HospitalInspections.org

Based on review of documentation in 1 of 3 PA credentialing files (# 3) and review of State of Oregon Medical Board OARs, it was determined that the CAH failed to ensure that the PA's credential records clearly delineated the type of supervision required by the PA's designated supervising physician in accordance with the Oregon Medical Board PA supervision requirements.

Findings include:

1. The current rules of the Oregon Medical Board at OAR 847-050-0010(10)(a)(b)(c) define supervision as it is related to the physician and PA relationship:
"(10) 'Supervision' means the routine review by the supervising physician or designated agent, as described in the practice agreement or Board-approved practice description of the medical services provided by the physician assistant. The supervising physician or designated agent and the physician assistant must maintain direct communication, either in person, by telephone, or other electronic means. There are three categories of supervision:
(a) 'General Supervision' means the supervising physician or designated agent is not on-site with the physician assistant, but must be available for direct communication, either in person, by telephone, or other electronic means.
(b) 'Direct Supervision' means the supervising physician or designated agent must be in the facility when the physician assistant is practicing.
(c) 'Personal Supervision' means the supervising physician or designated agent must be at the side of the physician assistant at all times, personally directing the action of the physician assistant."

The current rules of the Oregon Medical Board at OAR 847-050-0037(3) contains additional language related to PA supervision:
"(3) The type of supervision and maintenance of supervision provided for each physician assistant must be described in the practice agreement or Board-approved practice description."

2. Review of the hospital's medical staff credential file for PA 3 revealed a "Physician Assistant Privilege Form" that contained a list of privileges with corresponding columns labeled as "Direct Supervision" and "Indirect Supervision". The form defined "Direct Supervision" as "...under the direct observation and physical presence of the supervising physician." "Indirect Supervision" was defined as "...may practice privileges granted without the direct observation and physical presence of the supervising physician."

Documentation on the "Physician Assistant Privilege Form" reflected that PA 3 had completed and signed the form on 05/10/2014. That same form was signed and dated by a "Supervising Physician" on 05/13/2014, and signed by the "Chief of Staff" on 07/08/2014. A letter in the credential file reflected the PA had been granted privileges at the hospital on 07/23/2014. The letter reflected the PA had "...also been granted the following additional requested privileges: Administer Ordered Medication."

However, the privileges delineated on the form for PA 3, and subsequently granted, were not clear. The following privileges were checked as both "Direct Supervision" and "Indirect Supervision":
* "Assist in surgery in accordance with department of surgery policy and procedure."
* "With verbal orders from supervising physician, may arrange hospital and Nursing Home admission."
* "May record orders approved by the supervising physician..."
* "May order outpatient lab and x-rays without supervising physician's authorization and or signature."
* "Suture wounds."
* "Remove and care of invasive lines in accordance with privilege granted the supervising physician."
* "Remove sutures."
* "Apply/remove a splint."
* "Incision and drainage of simple abscesses."

Privileges were further not clear as the privileges form contained a privilege for "Administer ordered medication." The "Direct" and "Indirect" columns had been originally checked, however, had then been crossed out by a line that led to a handwritten entry in the margin of the form. That note read "no...confirmed by [supervising physician]" and was dated 07/07/2014.

Based on observation and interview it was determined that the physical environment of the CAH was not properly maintained. Walls, floors, doors, and other areas in the kitchen and the corridor that extended past the rehabilitation department had surfaces that were not properly finished or were in disrepair; were cluttered and disorganized; or were not properly secured or labeled to ensure appropriate entry and use.

Findings include:

1. During tour of the dietary department on 03/08/2016 at 1500 the following observations were made:
* Baseboards throughout were peeling away from the walls, including in the dry food storage room.
* Linoleum floor surfaces throughout were excessively worn, discolored, had numerous cracks and marks, and a build-up of dark matter. The grout lines on the tile floor surfaces were discolored and dark.
* The linoleum splash guard on the wall around the floor sink in the janitor's closet was peeling away.
* The floor sink in the janitor's closet was stained, and unusable as it was filled with a variety of hoses, a toilet plunger, and a large container of a liquid solution.
* Wood surfaces on the walls in the dishwashing room were worn and unsealed.
* Walls had gouges and chipped and peeling paint throughout, including in the dry food storage room and the dishwashing room.
* Metal surfaces and pipes, and tile floor surfaces, on and near dishwashing equipment in the dishwashing room were corroded and/or covered with whitish and rust-like discolorations and build-up.
* Padded insulation covering a pipe located along a wall in the "back hall storage room" was ripped and coming apart.
* A painted wooden box with a closed, hinged lid was attached to the wall above the floor in the "back hall storage room". A gray/silver pipe was observed extending from both sides of the box horizontally along the wall. A handwritten sign on the box read: "6-9-12 Nothing against this white wood box Nothing on top or sides per maintenance." Staff present during the tour did not know what was in the box.

