HospitalInspections.org

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Based on interview and review of patient rights information, the Critical Access Hospital failed to provide written notice to patients that a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) was not present in the hospital 24 hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference:

42 CFR 489.20(w): "(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay, or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay, or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. On 05/20/21 at 2:25 PM, Surveyor #1 and #4 interviewed the hospital's acute care charge nurse (Staff #104). During the interview, staff #103 indicated that they did not have MD or DO on site 24 hours per day 7 days per week. Surveyor #1 asked what documentation is given to the patient indicating a MD or DO is not on site 24 hours per day 7 days per week. Staff #103 handed a packet to surveyor #1. Review of the documents showed that the disclosure notification to patients that an MD or DO is not on-site twenty-four hours per day, seven days per week was not mentioned.

2. On 05/20/21 at 3:00 PM, Surveyor #1 interviewed the hospital's Direct Nursing Supervisor (Staff #105). During the interview, the CNO indicated that they did not have MD or DO on-site 24 hours per day 7 days per week and handed a blank patient consent form that would indicate that information to Surveyor #1.

3. Review of the consent form revealed that it did not include written notice to patients that an MD or DO is not present in the hospital 24 hours a day, seven days per week. Staff #105 provided another consent form with the disclosure notification that a MD or DO is not on-site 24 hours per day 7 days per week. This consent form was not currently being used in the hospital.

4. On 05/20/21 at 3:10 PM, Surveyor #1 and Staff #105 toured the facility entrance; the acute care area, and emergency department. Surveyor #1 and Staff #103 were not able to locate any signage that would indicate an MD or DO is not on site 24 hours/ 7days per week. The hospital did not have a process for informing patients how the hospital would meet the medical needs of any patient who develops an emergency medical condition when a physician is not present.

5. At the time of the inspection, Staff #105 confirmed the lack of signage indicating that an MD or DO is not on site 24 hours a day, 7 days a week.
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Based on observation, interview and document review, the hospital failed to ensure appropriate utilization of its 25 Certified Critical Access Hospital beds.

Failure to appropriately utilize Certified Critical Access Hospital beds creates risk of limited capacity for inpatient and swing patient care resulting from poor resource allocation.

Findings included:

1. The Critical Access Hospital failed to ensure that Certified Critical Access Hospital beds were used only for the care of inpatients, swing-bed patients, or observation patients according to Critical Access Hospital regulatory requirements.

Cross Reference: C-0902

The cumulative effect of these deficiencies resulted in the provision of substandard care to the hospital's swing-bed patients. The Condition of Participation for: Number of Beds and Length of Stay was NOT MET.

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Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that Certified Critical Access Hospital beds were used for inpatients, swing-bed patients or observation patients according to Critical Access Hospital regulatory requirements.

Failure to appropriately utilize Certified Critical Access Hospital beds creates the risk that the facility will exceed its capacity for patient care, which may result in poor patient outcomes due to inadequate care or poor resource allocation.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Acute Care and Booker Rest Home Swing Bed," policy number 384, effective date 11/03/20, showed that Swing Bed Services are designed to meet the needs of patients requiring skilled nursing care and/or rehabilitation services.

Document review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 03/01/19, showed that patients may be admitted to the Hospital for Acute Care, Observation, or Swing bed (Skilled Nursing or Rehab Care) only by a physician member of the hospital staff.

Document review of the hospitals floor plans titled, "Overall Floor Plan," showed that CAH beds #1 through #13 were located in the Acute Care area of the CAH and CAH beds #201 through #212 were located in the Booker Rest Home Hallway #1. The total number of CAH beds equaled 25.

2. On 05/18/21, Surveyor #5 and Surveyor #10 toured the Critical Access Hospital (CAH). The bed count showed 13 CAH beds physically located in the Acute Care area of the CAH and 12 beds physically located in the Booker Rest Home Hallway #1 area of the hospital.

3. On 05/18/21 at 9:40 AM, during interview with Surveyor #5, the Director of Nursing for Acute Care (Staff #501) stated that 13 Swing Beds were located in the Acute Care area of the hospital and 12 Swing Beds were located in the Booker Rest Home area. The 12 beds in the Booker Rest Home were utilized for "Custodial Care patients" who required Long-Term Care. The patients located in the Booker Rest Home received care under the Long-Term Care Skilled Nursing Facility Regulations and were not billed under Medicare.

4. On 05/18/21 at 2:15 PM, the hospital's Chief Executive Officer (Staff #507) stated that the patents located in the Booker Rest Home Swing Beds had depleted their 100-day Medicare Benefits. The hospital received financial reimbursement for the patients as "custodial swing bed patients" and these patients were placed in the hospital's Swing Beds located at the Booker Rest Home and care was provided based on Booker Rest Home Long-Term Care requirements.

5. On 05/19/21 at 10:43 AM, Surveyor #5, the Director of Nursing for Booker Rest Home (Staff #503), and the Social Services Designee for the Booker Rest Home (Staff #504) reviewed the medical records for swing bed patients located in the Booker Rest Home, including Patient #505, #507, and #510. Staff #503 stated that the Patients located in beds #201 through #212 in the Booker Rest Home were referred to as "Booker Swing Patients." Staff #503 verified that the patients were located in beds that were certified by the hospital's licensed "Swing Beds Program." Staff #503 stated that the 13 "Swing Beds" located in the hospital were Supervised by the Director of Nursing for Acute Care (Staff #501), and the "Swing Bed" patients located in the 12 rooms in the Booker Rest Home were Supervised by the Director of Nursing for Booker Nursing Home (Staff #503). Staff #503 stated that the Booker Rest Home Swing patients were "Custodial Care Patients," and were long-term care residents without plans to discharge.

