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Based on record review and interview, the Critical Access Hospital failed to provide Medicare patients with a notice regarding their right to appeal before being discharged as required by federal regulation for two out of four patients reviewed (Patients #1 and #6).

Failure to provide this notice to Medicare patients limits patients' ability to contest their discharge and to appeal to a quality improvement organization.

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.

Findings:

1. Review of the records of two patients revealed the following:

a. Patient #1 was a 94 year old admitted for a swing bed stay on 1/9/2015. The "Important Message from Medicare" information form was signed by the patient on 1/17/2015.

b. Patient #6 was a 69 year old admitted for a swing bed stay on 1/14/2015. The "Important Message from Medicare" information form was signed by the patient on 1/19/2015.

2. An interview on 1/22/2015 at 4:00 PM with the clinical nurse manager (Staff Member #1) confirmed the above findings.

Based on observation and interview the Critical Access Hospital failed to ensure that medications used in emergency carts were maintained so the expired items were not available for patient use.

Failure to properly maintain emergency carts puts patients at risk of having an outdated drug available for patient use.

Findings:

1. On 1/20/2015 at 1:20 PM in the medical-surgical unit, Surveyor #2 found one vial of Glucagon 1mg injectable with an expiration date of 11/2014 in the crash cart.

2. On 1/21/2015 at 8:40 AM in the emergency room, Surveyor #2 found the following items in the crash cart: four 5ml syringes of 2% lidocaine with an expiration date of 12/1/2014; two syringes of ephedrine 50mg/ml with an expiration date of 12/2014; one 500ml intravenous bag of lidocaine 4mg/ml with an expiration date of 11/2014 and one intravenous bag of dobutamine 1000mcg/ml in 5% dextrose in water with an expiration date of 11/2014. In addition, Surveyor #2 found one 20ml vial of 1% lidocaine with epinephrine with an expiration date of 7/2014 in the chest tube insertion kit and one 20ml vial of 1% lidocaine with epinephrine with an expiration date of 1/1/2015 in the central line kit.

3. An interview on 1/21/2015 at 8:40 AM with the clinical nurse manager (Staff Member #1) confirmed the above observations.

4. On 1/22/2015 at 7:30 AM in the operating room, Surveyor #2 found one 50ml syringe of 8.4% sodium bicarbonate with an expiration date of 5/2014 in the crash cart. This finding was confirmed at the time of observation with the surgery manager (Staff Member #2).

Based on observation, interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a current comprehensive emergency preparedness plan to ensure the safety and well-being of patients during emergency situations and/or events.

Failure to develop and implement a current emergency preparedness plan places the safety of patients, staff and visitors of the facility at risk during non-medical emergencies.

Findings:

1. On 1/22/2015 at 2:40 PM, Surveyor #3 reviewed the hospital's emergency preparedness plan for the year 2003. The plan was not current, was not comprehensive and it did not contain an assessment of the most likely non-medical emergency events facing the facility and/or immediate area. And, the plan did not include guidance on how the facility would respond to emergency situations and events identified as the most likely to occur.

2. On 1/22/2015 at 2:55 PM during an interview between Surveyor #3 and a healthcare access associate (Staff Member #3), the staff member confirmed that the hospital's emergency preparedness plan was not current and did not contain all required information. S/he further indicated that the plan was reviewed in 2014 and is currently being revised.

Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION LIFE SAFETY CODE inspection reports.

Based on document review, the critical access hospital failed to ensure that its patient care policies received an annual review by the hospital's professional health care staff.

Failure to conduct an annual policy review puts patients at risk of unsafe or inadequate care.

Findings:

On 1/21-23/2015, Surveyor #2 reviewed the hospital's patient care policies and found several cover sheets that contained the most recent review dates for individual department policies. Several of the documented dates indicated staff members had not reviewed the policies within the last year: Examples of the out-of-date policies include:

a. Hospital department policy cover sheet titled "Swing Bed" last reviewed 3/1/2013.

b. Hospital department policy cover sheet titled "Emergency" last reviewed 3/1/2013.

c. Hospital department policy cover sheet titled "Surgery Department" last reviewed 6/26/2013.

d. Hospital department policy cover sheet titled "Anesthesia Department" last reviewed 6/26/2013.

Based on observation and interview, the Critical Access Hospital failed to ensure staff followed recognized infection prevention practices in order to provide a sanitary healthcare environment.