2. a. During tour of the Outpatient Rehabilitation Department on 03/09/2016 at 1545 and at 1615 the following observations were made of doors in the corridor of the department in which the treatment rooms were located:
* The first door was unfinished rough wood and was sealed closed with heavy-duty tape.
* The second door was unfinished rough wood, had a large unfinished wood handle and opened to a plant operations room. The floor of the room was disorganized and cluttered with a variety of facilities tools and supplies.
* The third door was unfinished rough wood and in place of a handle had a round hole located in the place where a door knob would be. That door opened to a plant operations room that was under construction.
* A fourth door was located at the end of the corridor. On the wall at the end of the corridor was a lighted "EXIT" sign with an arrow that pointed towards the fourth door. However, that door had a sign taped on it that read "Danger Construction Area Keep Out." That door opened to a small area that contained another door that led to the exterior of the building. That second door had a sign taped on it that read "Emergency Exit Only." The area between the two doors contained a ladder and a fire extinguisher, and ceiling tiles in that space were missing.
* During the observations multiple patients were observed in the Department, including small children who were active and playing in the area.

b. Staff present during the observations on 03/09/2016 at 1615 stated that the second and third unfinished wood doors were supposed to be locked.

3. Refer also to Tag C278, CFR 485.635(a)(3)(vi), Patient Care Policies related to infection prevention, that includes additional findings of areas within the hospital that were not maintained in good repair.

Based on observation, interview, review of preventive maintenance records, and review of policies and procedures it was determined that the CAH failed to ensure that all electrical and bio-medical patient care equipment had been tracked, inspected, and maintained to ensure an acceptable level of safety and quality in accordance with its policies and procedures.

Findings include:

1. The policy and procedure titled "General Electrical & Equipment Safety for Caregivers" dated effective 06/30/2014 was reviewed. It required that "All electrical appliances and equipment which are to be used in the hospital by patients, visitors, caregiver or medical staff must be approved as electrically and mechanically safe prior to use in any area of the hospital facility."

The policy and procedure titled "Inspecting, Testing, and Maintenance Criteria for Medical Equipment" dated effective 06/26/2014 was reviewed. It reflected it was "To describe the criteria that is used in determining whether clinical equipment is to be included in the medical equipment management program, listed in the inventory, and the frequency of inspection." The document indicated that "Clinical devices, whether part of a system or an individual piece of equipment, are included in the equipment inventory if it meets the criteria listed in this procedure. All clinical equipment is initially evaluated for inclusion in the hospital medical equipment management program based upon the five risk criteria explained below...Whenever new equipment is received by the Medical Center, it is evaluated for inclusion into the medical equipment management program inventory using the criteria described above and an initial inspection is performed." The document contained detailed description of risk criteria categories, frequency priority levels, placement of preventive maintenance labels on devices, and a lengthy list of types of items/equipment where risk and priority had been established.

2. During tours of the hospital throughout the survey equipment was observed.

* On 03/08/2016 at 1600 in the SANE room an electric Ritter exam chair was observed. Documentation on a sticker affixed to the chair reflected it was due for a safety check in December 2013. During interview with facilities staff on 03/11/2016 at 1150 it was confirmed there were no inspection records for this item other than the sticker on the chair.

* On 03/09/2016 at 1100 in the Lab a Precision incubator was observed. During interview with facilities staff on 03/11/2016 at 1320 it was confirmed there were no inspection records for the incubator.

* On 03/09/2016 at 1155 in the Imaging Department an Enthermics blanket warmer was observed. During interview with facilities staff on 03/11/2016 at 1150 it was confirmed there were no inspection records for the warmer.

