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Based on interview, observation, review of crash cart checklist documentation for 3 of 3 emergency crash carts, and policy review, it was determined the hospital failed to document that its emergency crash carts were maintained in accordance with its policy and to assure the integrity and availability of the contents of the carts.

Findings include:

1. An ED policy titled "EMERGENCY CRASH CART/DEFIBRILLATOR DAILY CHECK," revised 05/14/2012 was reviewed. The policy reflected "Crash carts will be checked daily...Check defibrillator...at 200 j...check for outdates on emergency medications..."

2. A Medical Surgical Unit (Med-Surg) policy titled "CRASH CART SECURITY AND ACCOUNTABILITY," revised 06/11/08 was reviewed and reflected "Purpose: To ensure that the crash cart and defibrillators in Med/Surg and [emergency room] are in working order...PROCEDURE: The Emergency Room RN shall visually inspect the lock located on the emergency crash cart at the beginning of each shift and complete the daily crash cart checklist. The lock number will be recorded on the checklist daily."

3. A Surgical Services policy titled "EMERGENCY CRASH CART SECURITY AND ACCOUNTABILITY," which lacked an effective or revised date, was reviewed. The policy reflected "The nursing personnel shall visually inspect the lock located on the emergency crash cart at each change of shift and document on the "Emergency Crash Cart and Defibrillator Check Signature Form." The policy lacked instructions regarding daily testing of the defibrillator per manufacturer's recommendation.

4. The Surgical Services crash cart had a manufacturer's maintenance manual titled "Operating Instructions" located on the top of the crash cart. The manual listed on page 8-2 a recommended maintenance schedule. Table 8-1 titled "Recommended Maintenance Schedule for Clinical Personnel" reflected "Complete Operator's Checklist...daily and as required. A detailed description of daily defibrillator charging and discharging was provided.

5. Tours of the hospital's Med-Surg unit, obstetrics, surgery and ED were conducted with nurse managers on 07/18-19/2012. Crash carts were observed in the ED, Surgical Services and Med-Surg departments

6. The Med-Surg crash cart defibrillator checklist titled "CRASH CART DAILY CHECKLIST" was reviewed. The checklist had columns with daily checks of defibrillator discharge every 24 hours. The checklists were reviewed for 04/2012, 05/2012, 06/2012 and 07/2012. The April 2012 checklist lacked documentation of checking the code cart for 13 of 30 days, the May 2012 checklist lacked documentation of checking the code cart for 9 of 31 days. Similar findings were identified for the June 2012 and July 2012 checklists. These findings were discussed the nurse managers and the CNO during the survey.

7. The ED crash cart defibrillator checklist titled "DAILY CHECK LIST FOR CODE CART = ER" reflected similar findings. The checklist had columns with daily checks of defibrillator discharge check every 24 hours, code cart red lock number, and signature. The checklist for February, 2012 lacked documentation of checking the code cart for 2 of 29 days, March 2012 checklist revealed 1 of 31 days that lacked documentation of checking the code cart and May, 2012 lacked documentation of checking the code cart on 4 days.

8. The Surgery crash cart checklists for 05/2012, 06/2012 and 07/2012 were reviewed. The top row on the form was labeled "Check Code Cart Weekly." The form listed the contents of 5 drawers and a bottom cabinet. The columns were designed to identify "weekly" checks, each week there was a line drawn down the entire sheet indicating that the code cart had been checked. The surgical service's policy failed to identify how often the crash cart defibrillator was to be discharged and the hospital failed to follow the guidelines set up by the manufacturer. During a tour of the surgical suite, it was discovered that the hospital failed to ensure the integrity of the crash cart by failing to lock it per hospital policy.

Based on the review of documentation in 2 of 3 medical records of patients who received blood transfusion services (Record #s 29 and 33) and policy review, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy. Vital signs and whether or not transfusion reactions were observed were not documented according to hospital policy.

Findings include:

1. The policy titled "WHOLE BLOOD AND PACKED CELLS," revised 2/19/2009 reflected "Consent shall be signed prior to infusion..explain procedure...Obtain IV access with large bore catheter...Confirm with another RN or physician to correctly identify blood product and patient identification...Check compatibility information on the bag...Double check blood product with physician order...Check expiration date on bag...Ask patient for their name and verify with arm band. Obtain and record baseline vital signs on transfusion record and blood bank form...avoid obtaining the blood from the Blood Bank until the patient and the IV line are prepared and ready for transfusion. If the transfusion must be delayed for some reason, the blood must be returned to the Blood Bank within 15 min. of the unit being signed out from the Blood Bank...Run the first 15 ml over 15 minutes while observing the patient for transfusion reactions...Take vitals after 15 minutes and record on transfusion record...Take and record vital signs every hour and as needed as well as at the end of the infusion...Ideally, blood should be infused over approximately 2 hours."

