 76 year old patient who was admitted to the ED on 10/08/17 for treatment of chest pain and shortness of breath. The patient arrived at 2:44 AM and was transferred to a higher level of care at 4:45 AM. The record indicated that the patient was in the triage area for 106 minutes and in the waiting room for 119 minutes. The record indicated that the ED physician started care at 3:21 AM, 37 minutes after the patient's arrival. There was no record of the time the ED physician arrived. The record indicated that the ED physician ordered administration of oxygen at 2:47 AM and that the nurse started the oxygen at 4:21 AM. The record indicated that the ED physician ordered insertion of a peripheral intravenous line at 2:47 AM. The ED nurse signed this order as completed at 3:55 AM. The record indicated that the ED physician ordered a bilateral blood pressure check at 2:47 AM. The ED nurse signed this order as completed at 4:21 AM.

b. Patient #4 was a 77 year-old patient who was admitted to the ED on 9/21/17 for treatment of chest pain. The patient arrived at 9:25 AM and was transferred to a higher level of care at 2:51 PM. The record indicated that the patient was in the triage area for 305 minutes. The record indicated that the ED physician arrived at 9:40 AM and started care at 12:11 PM, 3 hours and 46 minutes after the patient's arrival. The record indicated that the ED physician ordered administration of oxygen at 9:28 AM and that the nurse started the oxygen at 10:07 AM. The record indicated that the ED physician ordered an electrocardiogram at 9:29 AM and that the electrocardiogram was completed at 1:40 PM.

c. Similar findings were found in the records of Patients #5, #6, and #7.

3. During an interview with Surveyor #2 at 2:45 PM, the CIS confirmed the record review findings above. The CIS stated that the times entered into the electronic medical record (EMR) for ED care were not an accurate reflection of when care actually began and ended.

4. On 11/17/17 at 1:20 PM, Surveyor #2 interviewed a registered nurse who was currently working in the hospital's ED (Staff #17). The nurse stated that times recorded in the EMR were the time of the record entry unless manually changed by the care provider to the time of care delivery.


.

.
Based on interview, medical record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a process to ensure pathology reports were included in the patient's medical record, as demonstrated by 3 of 3 medical records reviewed (Patients #8, #9, #10).

Failure to ensure medical records are accurate and complete risks omissions in patient care, medical errors and potential patient harm.

Findings included:

1. The hospital's policy and procedure titled "Medical Records" (Approved 06/26/17) showed that medical records were to be accurate, created in the sequence of events as they occurred, and would be sufficiently comprehensive to support the diagnoses, course of treatment, and outcome of care.

2. On 11/17/17 from 8:30 AM to 10:00 AM, Surveyor #1 and the hospital's Chief Operations Officer (COO) (Staff #12) reviewed the medical records of three patients who had undergone colonoscopy procedures and removal of colon polyps. All three patient records included information that indicated the polyps had been sent for pathological testing. None of the records included the results of the biopsies.

3. During an interview with Surveyor #1 at the time of the record review, the COO accessed the electronic records system of the clinic associated with the hospital. The patients' clinic records included the biopsy results. The results had been sent to the clinic but were not part of the patient's hospital record.
.

.
Based on interview and review of the hospital's 2016 Critical Access Hospital program evaluation, the Critical Access Hospital failed to ensure that the program evaluation was part of the hospital's quality improvement program.

Failure to include the program evaluation as part of the hospital's quality improvement program limits the hospital's ability to improve patient care and services.

Findings included:

1. Review of the hospital's 2016 Critical Access Hospital (CAH) program evaluation revealed that the hospital had exceeded it's threshold for patient falls. The program evaluation showed that an action plan was needed to prevent future falls.

2. On 11/17/17 from 10:05 AM to 11:25 AM, Surveyor #1 interviewed the hospital's Chief Operations Officer (Staff #12) and quality program coordinator (Staff #18) and reviewed the hospital's quality improvement program. During the interview and program review, the quality program coordinator stated that he had not seen the hospital's 2016 CAH program evaluation and was not aware that an action plan to reduce patient falls had been recommended. The interview revealed that the CAH program evaluation was not developed through or part of the hospital's quality improvement program.
.

.
Based on interview and review of the hospital's quality improvement plan, the Critical Access Hospital failed to ensure that 1) medical staff members were included in the hospital's quality improvement program; and 2) that there was a mechanism for providing recommendations for hospital systems changes through the medical staff peer review process.

Failure to include the medical staff in the hospital's quality program limits the hospital's ability to improve patient care and services.

Findings included:

1. Review of the hospital's policy titled "Quality Improvement Plan (Approved 09/26/16) showed that the hospital's medical staff was to be included in the hospital's quality program.

2. On 11/17/17 from 10:05 AM to 11:25 AM, Surveyor #1 interviewed the hospital's Chief Operations Officer (Staff #12) and quality program coordinator (Staff #18) and reviewed the hospital's quality improvement program. During the interview and program review, the staff members stated that the medical staff were not involved in the hospital's quality improvement program. The staff members stated that recommendations for changes in hospital systems through the medical staff peer review process were given to individual department managers and were not communicated to the hospital's quality improvement committee.
.

.
Based on interview and review of the hospital's quality improvement plan, the hospital failed to implement its plan to improve patient care services by analyzing quality indicators and developing action plans for improvement as necessary.