* On 03/09/2016 at 1210 in the ultrasound room a Welch Allyn vital signs monitor was observed. During interview with facilities staff on 03/11/2016 at 1150 a preventive maintenance report for the monitor was reviewed. That report reflected the machine required an annual preventive maintenance that had last been done on 01/19/2015.

* On 03/09/2016 at 1545 in the Outpatient Rehabilitation Department the following equipment was observed: an electric Splint-Form 1000; an electric Waxwell paraffin moist heat treatment machine; a SciFit stationary bike; a SciFit treadmill; an electric mat table; and a Midland electric adjustable parallel bars. During interview with facilities staff on 03/11/2016 at 1150 it was confirmed there were no inspection records for those items.

* On 03/10/2016 at 1510 in Pre-Operative exam room a Hamilton Image electric exam chair was observed. Documentation on a sticker affixed to the chair reflected it was due for a safety check in August 2009. During interview with facilities staff on 03/11/2016 at 1150 it was confirmed there were no inspection records for this item.

* On 03/10/2016 at 1515 in the Echocardiogram room a Phillips Matrix Echo machine was observed. During interview with facilities staff on 03/11/2016 at 1320 it was confirmed there were no inspection, preventive maintenance or bio-medical records for this diagnostic device.

* On 03/10/2016 at 1600 in the surgery recovery room a Vena Flow Elite Aircast unit was observed. During interview with facilities staff on 03/11/2016 at 1150 the preventive maintenance report for the alternating pressure device was reviewed. That report reflected the device required an annual preventive maintenance that had last been done on 11/29/2013.

* On 03/10/2016 at 1615 in the surgery supply room a Berkeley Bio-Engineers portable vacuum system was observed. Documentation on a sticker affixed to the unit reflected "Date: 2/01". During interview with facilities staff on 03/11/2016 at 1320 it was confirmed that the only records for the unit reflected that it had been "retired out of service" from the St. Charles Bend hospital and there were no current inspection records. Facilities staff stated that they did not know how the unit came to be in service at St. Charles Madras.

Based on interview and review of grievance documentation for 4 of 7 patients/patient representatives who submitted grievances (Patients 22, 23, 24 and 25), and review of policies and procedures, it was determined that the CAH failed to fully implement grievance policies and procedures it had adopted to ensure that patients/patient representatives received written responses to their grievances. Written responses were not submitted or were not submitted timely to patients/patient representatives.

Findings include:

1. The p/p titled "Patient (Patient Representative) Complaint-Grievance Resolution Process" dated effective 04/01/2015 was reviewed and reflected "...If unable to resolve a complaint...Explain to the complainant you are filing a grievance on his/her behalf, an investigation will be conducted and a written response will be sent to the complainant in seven days...Manager or Designee...Investigates the documented grievance within seven days of receiving...Responds to the patient/patient representative in writing within seven days of receiving...If the grievance is not yet resolved, respond to the complainant using the form letter template CMS Mandatory 7 Day Initial Letter...The written response must minimally include...An explanation of the ongoing process involved to resolve the grievance...Anticipated date of next written response from the hospital."

2. Grievance documentation for Patient 22 was reviewed: A document titled "Event Summary with all Tasks" was reviewed and reflected the patient's representative submitted a grievance to the CAH on 09/09/2015. The summary reflected "[Patient] was seen...in the ER by [physician] the [physician] did not agree with the fact that [patient] was sick (sic) [He/she] said [patient] had a fever and was not acting right which [he/she] thought [patient] might have an infection or something. [Patient] was sent home and [he/she] didn't send discharge instructions with anything but the fact that [patient] had dementia. Then [patient] was brought back in three days...On this visit the [physician] did a full work up on [patient] and [patient] was very sick with pneumonia and had an infection, which caused sepsis. [He/she] felt this wouldn't have been the case if the first doctor would have been doing [his/her] job." There was no documentation reflecting a written response was provided to the patient's representative until 12/18/2015, more than 3 months after the CAH received the grievance.