6. At the time of the observation, Staff #503 verified that Patient #505, #507, and #510 were all "Booker Swing Bed" patients. She verified no admission orders for Patient #505 and #507. She verified that the orders for Patient #510 were for admission to the Booker Rest Home. Staff #503 stated that the patients were "Custodial Care" patients. Staff #503 stated that patients moved back and forth between the Booker Rest Home Long Term Care and the Swing Bed Program.

Staff #503 stated that it was not the practice to write admission/transfer or discharge orders when patients were transferring back and forth between the Long-Term Care and the Swing Bed Program. She stated that any further patient record review would show the same findings.

7. On 05/19/21, Surveyor #10 reviewed the electronic medical record review for 3 patients (Patient #1001, #1002 and Patient #1003). The admission orders for all 3 patients showed the patients were admitted to Booker Rest Home not to the Swing-Bed program. Patient #1001, #1002 and #1003 were occupying beds in the Critical Access Hospital (CAH) Swing Bed Program for Dayton General Hospital.

8. On 05/19/21 at 11:30 AM, during an interview with a Licensed Practical Nurse (LPN) (Staff #1006). Staff #1006 stated that the patients are residents of Booker Rest Home and not CAH patients.

9. On 05/20/20 at 9:00 AM, Surveyor #10 interviewed the Director of Nursing for Acute Care (Staff #1011) and Director of Nursing for BRH (Staff #1009). Staff #1011 and Staff #1009 verified that there would not be admitting orders for swing bed patients who are residents of BRH. Additionally, Staff #1011 and Staff #1009 confirmed that the patients residing at BRH are permanent residents of BRH.

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Based on observation, interview, and document review, the hospital failed to ensure that all facility and medical equipment is listed in an inventory which includes a record of maintenance activities.

Failure to maintain a complete inventory of equipment deemed safe to use and with record of preventative maintenance puts patients and staff at risk of injury or harm.

Findings included:

1. Document review of the hospital's policy titled, "Prevention of Electrical Accidents," policy number 326, effective 07/09/19, showed that any electrical equipment will be inspected by the Maintenance Department prior to being placed into use.

2. On 05/18/21 at 10:30 AM, Surveyors #1 and #4 inspected the Emergency Department (ED) with the Facilities Director (Staff #401). Surveyors observed 2 Philips Respironics Trilogy EV300 ventilators in the ED equipment area that did not have any asset/ID tags or preventative maintenance (PM) stickers. Staff #401 indicated he was not familiar with the equipment.

At the time of the observation, the Respiratory Therapy (RT) Manager (Staff #407) stated the hospital had received the 2 ventilators in January 2021, and that he had set the units up as CPAP machines for patient use. Staff #407 stated he was performing quality checks on the units when being used for patients. Staff #401 confirmed these units were not in the hospital inventory at the time of surveyor observation. Staff #401 had the hospital's BIOMED equipment contractor perform initial inspection/PM on the units later that same day, 5/18/21.

4. On 5/18/21 at 3:15 PM, Surveyors #1 and #4 and Staff #401 went to the clean linen room in the Booker Nursing Facility (also utilized by the critical access hospital swing bed patients). Surveyors observed a Pedigo P-2032 Warming Cabinet without ID tag or PM sticker.

5. At the time of the observation, Staff #401 confirmed the item was missed on the inventory and had not had PM done.
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Based on observation, interview, and document review, the hospital failed to ensure that dietary staff members implemented procedures for food safety consistent with the Federal Drug Administration Food Code.

Failure to implement the food safety requirements puts patients, staff, and visitors at risk for development of food borne illness.

Findings included:

1. Document review of the hospital's policy titled, "Food Temperatures," policy number 585, reviewed 04/13/20, showed that all hot foods must be cooked to an appropriate internal temperature, held and served at a temperature of at least 135 degrees Fahrenheit (F).

2. On 05/18/21 between 11:45 AM and 1:00 PM, the Dietary Manager (Staff #402), the Assistant Dietary Manager (Staff #403), Surveyor #1, and Surveyor #4 inspected the hospital's dietary services kitchen. During the inspection, surveyors used a thin-stemmed thermometer to assess the internal temperature of Potentially Hazardous Food (PHF) in the "steam line" hot holding case of the kitchen. The temperature of the PHF was below 135 degrees F.

3. Surveyors interviewed Staff #403 about the process for hot holding of PHF. Staff #403 stated she cooked the PHF to 165 degrees F, verified by thermometer (but not documented), then moved the PHF directly to the steam line for hot holding. Staff #403 confirmed the temperature of the PHF was below 135 degrees F and discarded the food.

Reference: Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. 2009 Food and Drug Administration Food Code (FDA) (3-501.16(A)(1)), Washington State Retail Food Code, WAC 246-215-03525.

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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

Failure to establish and implement policies and procedures for hospital services provided to all patients admitted to the hospital risks substandard and inconsistent care which can lead to negative patient outcomes.