Failure to provide a sanitary healthcare environment puts patients at risk of infection.

Reference: Association for Professionals in Infection Control and Epidemiology, Inc.; APIC Text of Infection Control and Epidemiology 2nd Edition, January 2005.

Findings:

On 1/22/2015 at 10:30 AM, Surveyors #1 and #3 observed the surgical team performing a between case cleaning of operating room #1. During the course of the cleaning procedure it was noted that a surgical technician (Staff Member #4) cleaned the overhead surgical lights after cleaning equipment and horizontal surfaces located directly under the surgical lights. This sequence of events is contrary to the recognized practice of cleaning from top to bottom and from clean to dirty. The surgical technician acknowledged this finding at the time of the observations.

Based on record review, review of hospital policies and procedures and interview, the Critical Access Hospital failed to ensure admission nutritional screening and assessments were complete according to facility policy for five of eight patients (Patients #1, #2, #3, #4 and #5).

Failure to assess patients for dietary needs places patients at risk of delayed treatment of nutrition deficiencies.

Findings:

1. The hospital's policy and procedure titled "Standard Screening" (undated) read in part:
"Ocean Beach Hospital will screen patients admitted for anticipated length of stay longer than 24 hours for nutritional risk. . . A. A certified dietary manager will screen patients within 24 hours of admit, Monday - Friday 8 - 4:30 PM."

2. Review of the records of five patients revealed the following:

a. Patient #1 was a 94 year old patient who had been admitted on 11/6/2014 for foot infection. Staff members did not complete the initial nutritional screening and assessment until 11/10/2014.

b. Patient #2 was a 92 year old patient who had been admitted on 11/20/2014 for left total hip repair. Staff members did not complete the initial nutritional screening and assessment until 11/25/2014.

c. Patient #3 was a 67 year old patient who was admitted on 9/18/2014 for metastatic cancer. Staff members did not complete the initial nutritional screening and assessment until 9/22/2014.

d. Patient #4 was an 83 year old patient who was admitted on 12/19/2014 for dementia. There was no documentation to indicate staff members had performed a nutritional screening.

e. Patient #5 was a 60 year old patient who was admitted on 1/14/2015 for diabetic ketoacidosis. Staff members did not complete the initial nutritional screening and assessment until 1/20/2015.

3. An interview on 1/22/2015 at 4:00 PM with the clinical nurse manager (Staff Member #1) confirmed the above findings.

Based on record review, review of hospital policies and procedures and interview, the Critical Access Hospital failed to ensure that hospital staff completed swing bed admission activity assessments for one of four patients reviewed (Patient #1).

Failure to develop and implement an activity plan for long-term care puts patients at risk of physical, mental, and psychosocial impairment.

Findings:

1. The hospital's policy and procedure titled "Activity Program" (Revised 12/12/2008) read in part: "2. Activity Director will review needs of the patient and complete Activities Assessment. 3. Activity Director will indicate appropriate activities on patient care plan."

2. On 1/21/2015 at 11:30 AM, Surveyor #2 interviewed the clinical nurse manager (Staff Member #1). Staff Member #1 confirmed that it was facility policy to assess swing bed patients for activity interests, and have the Activity Director develop an activity plan for these patients.

3. On 1/22/2015 at 10:00 AM, a review of the medical records of four swing bed patients revealed one of four records with no documentation of a comprehensive activities assessment and no evidence that staff members developed a patient activity plan.

Based on interview, record review and review of hospital policies and procedures, the critical access hospital failed to develop an individualized nursing care plan for patient care for two of four swing bed patients reviewed (Patients #2, #3).

Failure to develop an individualized plan of care that includes care interventions can result in the inappropriate, inconsistent or delayed treatment of patient's needs.

Findings:

1. The hospital's policy and procedure titled "General Operational Guidelines -Swing Bed Program" read in part: "2. Once the Resident Admission Assessment Form is completed, the RN and Charge Nurse with oversight from the Clinical Nurse Manager will develop a Care Plan within 7 days of completion of the admission assessment."

2. On 1/22/2015 at 10:00 AM, a review of the medical records of four swing bed patients revealed two of four records with no documentation of a nursing care plan.

3. During an interview with Surveyor #2 at the time of the record review, the clinical nurse manager (Staff Member #1) confirmed the absence of nursing care plans for Patients #2 and #3.