Failure to systematically collect and analyze facility performance data limits the hospital's ability to identify problems and formulate action plans. This reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. On 11/17/17 from 10:05 AM to 11:25 AM, Surveyor #1 interviewed the hospital's Chief Operations Officer (Staff #12) and quality program coordinator (Staff #18) and reviewed the hospital's quality improvement program. During the interview and program review, the surveyor reviewed quality committee meeting minutes. The minutes identified opportunities for improvement in hospital systems but did not have action plans that included improvement activities, responsible individuals, and timelines for completion. The quality program coordinator confirmed that this information was not documented in the meeting minutes.

2. Review of the hospital's policy titled "Quality Improvement Plan" (Approved 09/26/16), showed that the plan did not identify a process for documenting analysis of quality indicators and developing, implementing, and tracking action plans for improvement.
.

.
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 that included all of the required elements.

Failure to notify swing bed patients of the reason for transfer or discharge, the effective date, the location to which the resident is being transferred or discharged, and information regarding the appeal process risks violation of the patient's rights as long-term care residents.

Findings:

1. On 11/17/17 at 7:45 AM, Surveyor #1 interviewed the hospital's Chief Operations Officer (COO) (Staff Member #12) regarding how long-term care ("swing bed") patients were notified of an impending transfer or discharge. The COO stated that the patients were informed verbally but did not receive a written notice.

2. The hospital did not have a policy and procedure for providing written notice to swing bed patients of an impending transfer or discharge and their right to appeal to the long-term care ombudsman.
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop a written policy and procedure to prevent abuse and neglect of long-term care ("swing bed") patients.

Failure to prevent such a policy and to educate staff regarding this policy risks abuse of vulnerable hospitalized patients.

Findings included:

1. Review of the hospital's long-term care ("swing-bed") program policies and procedures revealed the hospital did not have a written policy and procedure to prevent abuse and neglect of swing bed patients.

2. On 11/17/17 at 7:45 AM during an interview with Surveyor #1, the hospital's Chief Operations Officer (Staff #12) confirmed that the hospital did not have an abuse and neglect prevention policy and procedure.
.

.
Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed an individualized activity plan in accordance with interests identified in the patient's activities assessment for 3 of 3 long-term care ("swing bed") patients reviewed (Patients #11, #12, #13).

Failure to develop and implement an individualized activities plan for long-term care patients risks impairment of physical, mental, and psychosocial well-being.

Findings included:

1. The hospital's policy and procedure titled "Swing Bed Activities Program" (Revised 11/04/15), under "Policy" stated: "Cascade Medical (CM) in compliance with RCW, swing bed patients will be provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident."

2. Review of the medical records of one long-term care patient currently hospitalized under the hospital's long-term care "swing bed" program (Patient #11) and two long-term care patients who had been hospitalized between 10/24/17 and 11/14/17 (Patients #12, #13) showed that hospital staff members had performed an assessment of each patient's activity interests. The records did not include plans for providing activities that met the patients' individual interests and needs.

3. On 11/15/17 at 12:10 PM during an interview with Surveyor #1, the hospital's activities program director (Staff #19) stated that although activity program staff members conducted an assessment of each swing bed patient's activity interests, the staff members did not develop an individualized activities plan for the patient based on the assessment findings.
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to provide social services by a qualified social worker holding a Bachelor's degree in social work or other human services field.

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

Findings included:

1. The hospital's policy titled "Swing Bed Program" (Approved 09/08/16) showed that the hospital would provide social services that included emotional health services and referral and discharge planning services to swing bed patients as deemed necessary by the patient's health care team. The policy stated that the Social Worker/Case Manager would determine the appropriateness of patient acceptance into the swing bed program and would evaluate the patient's eligibility for continued stay.

2. On 11/15/17 at 11:25 AM Surveyor #1 interviewed the Chief Operations Officer (COO) (Staff #12) about social services provided through the hospitals long-term care ("Swing Bed") program. The COO stated that social services were provided by a speech therapist who acted as a case manager (Staff #11). The hospital did not have a qualified social worker on staff or one available through an agreement or arrangement.
.

.

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to have a system in place that would assure the safety and well being of patients, staff and visitors in the event of a non-medical emergency. More specifically, the hospital failed to have a plan in place that would provide readily available potable water to patients, staff and visitors.

Failure to develop and implement an emergency water plan places patients, staff, and visitors of the facility at risk during non-medical emergencies.

Findings included:

1. Review of the hospital's policy titled "Disaster Plan", revised 2017, revealed the policy did not
have a water supply plan.

2. On 11/15/17 at 3:30 PM, Surveyor #2 reviewed the hospital's emergency preparedness plan and found that the plan lacked information on how the hospital will provide enough potable water in the event of a non medical emergency. During an interview with facility manager (Staff #1), the manager stated that the dietary department might have information on water supplies for the facility. On 11/16/17 at 8:30 AM Surveyor #2 interviewed the dietary manager (Staff #2) in regards to water supply in an event of a non-medical emergency. The dietary manager stated that they had bottled water on site but did not have a policy or procedure in place to ensure that the hospital had sufficient quantities for patients, staff or visitors in case of an emergency.
.

.
Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff were provided with sufficient training to properly handle non-medical emergencies.

Failure on the part of the facility to adequately train staff to handle non-medical emergencies puts patients, staff and visitors at risk of injury should such an emergency occur.

Findings included:

1. Review of the hospital's policy titled "Disaster Plan" (revised 2017) revealed the plan identified key individuals in a "Call List" to notify during a non-medical emergency event. Only 15 of the 36 employees identified on the list had emergency preparedness training.

2. On 11/15/17 at 3:45 PM, Surveyor #2 interviewed the facilities manager (Staff #1) who was in charge of implementing the emergency preparedness plan, and asked to see documentation on staff training in emergency preparedness. The manager provided a spreadsheet which identified only 40 out of 120 (33%) employees that had received training.