Findings included:

1. Failure to ensure that policies and procedures for swing bed patients were consistent throughout all areas of the hospital.

2. Failure to follow best practices based on nationally recognized organizations for blanket warmer cabinets.

Cross Reference: C 1006

3. Failure to ensure guidelines addressing consultations were developed and implemented.

Cross Reference: C 1014

4. Failure to ensure that a designated pharmacist had overall oversight of the entire CAH.

5. Failure to ensure that a designated pharmacist was responsible for medication management, quality processes for control, distribution, storage, and security are implemented for the CAH.

6. Failure to ensure medication storage areas were devoid of outdated or otherwise unusable medications.

7. Failure to ensure record keeping for the receipt and disposition of all controlled substances.

Cross Reference: C 1016

8. Failure to maintain a list of services describing the nature and scope of the services provided by the contractors.

Cross Reference: C 1042

9. Failure to oversee the performance of all patient care services and departments.

Cross Reference: C 1044

10. Failure to ensure that a Registered Nurse was designated responsible for all Nursing Services for the Critical Access Hospital.

Cross Reference: C 1046

11. Failure to ensure an effective process for patient identification.

12. Failure to assess and reassess a patient's pain.

Cross Reference: C 1049

13. Failure to develop an individualized plan of care.

Cross Reference: C 1050

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.

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Item # 1 Policies Directing Care of Swing Bed Patients

Based on record review and interview, the Critical Access Hospital (CAH) failed to ensure that policies directing care of swing bed patients were uniform for all swing bed patients in the CAH.

Failure to ensure that policies and procedures for swing bed patient are consistent throughout all area of the hospital risks inadequate care from potentially contradictory patient care policies.

1. Document review of the Critical Access Hospital's policy titled, Discharge Planning for Booker Residents," policy number 190, effective 11/11/19, showed that the facility will develop a discharge plan for effectively discharging Booker Rest Home (BRH) and Long term Care Custodial Residents residing in Hall One Swing Beds back into the community. The policy does not reference the swing bed patients located in the acute care unit at Dayton General Hospital (DGH).

2. Document review of the Critical Access Hospital's policy titled, "Discharge of an Acute/Swing Bed Patient," policy number 67, last reviewed 08/08/19, addressed only swing bed patients located at DGH and does not reference swing bed patients located in BRH.

3. Document review of the Critical Access Hospital's policy titled, "Swing Bed Service," policy number 384, no date, showed that all Swing Bed patients will be seen by the attending physician at least once every seven (7) days. This will be documented in the record under physician progress notes in the Acute Care Dept. The Long-Term Care Swing Bed Patients located in Booker Rest Home will be seen by the attending provider on admission, every 30 days for 90 days, then every 60 days thereafter, and as needed.

4. On 05/18/21 at 9:40 AM, during interview with Surveyor #5, the Director of Nursing for Booker Rest Home (Staff #505) and the Director of Nursing for Acute Care (Staff #501) stated that Staff #501 was responsible for the Swing Bed program located in the Acute Care area of the hospital and Staff #505 was responsible for the Swing Bed patients located in the Booker Rest Home area. The care and treatment of patients in the different locations were provided utilizing different policies and procedures that each Nursing Director was responsible for (Acute Care or Booker). The Swing Bed patients located in the Booker Rest Home received care under policies and procedures for the Booker Rest Home Long-Term Care facility. Patients located in the Booker Rest home area were long term patients that required 24-hour care.

5. On 05/18/21 at 10:00 AM, during interview with Surveyor #5, the Assistant Nursing Director for Booker Rest Home (Staff #503) stated that the patients located in the Booker Rest Home Swing beds were "Custodial Care" patients that received care under the Long-Term Care rules which were a higher level of rules than CMS. Staff #503 stated that the patients were not billed under Medicare but billed under Medicaid or Private Insurance.
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6. On 05/21/21 at 9:00 AM, Surveyor #10 interviewed the Director of Nursing of Acute Care for Dayton General Hospital (DGH) (Staff # 1011). Staff #1011 confirmed that swing bed patients located in the acute care unit at DGH do not share all the same policies that would govern swing bed patients located at Booker Rest Home (BRH).

7. At this same time, Surveyor #10 also interviewed the Director of Nursing for the BRH (Staff #1009). Staff #1009 stated that the 12 swing beds patients (Patients #1001, #1002, #1003, #1004, #1005, #1006, #1007, #1008, #1009, #1010, #1011, and #1012) residing at BRH are permanent residents with no plans for discharge. Staff #1009 verified that the swing bed patients located at BRH do not share the same policies that would govern swing bed patients located in the DGH acute care unit.

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Item #2 Patient Care Equipment

Based on observation, interview, and document review, the hospital failed to develop policies and procedures based on nationally recognized organizations for the use of patient care equipment.

Failure to follow best practices based on nationally recognized organizations for blanket warmer cabinets places patient at risk of burns.

Reference: Evidence-based guidelines and recommendations by organizations such as but not limited to Association of peri-Operative Registered Nurses (AORN) and Emergency Care Research Institute (ECRI) to determine optimal and safe temperatures for blankets warmers. Both AORN and ECRI recommend not to exceed maximum temperature setting of 130 degrees Fahrenheit (54 degrees Celsius) for blanket warming cabinets.

