HospitalInspections.org

Based on medical record review and administrative staff interview, the hospital failed to ensure that evidence existed to show that Medicare patients received a copy of the standardized notice "An Important Message from Medicare" upon or within two (2) days of admission and again within two (2) days of discharge for 10 of 11 Medicare patients reviewed for patient rights (P1-P3, P11-P16).

Failure to ensure that patients receive their rights, as required, places these patients at risk of harm related to a discharge that may be accomplished prior to the patient being ready for discharge.

Findings:

1. Per review of P1's medical record, the patient was admitted with medicare benefits. The record did not contain the notice titled "An Important Message from Medicare", upon admission on 2/6/2010. There was also no evidence that an additional copy was given to the patient, prior to discharge.

2. Per review of P2's medical record, the patient was admitted with medicare benefits on 2/3/2010. The record contained the notice titled "An Important Message from Medicare". No evidence was found that the notice had been given, a second time, to the patient prior to discharge.

3. Per review of P3, P11-P16's medical records, these patients were admitted with medicare benefits. The record contained the notice titled "An Important Message from Medicare" dated on the admission day. However, no evidence was found that the notice had been given, a second time to each patient, prior to discharge.

Per administrative staff interview on 2/11/2010, the second copy was to be given to the patients by the discharge planner. Per interview with the designated discharge planner, this second copy was frequently forgotten to be given to patients.

Based on observations and review of provided documentation, the hospital failed to ensure that code carts, more specifically, cardiac defibrillators on the carts were checked on a daily basis per facility policy.

Failure to ensure that emergency equipment is properly checked to ensure it is functioning places patients at risk of harm should the equipment be needed and/or it is not working properly.

Reference: Policy and Procedure "Crash Cart Procedure", effective 1/1/99, states in part: "Procedure A. Daily firing of Defibrillators will be done by the RN designated as above. B. When the Defibrillator has been fired, record the Date and By Whom on the Check List Provided which is located on the Clip Board at the side of the Cart".

Findings include:

1. On 2/9/2010 while checking the emergency cart located in the corridor adjacent to the endoscopic procedure room, the surveyor reviewed the "Crash Cart Record" log sheets. Documentation provided for review indicated that the log sheets had not been completed daily per policy. During the period of December 1, 2009 through January 31, 2010 there were forty-eight (48) dates on the checklists for which no entry had been made. By inference, it is assumed that the emergency cart was not checked per policy on those dates.

2. Follow-up review by the surveyor of "Crash Cart Record" log sheets on 2/11/2010 found that the emergency cart located adjacent to the med-surg nurses station had not been completed on twelve days (12) during the period between December 1, 2009 through January 31, 2010.

3. Crash Cart Record logs for the Emergency Department code carts indicated that checks had not been completed on three (3) days for the Ped's cart and no less than nine (9) days for the ER#2 cart during the period between December 1,2009 through January 31, 2010.

Based on observation and interview the facility failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA).

Findings include:

Refer to deficiencies written in the MEDICARE CRITICAL ACCESS HOSPITAL (RE-CERTIFICATION) FIRE LIFE SAFETY SURVEY, dated 2/9/2010 - 2/11/2010.

Based on observation, the hospital failed to prevent potential cross contamination between clean and soiled patient items during sorting, processing, transporting and storage processes performed in the Central Services (CS) department and/or other areas of the facility.

Failure to sort, process, transport and store sterile and clean items in such a manner or environment that they will not be subject to cross contamination from dirty items or airborne contaminates puts patients at risk of infection.

References: APIC Text of Infection Control and Epidemiology, Chapter 56, III. Central Services, 2005 edition; American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities, Part 2 Hospitals, 2006 edition.

Findings Include:

1. On 2/9/2010 while touring the facility the surveyor noted that the CS department processing space was being used for equipment processing functions that are considered to be incompatible, i.e. both dirty and sterile processing functions are performed in the same space without benefit of a physical barrier between the two.