3. Grievance documentation for Patient 23 was reviewed: A document titled "Event Summary with all Tasks" was reviewed and reflected the patient submitted a grievance to the CAH on 10/13/2015. The summary reflected "[Patient] called to report [he/she] was sent to the ER...for PICC line dressing change and lab to be prepared for an upcomign (sic) surgery. Patient...stepped outside. An ambulance was parked at the hospital. While outside, a nurse...came outside and stood 'within 3 inches of [patient's] face' and hollered at [patient], 'we don't have time for this, we're in a crisis here.' [Patient] said [he/she] was very confused and frustrated about being talked to like this..." There was no documentation reflecting a written response was provided to the patient until 11/19/2015, more than a month after the CAH received the grievance.

4. Grievance documentation for Patient 24 was reviewed: A document titled "Event Summary with all Tasks" was reviewed and reflected the patient submitted a grievance to the CAH on 11/18/2015. The summary reflected "Patient presented for services and...stated [he/she] was upset regarding the last time [he/she] was here. Stated the registration staff told [patient] [he/she] had not insurance...registration staff did not provide the support and assistance that [he/she] thought was needed." A written notice addressed to the patient dated 11/23/2015 was reviewed and reflected "I am writing to notify you that your concern about your experience during registration is being investigated..I anticipate the investigation should be concluded on December 23, 2015] (sic). Upon completion, a written summary of the investigation's findings and actions taken will be sent to you." There was no documentation reflecting a written summary was provided to the patient as indicated.

5. Grievance documentation for Patient 25 was reviewed: A document titled "Event Summary with all Tasks" was reviewed and reflected the patient submitted a grievance to the CAH on 01/05/2016. The summary reflected "[Patient's] son voiced concern...regarding [physician] questioning. [Patient's] son felt the doctor didn't give him a chance to answer questions and that [physician] seemed 'angry or something.' A written notice addressed to the patient dated 01/05/2016 was reviewed and reflected "I am writing to notify you that your concern is currently being investigated...I anticipate the investigation should be concluded in approximately 30 days. Upon completion, a written summary of the investigation's findings and actions taken will be sent to you." There was no documentation reflecting a written summary was provided to the patient as indicated.

6. During an interview on 03/10/2016 at 1545 the Clinical Risk Manager confirmed these findings.

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Based on observation, interview, and review of policies and procedures, and other documents it was determined the CAH failed to fully develop or implement policies and procedures for infection prevention in the following areas:
* Environmental surfaces were in disrepair and were not clean.
* Disinfection and cleaning supplies and processes in surgical services, SPD, and ED were not in accordance with manufacturer's instructions.
* Food and clinical supplies were improperly stored in a refrigerator/freezer in the ED.
* Signs for isolation precautions were not properly posted and PPEs were not properly used.
* Temperatures in surgical services and SPD were not monitored or maintained in proper parameters.
* Current construction in the building had not been properly managed.

Findings included:

1. a. During tours of the ED with the ED Manager the following observations were made:

* On 03/08/2016 at 1140 in the triage area a stool was observed. The material on the seat was torn and was not cleanable.

* On 03/08/2016 at 1530 in the soiled utility room numerous surgical instruments were observed on a towel next to the sink. At the time of the observation, the ED Manager indicated the instruments were contaminated and should be soaked in an enzymatic solution after being used. However, he/she acknowledged they had not been.

* On 03/08/2016 at 1530 in the soiled utility room an open one gallon container of V. Mueller enzymatic was observed and had no evidence of when it was opened and no expiration date. This was confirmed with the ED Manager at the time of the observation.

* On 03/09/2016 at 1105 in the refrigerator-freezer in the ED med room an unused tissue specimen container and applicator swab were observed; three containers of ice cream were observed and were melting; a container of yogurt was was observed and was outdated; and there was visible dust and food spills. There was no evidence of temperature monitoring for the refrigerator-freezer.

b. During an interview on 03/11/2016 at 1240, the Quality & Regulatory staff confirmed there was no evidence of temperature monitoring for the refrigerator-freezer unit.

2. a. During tour of the OR on 03/10/2016 beginning at 1600 with the Quality & Regulatory staff a laryngoscope blade, tracheal tube and syringe were observed in open peel pouches on the medication cart.

b. The p/p titled "Processing of Laryngoscope Blades" effective date 07/09/2014 was reviewed and reflected the following: "...To avoid cross-infection, the laryngoscope blade(s) must be cleaned, disinfected and sterilized after each intubation...Processed laryngoscope blades will be considered contaminated if the peel pouch has been opened and must be returned to Central Processing for reprocessing."

