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Based on staff interview and the review of documentation, it was determined the hospital failed to maintain a list of all contracted services provided to the hospital which included the scope and nature of the services provided.

Findings include:

1. A document titled "MID COLUMBIA MEDICAL CENTER CLINICAL PROFESSIONAL FEES AND PURCHASE SERVICES" was reviewed. The document had a label that was affixed with tape and stated: "11. List of all contracted services." The list included various services such as "COLOMBIA GORGE PATHOLOGY ASSOCIATES...MEDQUIST TRANSCRIPTIONISTS LTD...MID COLUMBIA SURGICAL SPECIALISTS..."

2. A "LABORATORY SERVICES AGREEMENT," signed/dated 04/13/2000 was reviewed and reflected the hospital had a contract with Quest Diagnostics. An interview was conducted on 01/12/2012 at 1400 with the Director of Lab Services. He/she revealed that the hospital had a contract with Quest Diagnostics for some of its clinical laboratory services. This service, including the scope and nature of the service provided was not on the hospital's list of contracted services.

3. Review of documentation from "John Fletcher Empiricos, LLC Radiation Safety Specialist" dated 08/08/1997 and 10/16/2000 was reviewed and reflected the hospital used the services of a radiation safety specialist for tasks including "Radiation survey...Radiation safety refresher training...Sealed source leak testing..." An interview was conducted on 01/10/2012 at 0815 with the Director of Diagnostic Imaging and he/she said the hospital had an agreement with the radiation specialist for tasks related to radiation safety. This service, including the scope and nature of the service provided was not included on the hospital's list of contracted services.

4. Review of a surgical equipment service agreement signed/dated 09/23/2011 reflected the hospital had a contract with Steris Corporation. This service, including the scope and nature of the service provided was not on the hospital's list of contracted services.

5. An interview was conducted with the Executive Vice President of Operations on 01/12/2012 at 1430. He/she acknowledged the hospital had a contract with Quest Diagnostics for laboratory services and that it was not included on the list of contracted services. He/she further acknowledged that the list was not a comprehensive list of all services provided to the hospital under contract. No further documented evidence of a comprehensive list of all contracted services was received for the duration of the survey which was completed on 01/12/2012 at approximately 1530.

Based on the review of documentation in 5 of 5 patient records of patients who received transfusions of blood or blood products (Record #s 4, 22, 23, 24 and 25), policy review, the review of blood bank documentation, and staff interview, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy.

1. The policy titled "TRANSFUSION OF BLOOD OR BLOOD COMPONENTS, dated revised 11/2011 was reviewed and reflected "Pre-Procedure...Prior to starting the procedure...Obtain baseline vital signs including assessment of lungs...Obtain a transfusion history from the patient...RN or LPN, only, will go to the lab to check out the Blood/Blood Components...Nursing will sign out the Blood/Blood Component on the log in the Blood Bank including time unit removed...Transfusion of Blood/Blood Components should be initiated within 30 minutes after the unit has been removed from the blood bank...If unable [to] start to infuse in a timely manner the product should be returned to lab within 30 minutes of checkout time in order to be re-issued at a later time...Upon return to the floor two staff members (RN, LPN, or MD) will do [bedside] verification...Blood unit slip will be signed by both staff members checking the unit and patient identification...Vital signs will be obtained 15 minutes after the infusion begins and then at least hourly during the infusion and at one hour post-infusion...Transfusion records will be completed by nursing staff and a copy will be placed in the patients chart and sent to lab."

2. Patient record #4 was reviewed and reflected that an order dated on 12/13/2011 and timed as 0700 called for a "T & C (type and crossmatch) 2 units of blood." The clinical record lacked an order to transfuse the patient with the blood. One unit of blood, Unit # 216R00890 was transfused on 12/13/2011 from 1800 to 2115.

3. Patient record #22 was reviewed and reflected the patient received one unit of blood on 10/18/2011. The record contained a "BLOOD BANK TRANSFUSION RECORD FORM" which reflected the transfusion was started at 1945. There was no documentation that a baseline transfusion history had been obtained from the patient prior to the start of the transfusion. The Nursing Education Coordinator presented the patient's "BLOOD BANK WORKSHEET" which he/she said was obtained from the lab. The worksheet reflected the blood had been issued at 2000, 15 minutes after the transfusion was started. The coordinator acknowledged that the documentation contained in the blood bank record versus the patient's medical record was inconsistent. The record lacked documentation whether or not the transfusion was initiated within 30 minutes after the unit had been removed from the blood bank; and the record lacked documentation that a transfusion history had been obtained from the patient as directed by the hospital policy.

The record reflected the patient received a second blood transfusion on 10/18/2011 which was started at 2140. The record lacked documentation that lung sounds were assessed prior to the start of the transfusion as directed by hospital policy.

4. Patient record #23 was reviewed and reflected the patient received one unit of blood on 10/14/2011 which was started at 2200. There was no documentation that a baseline transfusion history had been obtained from the patient prior to the start of the transfusion. The record contained a "BLOOD BANK TRANSFUSION RECORD FORM" which reflected "I HAVE VERIFIED RECIPIENTS NAME AND HOSPITAL NUMBER AND/OR B.D. TO BE AS SHOWN ON THIS FORM AND ON LABELS ATTACHED TO DONOR UNIT," followed by two signature lines. Only one of the lines held a signature. The record lacked documentation that two staff members had verified the donor unit and patient identification as directed by the hospital policy.