Reference: PEDIGO Model number #P2032 Blanket Warming Cabinet Operations and Care Manual; Page 7 Guidance and Manufacturer's Declaration, indicated that the essential performance of the appliance is to not exceed an internal temperature of 180F degree Fahrenheit for blanket warmers of 150 F degrees for fluid warmers. The operation manual does not provide safe temperature settings for the prevention of patient burns.

Findings included:

1. On 05/18/21 between the hours of 3:00 PM and 3:30 PM, Surveyor #1 and #4 observed 2 blanket warmer cabinets with different temperature settings. The blanket warmer cabinet in the "Booker" patient care area indicated a temperature of 145 degrees Fahrenheit. The blanket warmer cabinet in the emergency department indicated a temperature set at 120 degrees Fahrenheit.

2. During the observation Surveyor #1 interviewed the Nurse Manager (Staff #103) and requested to see the policy and procedures and manufacturer's instructions for use for the blanket warmer cabinet in the "Booker" patient care area. Staff #103 provided the manufacturer's instructions for use that did not indicate temperature recommendations for safe patient use. Staff #103 confirmed that policy and procedures based on best practices based on nationally recognized organizations were not developed.
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Based on document review and interview, the hospital failed to develop and implement policies and procedures for the medical management of health problems that included conditions requiring a medical consultation, situations and circumstances requiring consultations, and/or referral for care outside the hospital.

Failure to ensure guidelines addressing consultations are developed and implemented risks delayed care, inappropriate care, and poor patient outcomes.

Findings included:

1. On 05/19/21 at 1:30 PM, Surveyor #5 and the Director of Nursing Services for Acute Care (Staff #501) inspected the hospital's Emergency Department. During discussion with the Staff #501, Surveyor #5 asked under what circumstances would a consultation with medical staff or other professional healthcare staff, or referral outside the hospital should occur and specifically, what types of medical conditions require mid-level providers to get a consultation. Staff #508 stated that she did not know but she would investigate and provide the Surveyor with a copy of the hospital's policy.

2. On 05/20/21 at 2:05 PM, Staff #501 provided Surveyor #5 with a policy titled, "Non-Physician Provider Guidelines for calling Physician Back Up," reference number 4463, effective date "Not Approved Yet." Staff #501 stated that the policy had not been implemented as the hospital's Medical Staff felt that mid-level providers would know if they needed to get a consultation.

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Item #1 Pharmacy Oversight

Based on observation, interview, and document review, the Critical Access Hospital (CAH) failed to designate an individual who has overall oversight for the CAH's pharmacy services.

Failure to ensure that a designated pharmacist has overall oversight, entire CAH could lead to poor patient outcomes related to drug therapy.

Findings included:

1. Document review of the hospital's contracts titled, "The 340B Program Contract Pharmacy Service Agreement," effective date 10/20/16, is by and between Elk Drug, Inc. a Washington State corporation ("pharmacy") and Dayton General Hospital 1. This is an offsite pharmacy service, which per the contract with the facility, provides services to the Booker Rest Home (BRH) Long Term Care Facility of the Critical Access Hospital which includes 12 hospital Swing Bed patients located on the Long-Term Care unit.

2. Document review of the hospital's contracts titled, "Agreement for Remote Pharmacist Services," effective date 09/24/20, is by and between Pipeline Health Holdings, LLC ("pharmacy") and Dayton General Hospital 1. This is a remote pharmacy service, which per the contract with the facility, provides services to the Critical Access Hospital which includes swing bed patients. The contract shows that, "Pipeline shall provide a Pharmacy Director responsible for oversight of the performance of the pharmacy services."

3. Document review of the hospital's policy titled, "Pharmacy Duties in (BRH)," policy number 3983, effective date 03/27/17, showed the purpose of the policy is to ensure that a licensed pharmacist is available to provide pharmacy services to Booker Rest Home per WAC 388-97-1300, WAC 246-865-050, RCW 483.45 Pharmacy Services and the assigned agreement with Elk Drug for pharmacy services in BRH.

a. On 05/19/21 at 2:30 PM, Surveyor #10 inspected the medication room at Booker Resident Home (BRH) and interviewed the Director of Nursing of BRH (Staff # 1009). Staff #1009 verified that Elk Drug has oversight and is responsible for all the pharmacy services at BRH. Staff #1009 confirmed that BRH follows different policies and procedures for pharmaceutical services for their swing bed patients residing at BRH than the swing bed patients located in the CAH Acute Care area.

b. On 05/19/21 at 2:45 PM, Surveyor #10 interviewed the Director of Nursing of Acute Care Service (Staff #1011) at Dayton General Hospital. Staff #1011 stated that the pharmacist (Staff #1008) has oversight of all units at Dayton General Hospital including the Acute Care and the Swing Beds located in the Acute Care. Staff #1008 also confirmed that Elk Drug oversees the Pharmacy Services for the swing bed patients residing at BRH and that Pipeline provides after hours services and does not have oversight of Pharmacy Services for Dayton General Hospital 1. The Pharmacy Director for Dayton General Hospital does not oversee any pharmacy services for Booker Rest Home where 12 Critical Access Hospital beds are located. At the time of the Survey, 12 Swing Bed patients were located in the Booker Rest Home Swing Beds.