3. The surgical services department and scope procedure area were toured with the Director of IP and the Quality & Regulatory staff on 3/11/2016 beginning at 1130. The following observations were made:

* At the entrance between the hallway and the surgical services department the carpet, linoleum flooring, and threshold molding were visibly dirty, peeling and in disrepair. Those areas were not cleanable.

* The entry door to the scope procedure room at 1145 had areas of chipping and peeling paint. Those areas were not cleanable.

4. a. During tour of the scope procedure room on 03/11/2015 at 1145 an RN was interviewed and stated that the CAH had four endoscopes. The RN stated that for cleaning endoscopes he/she mixed "a couple squirts" of Intercept detergent with water. However, the RN acknowledged he/she did not measure the amount of water that was used to dilute the Intercept detergent.

b. The p/p titled "Endoscope Cleaning and Disinfection" dated effective 09/03/2015 was reviewed. The "Cleaning Solution" section of the policy reflected "...A hospital approved low suds-cleaning solution for endoscopes will be used according to manufacturers recommended concentration...Note: The concentration of the prepared solution changes when a scope has not received pre-cleaning or has been allowed to sit for one hour or longer." The "Cleaning" section reflected "...Fill a sink or basin with fresh clean water and hospital approved low suds detergent for cleaning endoscopes...Dilute detergent according to manufacturer's instructions."

c. Manufacturer's directions on the Intercept detergent container were reviewed with the RN and reflected "For cleaning of...endoscopes...and other apparatus where blood, mucus, protein or other hard to remove soils are encountered, use Intercept at 1/3 oz./gal of water (0.25% use concentration) with one full stroke of the hand-pump (1 oz.) to three gallons of water. If visible organic matter is present, use Intercept at 2/3 oz./gal of water (0.5%) concentration) which is two full strokes of the hand-pump (2 oz.) to three gallons of water."

5. a. The p/p titled "Endoscope Cleaning and Disinfection" dated effective 09/03/2015 was further reviewed and reflected the following: "...High-level disinfectant solutions will be tested at the end of each AER cycle and documented on the daily test log record..." The High-Level Disinfection" section reflected "Test the product for the Minimum Effective Concentration (MEC)...A product specific test strip will be used...according to manufacturer's instructions. Records will include...pass or fail determination..."

b. Records that included testing of the disinfectant solution used for AER were on forms titled "Daily Rapicide PA QA". Those records for 09/08/2015 through 03/08/2016 were reviewed. The records contained information for each endoscope processed that included a Rapicide indicator test for the chemical used in the scope reprocessor, and a leak test for the scope. Review of the log records reflected they were unclear and incomplete. Examples include but are not limited to the following:
* Log records for scope #2807073 on 01/19/2016 with reprocessor start time 0921 reflected "Rapicide PA" followed by spaces for "[Pass]" and "[Fail]." The Fail was circled and there was no documentation of actions taken or other information related to the failed entry.
* Log records for scope #2216852 on 10/29/2015 with reprocessor start time 1116 reflected "Rapicide PA" followed by spaces for "[Pass]" and "[Fail] 11/5." Neither the Pass or Fail were marked and it was not clear what the "11/5" entry referred to.
* Log records for scope #2216852 on 10/30/2015 with reprocessor start time 1102 reflected "Leak Test" followed by spaces for "Yes" and "No." Neither the Yes or No were marked to reflect whether the leak test had been completed.
* Log records for scope #2807073 on 12/01/2015 with reprocessor start time 1110 reflected "Rapicide PA" followed by spaces for "[Pass]" and "[Fail]." Neither the Pass or Fail were marked.
* Similar findings were identified in the following instances:
Scope #2003007 on 11/11/2015 with reprocessor start time 1052;
Scope #2216852 on 11/12/2015 with reprocessor start time 1043;
Scope #2897073 on 12/01/2015 with reprocessor start time 1110;
Scope #2216852 on 12/15/2015 with reprocessor start time 1021;
Scope #2807073 on 12/17/2015 with reprocessor start time 1106;
Scope #2003007 on 01/22/2016 with reprocessor start time 1313;
Scope #2216852 on 02/10/2016 with reprocessor start time 1230;
Scope #2003007 on 02/16/2016 with reprocessor start time 0918; and
Scope #2003007 on 02/26/2016 with reprocessor start time 1111.