2. On 2/9/2010 the surveyor used tissue paper to assess the direction of air flow into and out of the CS department at the two doors entering the space. This qualitative test showed that the CS department was negative to adjacent spaces and corridors (tissue movement into space). This finding suggests that unless operational controls are put into place to protect them, clean and sterile items could be compromised by airborne contaminates pull into the room.

2. During a tour of the facility on 2/9/2010, the surveyor found patient care items (gloves, bed pan, Betadine and feminine hygiene care products) stored in an unclean area under the sinks in rooms CC1 and CC2. This practice had the potential for exposing the items stored under the sinks to contaminated water from leaking pipes and/or condensation.

Based on interview and record review that facility failed to meet the nutritional needs of its inpatients by developing, following or implementing plans or policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC); and it failed to assure that meals ordered had been approved by the facility's medical staff.

Failure on the part of the facility to assure regulatory compliance with food service codes and/or to serve meals that are not on an approved dietary formulary puts patients, staff and visitors at risk of food borne illness and/or being served meals that do not meet the nutritional needs of its patients.

Finds include:

1. During discussions with the facility's Registered Dietitian (RD) on 2/9/2010 the surveyor was informed that an interdisciplinary plan for nutritional therapy was not available. However, it was pointed out that a periodic review of "a plan" had been performed as recently as April 2009.

2. During discussions with the facility's RD on 2/9/2010 the surveyor was informed that an interdisciplinary approach to meeting a patient's dietary needs was not being employed by the facility's pharmacist, infection control professional, nurses and/or dietary staff.

3. On 2/9/2010 the surveyor was presented with several hardcopy P&P's for review. During staff interview the surveyor was informed that most of the material (P&P's) presented was in draft form and had not been formally approved for use in the facility.

4. During a computer file search (Lucidoc) on 2/9/2010 the surveyor found three documents related to the dietary program. Dietary Scope of Service, Quality Presentation of Meals and Cleaning of Kitchen Equipment.

5. None of the documentation presented to the surveyor during the course of the survey referenced the Washington State Retail Food Code Working Document; Chapter 246-215 WAC Modification of the 2001 FDA Food Code.

6. During a tour of the kitchen the surveyor inquired about the type and concentration of the chemical sanitizing agent being employed. Staff indicated that the sanitizer was a quaternary ammonium compound solution. The manufacturer's recommended concentration of 200 ppm was noted on the product container. When staff was asked to verify the concentration of the sanitizing agent being used (bucket of solution) a packet of chlorine test strips was presented. On being advised that quaternary ammonium compound test strips should be used the staff person presented a test strip dispenser that showed signs of prior wetting which would make the test unreliable. Further examination of the label for the test strip dispenser showed that the test strips were for measuring pH not quaternary ammonium compound.

7. During discussions with the facility's RD on 2/9/2010 the surveyor was informed that a current nutritional diet formulary had not been approved for use by the facility's medical staff.

Based on medical record review and review of provided documents, the hospital failed to ensure that the medical record was completed for 7 of 10 records reviewed (P11, P12, P14, P17-P19, P21).

Failure to have reports, orders, notes, etc. properly completed and placed in the record places patients at risk of receiving or not receiving care and services because of potential errors in dictation.

Findings:

1. Per review of Patient #17's medical record, the patient was seen in the Emergency department (ED) on 2/1/2010. The record had an "ER/Triage Form" which included physician orders for the patient's treatment. The form has a signature, date/time block at the bottom. As of 2/10/2010, the physician orders had not yet been signed or authenticated by the physician. the dictated physician note dated 2/1/2010 had not been authenticated, as of 2/10/2010 (9 days later).

2. Per review of Patient #'s 12, 8,19 and 21 medical records, these patients were seen in the ED between 7/21/2009 and 2/2/2010. Their records had an "ER/Triage Form" which included physician orders for the patient's treatment. As of 2/10/2010, the physician orders had not yet been signed by the physician.