Item #2 Storage, Handling, Dispensing, Procurement and Administration ff Drugs and Biologicals for the Entire CAH.

Based on observation, document review, and interview, the Critical Access Hospital (CAH) failed to have written patient care policies addressing storage, handling, dispensing, and administration of drugs and biologicals for the entire CAH.

Failure to ensure that a designated pharmacist is responsible for medication management, quality processes for control, distribution, storage, and security for the CAH could lead to poor patient outcomes related to drug therapy.

Findings included:

1. Document review of the hospital's policy titled, "Monthly Inspections of Areas where drugs are dispensed, administered or stored" policy number 4311, last reviewed 02/01/21, showed that monthly inspections of all pharmacy items stored on the Acute Care Nursing unit, Emergency Department, crash carts and all other locations where drugs may be stored will be completed. The pharmacy department will perform the monthly inspections as they are ultimately responsible for all medications stored in the facility. This does not prohibit other departments from performing their own inspections for outdated medications.

Document review of the hospital's policy titled, "Guidelines for the Procurement of Pharmaceuticals," policy number 1045, effective 03/15/19, showed that the Director of Pharmacy makes decisions relating to vendor, brand, etc. at Dayton General Hospital.

2. On 05/19/21 at 14:30 PM, Surveyor #10 interviewed the Director of Nursing at Booker Resident Home (BRH) (Staff #1009). Staff #1009 stated that the Pharmacist from the hospital (Staff #1008) will check in any medications procured from any pharmacy outside of the Elk pharmacy. Staff #1009 stated that the pharmacist at the hospital, Staff #1008 will validate and relabel the medication than return it to BRH.

3. On 05/19/21 at 2:30 PM, Surveyor #10 interviewed the Director of Nursing at Booker Resident Home (BRH) (Staff #1009). Staff #1009 stated that the Assistant Director of Nursing (Staff #1010) performs monthly medication outdate audits and stated that the pharmacist from Elk pharmacy performs a pharmacy consulting report monthly. Staff #1009 confirmed that pharmacist (Staff #1008) does not oversee any pharmacy services for BRH including the storage, handling, dispensing, and administration of drugs and biologicals.

4. On 05/16/21 at 1:30 PM, Surveyor #10 inspected the CAH pharmacy and interviewed the Pharmacy Technician (Staff #1007). Staff #1007 stated that the nurses at BRH inspect the medication room and medication carts at BRH monthly. She noted that the pharmacy does not have oversight of the prescribed or over the counter medication for the swing bed patients at BRH.

5. On 05/19/21 at 2:35 PM, Surveyor #10 interviewed Licensed Register Nurse (Staff #1006) from BRH. Staff #1006 stated that the physician writes the prescription and it is sent to Elk Drug, Elk Drug fills the prescription and delivers the medication to a nurse at BRH. Staff #1006 stated that there is an attached inventory list of the medication. The nurse checks this list and validates that the inventory delivered is correct. The nurse then faxes the completed inventory list to Elk pharmacy. Staff #1006 stated that the pharmacist from the hospital is not involved in the procurement of medications for the BRH swing bed patients.

6. On 05/19/21 at 2:00 PM, Surveyor #10 inspected the CAH pharmacy and interviewed the Pharmacy Technician (Staff # 1007). Staff #1007 stated that the CAH pharmacy provides BRH with over the counter medications. Staff #1007 stated that BRH receives a "Booker House Supply Order List" whenever BRH needs over the counter medication. Staff #1007 states the pharmacist fills the order and it is delivered to a registered nurse at BRH.

Item #3 Unusable Medications

Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date for 3 of 6 insulin pens inspected.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability or efficacy.

References:

Novolog® Flex Pen® manufacturer's instructions for use, revised 05/15, states, "Do not use Novolog® past the expiration printed on the label or 28 days after you start using the pen."

BASAGLAR® KwikPen® manufacturer's instructions for use, revised 11/19, instructs patients to "Store the Pen you are currently using at room temperature [up to 86°F (30°C)] and away from heat and light. Throw away the Pen you are using after 28 days, even if it still has insulin left in it."

Humulin® N KwikPen® manufacturer instructions for use, revised 06/20, states "Do not use your Pen past the expiration date printed on the Label or for more than 14 days after you first start using the Pen." Patients are instructed to throw away the HUMULIN N Pen in use after 14 days, even if it still has insulin left in it.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Labeling of Medication Bottles and Dispensing of Multi-Dose Vials," reference number 3991, effective 06/14/17, showed that if an over the counter or multi-use medication is opened the nurse should take a black sharpie and write the date it was opened on a part of the container that is visible but not over the label. Medications in vials and multi-dose vials should be discarded after 28 days or by manufacturers recommendations.

2. On 05/18/21 at 10:41 AM, Surveyor #5 and the Booker Rest Home (BRH) medication Nurse (Staff 506) inspected the medication room located in the BRH. Surveyor #5 reviewed the medication drawers for 3 hospital Swing Bed patients who received their medications from the medication room located in the BRH building. The inspection showed the following:

a. Patient #505, one Novolog® Flex Pen® and one BASAGLAR® KwikPen® opened and undated.

b. Patient #506, one Humulin® N KwikPen® opened and undated.