2. A "BLOOD TRANSFUSION SLIP" was contained within each of the medical records reviewed. The form included a "IDENTIFICATION PRIOR TO TRANSFUSION" section which reflected "I (we) certify that before starting transfusion, I (we) have checked that (1) "the name and hospital number of this form agree with patients name band..." A section titled "ADMINISTRATION," contained DATE...COMPLETED BY...and time increments where vital signs were to be checked as follows: "BEFORE..AFTER." This section also contained "ANY TRANSFUSION REACTION:" space with corresponding "YES" and "NO" checkboxes.

3. Medical record #29 was reviewed. The "Blood Transfusion Slip" reflected the patient received one unit of blood on 05/12/12 which was started at 1102 and stopped at 1430. Vital signs were documented at 1102 and 1430. The record lacked documentation that vital signs were obtained 15 minutes and one hour after the start of the transfusion as directed by hospital policy.

4. Medical record #33 was reviewed. The "Blood Transfusion Slip" reflected the patient received one unit of blood on 06/18/2012 which was started at 1040 and stopped at 1315. Vital signs were documented at 1040 and 1315. The record lacked documentation that vital signs were obtained 15 minutes and one hour after the start of the transfusion as directed by hospital policy.

Another transfusion for this patient was initiated at 1320 and ended at 1514. Vital signs were documented at 1320 and 1514. The record lacked documentation that vital signs were obtained 15 minutes and one hour after the start of the transfusion per hospital policy. The Transfusion Reaction "yes/no" checkboxes were blank.

5. These findings were reviewed with the CNO on 07/18/2012 at 1640.

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. During the CAH recertification and State relicensure survey, it was determined that many policies were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of hospital patient care policies that have not been reviewed for more than a year:

-MEDICAL SURGICAL UNIT policy titled "CLINICAL LABORATORY SPECIMENS COLLECTION AND CARE," last revised 02/17/2009;
-MEDICAL SURGICAL UNIT policy titled "IV THERAPY," last revised 07/10/2010;
-MEDICAL SURGICAL UNIT policy titled "WHOLE BLOOD AND PACKED CELLS," last revised 02/19/2009;
-NURSING/EMERGENCY DEPARTMENT policy titled "Sexual assault exam," effective 02/25/2008;
-NURSING SERVICE policy titled "CODE/NO CODE GUIDELINES," last revised 06/11/08;
-NURSING SERVICES policy titled "IV THERAPY- PEDIATRICS," last revised 03/20/2009;
-NURSING SERVICE policy titled "RESTRAINT MANAGEMENT Acute Care Restraints," effective 08/13/2010;
-Nursing Services protocol titled "Fall Risk Protocol,: last reviewed 01/19/2005;
-WALLOW COUNTY HEALTH CARE DISTRICT (WCHCD), ADMINISTRATIVE POLICY (AP), titled "CRITICAL ACCESS HOSPITAL: PROGRAM ELEMENTS," last reviewed August 2008;
-WCHCD, AD, titled "EMERGENCY DEPARTMENT PHYSICIAN CALL," last revised 07/01/2010;
-WCHCD policy titled "ER MEDICAL SCREEN PROCESS," last approved 03/11/2011;
-WALLOWA MEMORIAL HOSPITAL Nursing Service Procedure titled "Organ/Tissue Donation," 10/01/1999.

2. During an interview with the CNO on 07/18/2012 at 1630, he/she confirmed that the patient care policies and procedures were not being reviewed annually. The CNO stated that the hospital is in the process of moving all policies and procedure into a computerized system.

Based on review of medical records for 3 of 4 patients (Record #s 1, 2 and 5) who underwent a surgical procedure with general anesthesia, and policy review, it was determined the hospital failed to ensure documentation that an evaluation for anesthesia recovery was performed by a qualified practitioner in accordance with hospital policy.

Findings include:

1. Review of the policy titled, Pre and Post Anesthesia Evaluation Policy," which lacked an effective or reviewed date, identified the following internal requirements: "All patients receiving anesthesia or sedation and analgesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services."

2. Patient record #1 was reviewed: The record reflected the patient underwent a left inguinal hernia repair surgery on 06/12/2012. The physician operative report transcribed 06/12/2012, reflected the patient received general anesthesia for the procedure. Review of the record identified it lacked documentation that a post-anesthesia evaluation had been completed in the 48 hour timeframe in accordance with hospital policy.

3. Patient record #2 was reviewed: The record reflected the patient underwent a laparoscopic sigmoid resection surgery on 05/02/2012. The physician operative report dated 05/02/2012, reflected the patient received general anesthesia for the procedure. Review of the record identified it lacked documentation that a post-anesthesia evaluation had been completed in the 48 hour timeframe in accordance with hospital policy.