3. Per review of Patient #14's medical record, the patient was admitted on 8/5/2009. The physician admission note was dated 8/5/2009. The document showed the note was dictated on 8/5/2009 and not electronically authenticated until 8/15/2009 (10 days later). Another note was found dated 8/6/2009 and not electronically authenticated until 8/17/2009 (11 days later). A subsequent note was dated 8/7/2009 and not authenticated until 8/17/2009 (10 days later).

4. Per review of Patient #11's medical record, a physician note was dated 7/1/2009. The document showed the note was not electronically authenticated until 7/13/2009 (12 days later). Another note was found dated 7/2/2009 and not electronically authenticated until 7/13/2009 (11 days later). A subsequent note was dated 7/5/2009 and not authenticated until 7/13/2009 (8 days later).

5. Per review of hospital provided documents, the following physicians had medical record documentation needing authentication: a) between 12/25/2009 and 1/5/2010 Physician #1 had fifty-four (54) medical records needing authentication of some sort; b) between 12/18/2009 and 12/21/2009 Physician #2 had twenty-eight (28) medical records needing authentication of some sort; c) between 1/15/2010 and 1/21/2010 Physician #3 had forty-one (41) medical records needing authentication of some sort; d) between 10/31/2009 and 11/7/2009 Physician #4 had thirty-four (34) medical records needing authentication of some sort. All of the above examples had not been corrected as of 2/10/2010.

Based on medical record review and administrative staff interview, the hospital failed to ensure that the records contained the actual date and time when staff authenticated their telephone/verbal patient care orders for 4 of 4 records reviewed for signature authentication (P12, P14, P15, P22).

Failure to ensure that medical record documentation shows an authentication of verbal/telephone orders places all patients at risk of receiving or not receiving care as specified by the physician due to an inaccurately transcribed order.

Findings:

1. Per review of patient #14's medical record, the patient was admitted on 8/5/2009. Per review of the Physician Orders form dated 8/7/2009, a telephone order had been added to the chart at 11:00 AM. The physician authenticated this order by signature only, there was no date or time the authentication had been done.

2. Per review of patient #12's medical record, the patient was admitted on 7/21/2009. Per review of the Physician Orders form dated 7/23/2009, a telephone order had been added to the chart at 8:03 PM. The physician authenticated this order by signature only, there was no date or time the authentication had been done.

3. Per review of patient #22's medical record, the patient was admitted on 8/19/2009. Per review of the Physician Orders form, a telephone order was taken on 8/19/2009 in the afternoon; and on 8/20/2009 at an unknown time. The physician authenticated these orders with a signature only (no date or time of the signature).

4. Per review of patient #15's medical record, the patient was admitted on 8/2/2009. Per review of the Physician Orders form, a telephone order was taken on 8/2/2009 at 10:12 PM; on 8/6/2009 at 10:25 AM and at 8:45 PM. The physician authenticated these orders on 9/5/2009 (more than a month later).

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information from a representative sample of "open" patient records.

Failure to document the inclusion of open records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that open records were included in the sample. Per administrative staff interview on 2/10/2010, it was stated that the record review process was set-up to only have closed records sent to the reviewer. Thus, open records were never reviewed as part of the audit process.

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that health care policies had been reviewed, as a result of annual program evaluation findings.

Failure to document the review of policies that were found to need updating, as a result of the program evaluation, places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies had been reviewed, as a result of program evaluation identified issues that had a concurrent policy relation.

Based on review of the quality assurance program plan, review of committee minutes and administrative staff interview, the hospital failed to ensure that the quality plan included the provision to collect, measure and assess data related to patient deaths, medication administration and patient injuries and falls.

Failure to include data related to all patient care services that affect patients places patients at risk of harm related to potential care and treatment issues not being identified and corrected.

Findings:

1. Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to patient deaths.

2. Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to medication administration and errors.

3. Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to patient injuries and falls.

Per administrative staff interview, no evidence could be provided to show that the hospital quality assurance system had been collecting, measuring and assessing data regarding the above mentioned issues.