6. a. The p/p titled "Guideline for Isolation Precautions," dated effective 08/27/2015 was reviewed and reflected "To provide strict rules and practices...for isolation precautions...This will include caregivers, visitors, licensed independent practitioners (LIPs), or anyone having contact with an infectious patient or the patient's environment..." The instructions section of the policy reflected the following: "...Place the appropriate isolation sign below the room number sign near the patient room...Don the disposable gown (if indicated)...making sure that it is secured behind your neck and around the waist."

b. During a tour of the M/S unit conducted with the M/S Manager on 03/08/2016 observations were made related to isolation precautions as follows:
* At 1205, the door of patient room 115 was observed from the hallway. The door was open and had a caddy attached to it that contained disposable gowns. A "Droplet Precautions" sign was attached to the caddy. The sign was partially covered by a gown that was in the caddy, and with the door in the open position, the sign was not visible from all angles of the hall. A CAH staff person was observed inside the room. The staff person's gown was not secured and was open in the back.
* At 1210, a "Contact Precautions" sign was observed hanging on the open door of patient room 116. The sign was not visible from all angles of the hall outside the room. This was confirmed at the time of the observation with the M/S Manager.

7. a. The p/p titled "Infection Prevention HVAC Monitoring" dated effective 08/25/2015 was reviewed and reflected "The HVAC system is intended to reduce the amount of environmental contamination...in the surgical suite, procedure room...and Central Processing...All areas in use will monitor and record at a minimum once daily on a Room Environmental Tracking Log...temperature, humidity, and pressure in each of the OR rooms...central processing, or procedural rooms..." The "Temperature" section of the policy reflected "...Operating rooms...and Central Processing (Sterile processing) will be maintained between 68-78 [degrees] F...Central Processing and Decontamination: 72-78 [degrees] F...Procedural rooms including endoscopy units: 68-73 [degrees] F." The policy further reflected "...OR staff will check temperature...before the beginning of the first case and enter it in the log. If temperature...[is] not within range, OR staff will notify Facilities and Infection Prevention...If after, making all possible adjustments and the levels are still not within the acceptable range within 45 minutes, make the following notifications...Notify the Manager or Supervisor in the affected areas of the condition so they can make appropriate clinical decisions..."

b. Temperature logs for Central Processing for December 2015, January 2016 and February 2016 were reviewed. The temperature was recorded once a day on 18 days in February 2016. Documentation on the logs reflected that all 18 temperatures were outside the required temperature range and there was no evidence of actions taken in accordance with CAH policy. Examples included but were not limited to the following:
On 02/01/2016 at 1230 the temperature was recorded "81.5";
On 02/03/2016 at 0945 the temperature was recorded "82.0";
On 02/04/2016 at 1000, 02/08/2016 at 0830, 02/09/2016 at 0900, and 02/24/2016 at 0930 the temperature was recorded "80.0";
On 02/11/2016 at 0800 the temperature was recorded "79.4";
On 02/012/2016 at 0710 the temperature was recorded "79.5";
On 02/16/2016 at 0700 the temperature was recorded "79.9"; and
On 02/18/2016 at 0810 the temperature was recorded "79.6."
Similar elevated temperatures were identified during review of temperature logs for Central Processing for December 2015 and January 2016.

c. Temperature logs for the OR for December 2015, January 2016 and February 2016 were reviewed. The temperature was recorded once a day for 11 days in February 2016. Documentation on the logs reflected that all 11 temperatures were outside the required temperature range and there was no evidence of actions taken in accordance with CAH policy. Examples included but were not limited to the following:
On 02/01/2016 at 1218 the temperature was recorded "67.8";
On 02/02/2016 at 0655 the temperature was recorded "64.7";
On 02/05/2016 at 0652 the temperature was recorded "65.1";
On 02/17/2016 at 1716 the temperature was recorded "64.9"; and
On 02/20/2016 at 1839 and on 02/22/2016 at 0420 the temperature was recorded "65.4."
Similar temperatures were identified during review of temperature logs for the OR for December 2015 and January 2016.
This report reflects the findings of an unannounced, onsite EMTALA complaint investigation #OR10191. The hospital was evaluated for compliance with CFR 489.20 through 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases. The deficiencies identified are contained in this report.