3. At the time of the observation, Staff #506 verified the undated insulin pens and stated that she did not know the hospital's policy for expiration of insulin pens or the policy for dating opened pens, and stated that it could be 30 days. Staff #506 stated that the medications for all Swing Bed patients in beds located in the Booker Rest Home rooms #201-212 of the BRH building were provided by Elks Pharmacy or their own personal pharmacy and that the Staff at BRH prepared and administered the medications.

Item #4 Record Keeping for Receipt and Disposition of All Controlled Substances

Based on observation, document review, and interview the Critical Access Hospital (CAH) failed to have oversight of record keeping for the receipt and disposition of all controlled substances.

Failure to ensure that record keeping for the receipt and disposition of all controlled substances could impair the hospitals ability to provide quality care in a safe environment.
Findings included:

1. Document review of the Critical Access Hospital's policy titled, " Pharmacy Duties in Booker Rest Home," policy number 3983, no date, showed that the facility is contracted with Elk Drug and the pharmacist from Elk drug will conduct and document periodic, random controlled substance audits.

2. Document review of a hospital document titled, "Pharmacy Consulting Report Booker Rest Home," showed that the pharmacist from Elk Drug conducted a controlled substances audit for the months of 02/21, 03/21, 04/21, and 05/21. The audit showed the letter "Y" next to the control substance audit.

3. On 05/20/21 at 2:30 PM, Surveyor #10, interviewed the Director of Nursing for Booker Rest home (BRH) (Staff #1009) regarding the controlled substances audits. Staff #1009 stated that she was unable to produce a document to determine if there was any discrepancy in the audits performed monthly. Staff #1009 stated that BRH maintains a separate audit recording system than Dayton General Hospital and verified that the pharmacist from Elk Drug, and not the pharmacist from the hospital, has oversight over the swing bed patients located at BRH.

4. On 05/20/21 at 1:45 PM, Surveyor #10 interviewed Pharmacy Technician (Staff #1007). Staff #1007 stated that the Pharmacist (Staff #1008) and Staff #1007 conduct audits on controlled substances for the pharmacy at Dayton General Hospital and maintained the logs. Surveyor #10 reviewed the monthly logs. Surveyor #10 observed that the hospital records did not include any evidence that the pharmacist from the hospital reviewed the BRH audits or provided any oversight for the receipt and disposition of all controlled substances in the hospital.


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Based on document review and interview, the hospital failed to maintain a list of services furnished under arrangement or agreements that described the nature and scope of the services provided.

Failure to maintain a list of services describing the nature and scope of the services provided by the contractors created a situation where the facility could not know which services were contracted and could not ensure the quality of those services.

Findings included

1. Document review of a list of hospital patient care services furnished under arrangement or agreements (contracts) titled, "Accounts Payable Dayton General MIS Vendor Dictionary (Summary)," run date 05/20/21 at 7:48 AM, showed a document consisting of 38 pages and included approximately 2,053 contracted services listed in line item format.

2. On 05/20/21 at 11:00 AM, Surveyor #5 and the Chief Executive Officer (Staff #507) reviewed the Critical Access Hospital's (CAH) process for tracking and reviewing services furnished under arrangement. Review of the list provided to the Surveyor showed that the document failed to include:

a. The service(s) being offered;

b. Whether the services are offered on- or off-site;

c. Whether there is any limit on the volume or frequency of the services provided; and

d. When the service(s) are available.

The list appeared to contain both patient care and non-patient care services.

3. At the time of the observation, Staff #503 verified the finding and stated that the list contained all the hospital's contracted services.

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Based on interview, document review, review of the hospital's quality and performance improvement program, and Governing Body documents, the hospital failed to ensure that performance measures for all patient care services furnished under arrangement or agreements (contracted) were developed and evaluated, and failed to ensure that all patient care services furnished under arrangement or agreements were evaluated through the hospital's quality program for 2 of 3 contracts reviewed.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospital's Governing Body document titled, "By-Laws of the Columbia County Public Hospital District #1," reference number 1735, effective 02/11/19, showed that the Board of Commissioners is ultimately responsible for all activities in the District and the condition of the physical plant and shall have a program for the on-going management of the District Quality Assurance Program and Risk Management Programs. The Quality Assurance Program will review the services rendered in the District in order to improve the quality of medical care of patients.

Document review of the hospital's Quality Plan titled, "Quality Improvement Plan 2021," reference number 1142, effective 04/07/21, showed that the hospital's Governing Body is ultimately responsible for the quality of care the organization provides.

Document review of a list of hospital patient care services furnished under arrangement or agreements (contracts) titled, "Accounts Payable Dayton General MIS Vendor Dictionary (Summary)," run date 05/20/21 at 7:48 AM, showed approximately 2,053 contracted services listed in line item format.