4. An interview was conducted with the Operating Room Manager on 07/19/2012 at 1215. He/she reviewed Patient record #s 1 and 2, and acknowledged the records lacked documentation that a post-anesthesia evaluation had been conducted.

5. Patient record #3 was reviewed: The record reflected the patient underwent a laparoscopic appendectomy surgery on 04/30/2012. Review of the physician operative report transcribed 05/01/2012 identified the patient received general anesthesia for the procedure. The CRNA pre-anesthesia evaluation form dated 04/30/2012 at 1620 was reviewed. The bottom of the form included a CRNA post-anesthesia evaluation. Review of the post-anesthesia evaluation identified it lacked a date and time in order to determine whether or not it had been completed within 48 hours after the surgical procedure in accordance with hospital policy.

Based on the review of documentation contained in 1 of 3 records of patients who expired at the hospital (Record # 29), policy review, and medical staff rules and regulations, it was determined that the hospital failed to ensure documentation of timely notification of the Organ Procurement Organization (OPO) as required and OPO notification was not documented in all cases in accordance with hospital policy.

Findings include:

1. A policy titled "Organ/Tissue Donation," dated 10/1/99 was reviewed and reflected "Wallowa Memorial Hospital will work in collaboration with donation agencies to increase the number of tissues and organs available for transplant...In the event a death occurs within our facility, we are to call the Donor Referral Line at...to determine potential acceptability for the tissues...If the potential for organ or tissue procurement is present, then the RN proceeds with the request for anatomical donation. If the next of kin are in agreement for donation, a Consent for Tissue and Organ Donation must be signed...You must get authorization from the donor agencies to NOT make a request. Copies of the consent form must go to the procurement agency...Procedure: 1. Hospital staff who request for organ and tissue donation must receive training from the donation agencies with a frequency determined by the donation agencies. 2. After medical suitability has been determined by the donation agency, a requestor who has been trained by the donation agencies will offer the next-of-kin the option of donation. 3. The Record of Request must be completed for all deaths and placed in the patient's medical record..."

The policy did not include a clear definition of a timely referral of all patients to the OPO to ensure the OPO was contacted as soon as possible after a patient had died, had been placed on a ventilator due to a severe brain injury, or had been declared brain dead. In addition, the policy did not include the definition of "imminent death," how the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose.

2. Patient record #29: Review of the record reflected the patient was admitted to the hospital on 05/12/2012 at 0130. The "RECORD OF REQUEST FOR ANATOMICAL DONATION" form had not been completed and failed to confirm the request for anatomical donation was made per hospital policy.

Based on interview, review of documentation in 4 of 4 records (Record #s 6, 7, 8 and 9) of patients who were discharged from a hospital Swing-bed, and policy review, it was determined that the hospital failed to ensure the provision of a written notice before transfer or discharge with all of the elements required by this regulation and in accordance with hospital policy.

Findings include:

1. Review of the Swing-bed policy titled, "Admission, Transfer & Discharge Requirements," reviewed 06/2012 identified the following internal requirements: "...Before Wallowa Memorial Hospital transfers or discharges a patient, we must...Notify the patient and, if known, a family member or legal representative of the patient of the transfer or discharge and the reasons for the move in writing...The written notice must include the following...The reason for transfer or discharge...The effective date of transfer or discharge...The location to which the patient is transferred or discharged..."

2. During an interview with the Discharge Planner on 07/19/2012 at 1700, he/she stated that the only discharge notice which was provided to Swing-bed patients was a brochure titled, "Leaving the nursing facility."

Review of the brochure, "Leaving the nursing facility," revised 03/2009 identified it lacked the following transfer and discharge notice requirements: The reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was transferred or discharged.

3. Swing-bed patient record #6: Review of the record reflected the patient was admitted to a hospital Swing-bed on 05/07/2012 and discharged on 05/22/2012. The record lacked documentation of a written discharge notice which included the reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was transferred or discharged.

4. Swing-bed patient record #7: Review of the record reflected the patient was admitted to a hospital Swing-bed on 03/12/2012 and discharged from the Swing-bed on 04/04/2012. The record lacked documentation of a written discharge notice which included the reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was transferred or discharged.

5. Swing-bed patient record #8: Review of the record reflected the patient was admitted to a hospital Swing-bed on 05/09/2012 and discharged from the Swing-bed on 05/28/2012. The record lacked documentation of a written discharge notice which included the reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was transferred or discharged.

6. Swing-bed patient record #9: Review of the record reflected the patient was admitted to a hospital Swing-bed on 04/16/2012 and discharged from the Swing-bed on 05/14/2012. The record lacked documentation of a written discharge notice which included the reason for the transfer or discharge, the effective date of the transfer or discharge, and the location to which the patient was transferred or discharged.