The following abbreviations and acronyms may be used in this report:

AMA = Against Medical Advice
CFR = Code of Federal Regulations
CNO = Chief Nursing Officer
CXR = Chest X-Ray
ED or ER = Emergency Department/Emergency Room
EMC = Emergency Medical Condition
EMTALA = Emergency Medical Treatment and Active Labor Act
HH = Home Health
LIP = Licensed Independent Practitioner - MD and RN NP
MD = Physician or Doctor
MICU = Medical Intensive Care Unit
MSE = Medical Screening Examination
NP = Nurse Practitioner
Oxygen saturation = The level of oxygen carried by red blood cells through the arteries and delivered to internal organs. A low saturation level could indicate a respiratory illness or other medical condition.
OHSU = Oregon Health Sciences University
PHRMH = Providence Hood River Memorial Hospital
pt = Patient
Pulse oximeter = A medical device for monitoring a patient's oxygen saturation levels.
RN = Registered Nurse
SBAR = Situation, Background, Assessment, Recommendation








d. Temperature logs for the procedure room for December 2015, January 2016 and February 2016 were reviewed. The following temperatures recorded were outside the temperature range reflected in the CAH's policy:
On 02/11/2016 at 0839 the temperature was recorded "74.1";
On 02/12/2016 at 1028 the temperature was recorded "74.8"; and
On 02/30/2016 at 0700 the temperature was recorded "74.4."

8. a. Refer to the findings at Tag C221, CFR, 485.623(a), Construction, that reflects that a construction project was underway in the corridor of the Outpatient Rehabilitation Department.

b. During an interview with the Director of IP on 03/11/2016 at 1000 he/she stated the plywood doors leading to the construction work areas in the Outpatient Rehabilitation Department corridor had not been maintained in accordance with CAH IC policies and procedures. He/she stated that appropriate door handles or closures were not in place to ensure those areas were secure and that negative pressure was maintained.

Based on interview, review of documentation in five of 21 medical records reviewed (Patients 10, 14, 16, 19, and 20), and review of policies and procedures it was determined that the CAH failed to ensure that medical records were complete and accurately documented. Patient care documentation in medical records was not complete, clear or accurate in the following areas:
* Care and services provided to a registered outpatient in response to a change of condition;
* Timely pre-operative H&P, H&P update, and post-operative physician notes; and
* Timely, clear, and complete blood transfusion vital signs.

Findings include:

1. a. The medical record of Patient 10 was reviewed. The record reflected the patient was admitted on 03/09/2016 at 1002 for outpatient radiology services. The admitting complaint/diagnosis was unclear as it was "Other Specified Counseling." A physician's order electronically signed and dated on 03/03/2016 at 1655 reflected "...Radiology-paracentesis every 2 weeks starting on or around 3/11/2016..."

A "Miscellaneous Exam Worksheet" was dated "3-9-16" but was not timed. An ultrasound tech's entries on the form were initialed but not dated and timed. The handwritten notes on the worksheet reflected "10 lites (sic) of redish (sic) fluid removed. Vitals stable post procedure until Pt. sat up. Upon sitting up pt. became light headed, then became non responsive. [He/she] was transferred (sic) to ED & monitored. [Physician] met [with] Pt. when [he/she] stabalised (sic) & Pt. was released to go home."

A physician procedure note electronically signed and dated on 03/09/2016 at 1438 reflected the following: "Successful ultrasound guided paracentesis. 10 liters of reddish tinged fluid was removed and discarded. The patient's vital signs were stable until the patient sat up. Upon sitting up, the patient became lightheaded and nonresponsive. The patient was transferred to the emergency department and resuscitated without complication. After the patient was stabilized in the ED, the patient was released."

The only documentation of care and services provided in the ED was an ECG reading dated 03/09/2016 at 1203 that reflected the ECG was performed in the ED. There were no physician's orders or other clinical documentation for care and services rendered in the ED.

b. In response to multiple requests for all medical record documentation for Patient 10, on 03/10/2016 at 1400 the QIC provided a copy of an email dated and timed on 03/10/2016 at 1327. It contained a computer screenshot of an RN's ED note for Patient 26, who was not Patient 10. The QIC stated that the ED RN entered the note in the wrong patient's record.