2. On 05/20/21, Surveyor #5 requested to review the hospital's contracted service evaluation for 3 contracts including "Medcall NorthWest (staff agency)," "Inland Imaging Business Associated (Radiology Services)," and "Elks Pharmacy (Pharmacy Services provided to Hospital Swing Bed Patients in Rooms 201-212)." Surveyor #5 was provided with 18 hospital contractor review documents titled, "Vendors 2020." Each document contained the names of multiple contracted vendors, the department responsible, and the quality indicators for each contracted service. The review showed the following:

a. Surveyor #5 found no evidence in any of the "Vendor 2020" documents that "Inland Imaging Business Associates" was reviewed.

b. Surveyor #5 found no evidence in any of the "Vendor 2020" documents that "MedCall NorthWest" was reviewed.

c. The Vendor Review documents contained a pre-formatted template that listed the same indicators for all patient care and non-patient care services in column format titled, "Responsive?" "Professional?" and "Issues?" Surveyor #5 found no evidence that the hospital chose indicators that would measure and determine quality of care to assure that patient care services were provided in a manner that ensured compliance with the applicable requirements of the hospital's Conditions of Participation.

d. Surveyor #5 found no evidence that when issues were identified in the column titled, "Issues" or by written notes on the documents, that interventions were developed, and implemented and those actions were evaluated for effectiveness through the hospitals Quality Program or Governing Body.

3. On 05/20/21 at 11:00 AM, the Chief Executive Officer (Staff #507) stated that the process for contract review included going to the different contract owners and asking them about the contracted services responsiveness, professionalism and issues and then documenting their responses on the Vendor review form. There was no data collection or data analysis. Staff #507 stated that this was the format the hospital had been using for many years based on regulatory agency feedback, but that the hospital always aimed to improve processes and would review the current process and documents.

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Based on observation and interview the hospital failed to ensure that a Registered Nurse was designated responsible for Nursing Services for all patients admitted to the Critical Access Hospital (CAH).

Failure to ensure that a Registered Nurse was designated responsible for all Nursing Services for the Critical Access Hospital risks failure to develop and maintain consistent and uniform nursing policies and procedures, consistent and uniform supervision of nursing staff, and consistent, uniform, and ongoing review and analysis of the quality of nursing care that meets the needs of each patient.

Findings included:

1. On 05/18/21 at 10:00 AM, Surveyor #5, the Director of Nursing for Acute Care (Staff #501) and the Director of Nursing for Booker Rest Home (Staff #503) inspected Critical Access Hospital Swing Beds located at the Booker Rest Home. Surveyor #5 observed 12 patients located in the 12 CAH beds in the Booker Rest Home Hallway #1.

2. At this time, Staff #501 stated that 13 CAH Swing Beds were located in the Acute Care area of the hospital and 12 CAH Swing Beds were located in the Booker Rest Home area. The 12 beds in the Booker Rest Home were utilized for "Custodial Care patients" who required Long-Term Care. The patients located in the Booker Rest Home received care under the Long-Term Care Skilled Nursing Facility Regulations and were not billed under Medicare. Staff #501 stated that she was responsible for oversight of the 13 CAH beds in the Acute Care area and that Staff #503 was responsible for oversight of the 12 CAH beds located at Booker Rest Home. Staff #501 stated that she was responsible for policy and procedure for patients located in the Acute Care area (13 CAH beds) and Staff #503 was responsible for the patients and policy and procedures for patients located in the Booker Rest Home area (12 CAH beds).

3. Staff #503 verified that she is responsible for staffing for the Booker Rest Home and Staff #501 is responsible for staffing for Acute Care and Emergency Department. Staff #503 stated that the Booker Rest Home staff clock into Long-Term care when caring for patients in Hallway #2 and Swing Bed when caring for patient in Hallway #1, but that all staff are employees of Dayton Hospital.

4. On 05/19/21 at 10:43 AM, Surveyor #5, the Director of Nursing for Booker Rest Home (Staff #503), and the Social Services Designee for the Booker Rest Home (Staff #504) reviewed the medical records for 3 Swing Bed Patients (Patient #505, #507, and #510) located in the Booker Rest Home CAH beds. Staff #503 stated that the Patients located in beds #201 through #212 in the Booker Rest Home were referred to as "Booker Swing Patients." Staff #503 verified that the patients were located in the hospital's licensed "Swing Beds Program." Staff #503 stated that the 13 "Swing Beds" located in the hospital were Supervised by the Director of Nursing for Acute Care (Staff #501), and the "Swing Bed" patients located in the 12 rooms in the Booker Rest Home were Supervised by the Director of Nursing for Booker Nursing Home (Staff #503). Staff #503 stated that the Booker Rest Home Swing patients were "Custodial Care Patient's," and were long-term care residents without plans to discharge.


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#1 Patient Identification

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to develop and implement a policy to ensure staff identified patients prior to medication administration for 2 or 2 medication administrations observed (Patient #508 and #509).

Failure to ensure an effective process for patient identification places patients at risk of receiving the wrong medication, patient harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Administration of Drugs," reference number 1027, effective date 05/28/20, showed that medication administration must comply with Nursing and Pharmacy policy and procedure, general hospital policy, state and federal rules and regulations, and accepted standards of practice based on guidelines or recommendations issued by nationally recognized organizations with expertise in medication preparation and administration. Medications will be administered to patients by or under the supervision of appropriately licensed personal, in a safe, effective manner, in accordance with the physician order. The policy does not reference patient identification prior to medication administration.

2. On 05/19/21 at 12:04 PM, Surveyor #5 observed a Licensed Practical Nurse (Staff #506) prepare medication for Patient #508 from a rolling medication cart located in the Booker Rest Home Medication Room. Staff #506 took the prepared medications to the dining room and administered the medications to Patient #508. Staff #506 failed to identify the patient prior to administering the medication.