5. Patient record #24 was reviewed and reflected the patient received one unit of blood on 06/11/2011 which was started at 1205. There was no documentation that a baseline transfusion history had been obtained from the patient prior to the start of the transfusion. The record lacked documentation that vital signs were obtained and lung sounds were assessed prior to the start of the transfusion as directed by the hospital policy.

6. Patient record #25 was reviewed and reflected the patient received one unit of blood on 12/23/2011. The record contained a "BLOOD BANK TRANSFUSION RECORD FORM" which reflected the transfusion was started at 2350. The record lacked documentation that a baseline transfusion history had been obtained from the patient prior to the start of the transfusion as directed by the hospital policy.

The record reflected the patient received a second blood transfusion on 12/24/2011 which was started at 0220. The record lacked documentation that lung sounds were assessed prior to the start of the transfusion. A form titled "MID-COLUMBIA MEDICAL CENTER ICU/CCU," dated 12/23/2011 to 12/24/2011 reflected that a full set of vital signs were not obtained until 0300, 40 minutes after the transfusion was started.

7. An interview was conducted on 01/11/2012 at 0800 with the Nursing Education Coordinator. These findings were discussed and he/she reviewed the medical records listed above. He/she acknowledged that the records lacked all of the required documentation in accordance with the hospital policy. No further documentation was received for the duration of the survey which was completed on 01/12/2012 at approximately 1530.

Based on the review of policies and procedures, review of patient records, and staff interviews, it was determined hospital staff failed to implement written policies and procedures for ensuring that the hospital works cooperatively with the designated organ procurement organization, tissue bank and eye bank.

Findings include:

The hospital had a policy titled "Body, Organ Donations" last reviewed on 1/2009, that stated: "Protocols:...Non-Beating Heart: Patient has expired and has no heartbeat.....(2) The required Referral form is completed for every death and placed in the medical record."

Based on the review of 6 patient records (Records # 15, 16, 17, 18, 19, and 20), it was determined that 3 of these records (Records # 15, 17, and 19) lacked documentation in the form of the "Required Referral Form: Organ and Tissue Donation" as required by the hospital's policy and procedure.

The findings were discussed with the hospital's Nurse Educator at approximately 1005 on 01/12/2012, and at 1100, the nurse educator was given the names of the expired patients to see if he/she could locate the missing documentation. The Nurse Educator was unable to locate additional documentation and forwarded the information to a former Nurse Supervisor, now the Wound Care Specialist for the organization. At approximately 1500, the Wound Care Specialist stated that he/she was unable to locate the "Required Referral Form: Organ and Tissue Donation" for records # 15, 17, and 19.

Based on the review of 11 patient records of patients receiving anesthesia at the hospital (Records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, and 13), it was determined 2 of 11 patient records (Records # 5 and 7) lacked documentation to reflect that all patients received a pre-anesthesia evaluation performed within 48 hours prior to surgery or a procedure requiring anesthesia services. Examples include, but are not limited to, the following:

The Anesthesia Record had an area labeled "Pre-Anesthesia Evaluation." In this area, the pre-anesthesia evaluation was documented. The listed clinical records of patients receiving anesthesia, (Records 5 and 7) lacked a time as to when the preoperative anesthesia evaluation occurred.

These findings were shared with the Physician Director of Anesthesia during the tour of the Anesthesia area at 1017 on 01/11/2012, and with the executive team at the exit conference on 01/12/2012 at approximately 1530.

Based on the review of 11 patient records of patients receiving anesthesia at the hospital (Records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, and 13), it was determined 2 of 11 (Records # 9 and 13) lacked documentation to reflect that all patients received a post-anesthesia evaluation performed no later than 48 hours after surgery or a procedure requiring anesthesia services. Examples include, but are not limited to, the following:

The Anesthesia Record had an area labeled "Post-Anesthesia Evaluation." In this area, the post-anesthesia evaluation was documented. The listed patient records of patients receiving anesthesia, (Records # 5 and 7) lacked a time as to when the post-operative anesthesia evaluation occurred.

These findings were shared with the Physician Director of Anesthesia during the tour of the Anesthesia area at 1017 on 01/11/2012, and with the executive team at the exit conference on 01/12/2012 at approximately 1530.

Based on the review of documentation in 1 of 2 medical records of patients who received Swing-bed services (Record #26), the review of Swing-bed policies, and staff interview, it was determined the hospital failed to provide an on-going program of activities that was directed by a designated qualified individual. Activities assessments were not completed in accordance with established timeframe as required by hospital policy.

1. A Swing-bed policy titled "Skilled Swing Bed Procedures," dated revised 08/2010 reflected "Activities are coordinated and supervised by the designated Activities Coordinator. The Activities Coordinator is under the supervision of the Director of Performance and Quality...The initial activity assessment will be completed by the Activities Coordinator...within 72 hours of admission to Swing bed status...All Activities Coordinator visits will be documented in the patients record."

2. Patient record #26 was reviewed and reflected the patient was admitted to a Swing-bed on 05/11/2011 and was discharged home on 05/15/2011. The record lacked documentation that an Activities assessment had been completed by an Activities Coordinator as required by hospital policy.

3. An interview was conducted with the RN Case Manager on 01/11/2012 at 1330. He/she reviewed the Swing-bed record of Patient #26 and acknowledged that the record lacked a documented Activities assessment.

4. An interview was conducted with the Director of Performance and Quality Systems on 01/11/2012 at 1350. He/she said the hospital had no current qualified designated Activities Coordinator for Swing-bed patients, nor did the hospital have a designated Activities Coordinator when Patient #26 received Swing-bed services from 05/11/2011 to 05/15/2011 as directed by hospital policy.