The note was dated 03/09/2016 at 1216 and reflected "1200 was called to U/S room for a pt unresponsive. [Physician] too (sic) 10 liters of paritenal (sic) fluid from a tap. Glucose was taken, 115, did have several episodes of temors (sic), came around but not oriented, taken to ER VS 124/86 87 20 100RA, pt woke up with nurse getting ready to start IV and [he/she] refused. Is staying Oriented x 3 now, [family] at bedside. is (sic) able to sip OJ."

c. The medical record of Patient 10 lacked:
* Evidence of the vital signs referred to in the various notes;
* The time the ultrasound procedure was started;
* The time the ultrasound procedure was completed;
* The time of the patient's change of condition;
* The time the patient was "transferred" to the ED;
* Physician's orders for care and services rendered in the ED;
* The extent of the "resuscitative efforts" in the ED;
* The time the patient was discharged;
* Where the patient was discharged from;
* The patient's condition at discharge; and
* Discharge instructions provided to the patient.

In addition, the RN documented information about Patient 10's change of condition in the medical record of Patient 26.

d. An interview was conducted with the QIC on 03/11/2016 at 1255. He/she acknowledged the medical record was unclear. The QIC stated "This is an opportunity for us."

2. The medical record of Patient 14 reflected he/she was admitted to the hospital on 01/18/2016 for a liver biopsy. The medical record contained a physician's H&P that was completed in a physician's office on 10/27/2015.

An "Outpatient/Perioperative Physician's Record & H&P Exam Update Note" form in the medical record was divided into three sections. The first section of the form contained the following statement: "I hereby certify that the patient's relevant history and physical examination is substantially unchanged from the dated and time I or _____ performed the examination on _____." The fields in that section of the form were blank but that section was signed by a physician and was dated and timed as 01/18/2016 at 0811.

The second section of the form contained the following statement: "Document any relevant history and/or physical information which has changed prior to admission/procedure or complete in its entirety when H&P is greater than 30 days." That section contained multiple fields which comprised a H&P to be recorded prior to surgery. Although the only H&P in the record had been conducted more than 30 days prior, on 10/27/2015, the fields in that section of the form were not completed and were blank. That section was signed by the physician and dated and timed as 01/18/2016 at 0816.

The third section of the form was for documentation of the operative note to be recorded after surgery. Although the fields in that section of the form had not been completed a handwritten entry in the section denoted "See dictation..." That section was signed by the physician and was dated and timed as 01/18/2016 at 0811, the same time as the signature in the first section of the form, and prior to the signature in the second section of the form.

3. The medical record of Patient 16 reflected he/she received a blood transfusion that was started on 11/09/2015 at 0725 and was stopped at 1000. The "Transfusion Record" contained spaces for vital signs to be recorded during the transfusion to monitor the patient's condition. Vital signs recorded at 0840 were incomplete and lacked the temperature and respirations. It was not clear what time the next set of vital signs were recorded. The time was during the 9:00 a.m. hour, but the minute portion of the time had been altered by a writeover. That set lacked the temperature and respirations.

4. The medical record of Patient 19 reflected he/she received a blood transfusion that was started on 12/17/2015 at 1214 and was stopped at 1450. The "Transfusion Record" contained spaces for vital signs to be recorded during the transfusion to monitor the patient's condition. It was not clear what time the second set of transfusion vital signs were recorded. The time was during the 12:00 hour, but the minute portion of the time had been altered by a writeover.

Patient 19 received a second blood transfusion that was started on 12/17/2015 at 1625 and was stopped at 2010. The temperature value recorded for the vital signs at 1820 had been altered by a writeover. In addition, vital signs recorded in the "3 Hours After Start" space on the transfusion form were recorded at 2010, three hours and forty-five minutes after the transfusion start.

5. The medical record of Patient 20 reflected he/she received a blood transfusion that was started on 01/22/2016 at 1722 and was stopped at 2003. Vital signs recorded at 1811 lacked the temperature and respirations. Blood pressure readings recorded at 1811 and 1911 had been altered by writeovers.





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