3. On 05/19/21 at 12:10 PM, Surveyor #5 observed a Licensed Practical Nurse (Staff #506) prepare medication for Patient #509 from a rolling medication cart located in the Booker Rest Home Medication Room. Staff #506 took the prepared medications to the dining room and administered the medications to Patient #509. Staff #506 failed to identify the patient prior to administering the medication.

4. On 05/19/21 at 12:06 PM, Surveyor #5 interviewed Staff #506 after administration of medications to Patient #508, about the hospital's process for patient identification. Staff #506 stated that the patient's picture is on the electronic medication record (EMAR). Staff #506 stated that the rolling cart (which contains the EMAR) had been broken for some time and so it had to stay in the medication room, instead of rolling the cart to the patient. Staff #506 stated that she was unsure of the hospital's policy, but she has worked with the patients for years and knows them. Staff #506 was unable to tell Surveyor #5 what patient identifiers the hospital uses.

Item #2 Pain Assessment and Reassessment

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 4 of 4 patient records reviewed (Patient #501, #502, #503, and #504).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pain Assessment," reference number 210, reviewed 01/28/19, showed that staff will assess a patients pain on admission, every shift, quarterly, and as needed using the pain assessment tool through the electronic health record. Staff will document the effectiveness of pain medication within approximately one hour of receiving the medication.

2. On 05/19/21 at 2:49 PM, Surveyor #5 and a Medical Records Specialist (Staff #502) reviewed the medical records for 4 patients receiving as needed (PRN) medication in the hospital's Emergency Department (Patient #501, #502, #503, and #504). The medical record review showed the following:

Patient #501

a. On 02/04/21, Patient #501 was admitted to the Emergency Department with a Compression Fracture to the 3rd Lumbar. The medical record review showed that at 11:45 PM, Patient #501 received Hydrocodone (an opioid pain medication) and Lorazepam (a benzodiazepine used to treat anxiety) for pain of 8/10. Surveyor #5 found no evidence staff reassessed the patient for medication effectiveness after administration.

Patient #502

b. On 02/13/21, Patient #502 was admitted to the Emergency Department with a fractured left rib. At 3:28 PM, the medical record showed that Patient #502 received Tylenol 650 mg. Surveyor #5 found no evidence staff assessed the patient's pain prior to medication administration or reassessed the patient's pain for medication effectiveness after medication administration.

Patient #503

c. On 01/20/21, Patient #503 was admitted to the Emergency Department for a Fractured Left Humerus. At 5:56 PM, the patient received Fentanyl 75 micrograms. Surveyor #5 found no evidence staff assessed the patient pain prior to medication administration or reassessed the patient's pain for medication effectiveness after administration.

Patient #504

d. On 01/17/21, Patient #504 was admitted to the Emergency Department for a crushed left foot. At 3:38 PM, the patient received Tylenol 1,000 mg. Surveyor #5 found no evidence staff assessed or reassessed the patient pain.

3. At the time of the observations, Staff #502 verified the finding and stated that the hospital's policy was to assess pain prior to administering pain medication and reassess pain after giving pain medication.

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Based on interview, record review, and review of policies and procedures, the hospital failed to develop and keep current an individualized plan of care for 2 of 2 patients who developed hospital acquired wounds reviewed (Patient #507 and #510).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient's needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Booker Rest Home: Impaired Skin Integrity and Pressure Ulcer Prevention," reference number 1730, effective date 12/30/19, showed that the charge nurse is responsible to start an active problem when is present on admission or developed during the resident's nursing home stay. The charge nurse will start an active problem on the Wound Active Problem Board, start a Wound Assessment in the Electronic Health Record, take pictures, make a progress note and implement interventions that focus on healing and preventing further breakdown.

Document review of the hospital's policy titled, "Emergency Department, Acute Care, Booker Rest Home: Pressure Injury Prevention," reference number 095, effective date 05/08/19, showed that staff are to update the care plan and document a complete skin assessment and interventions used to prevent pressure ulcers and the patient's response to those interventions.

2. On 05/18/21 from 11:23 AM until 12:00 PM and on 05/19/21 from 8:30 AM until 9:30 AM, Surveyor #5, the Booker Rest Home Social Worker Designee (Staff #504) and the Assistant Director of Nursing for the Booker Rest Home (Staff #503) reviewed the medical record for a Swing Bed patient, Patient #507. The review showed that the patient developed a 6 cm by 3 cm Deep Tissue Injury (pressure wound) to the left inner buttock on or about 03/30/21.

Surveyor #5 found no evidence the that the problem alteration in skin integrity and appropriate interventions and goals were added to the patients care plan. Surveyor #5 found no evidence that the Deep Tissue Injury was addressed by the Interdisciplinary care team during the patients quarterly review on 04/15/21.

3. On 05/18/21 at 12:00 PM, Staff #503 verified the finding and stated that the hospital changed from a paper documentation system to a computer documentation system on 03/01/21 and staff were still learning the system.

4. On 05/19/21 at 11:00 AM, Surveyor #5 and the Assistant Director of Nursing for the Booker Rest Home (Staff #503) reviewed the medical record for a Swing Bed patient, Patient #510. The review showed that the patient developed a wound to his right lateral leg stump on about 04/22/21.

Surveyor #5 found no evidence the that the problem alteration in skin integrity and appropriate interventions and goals were added to the patients care plan.

5. At the time of the finding, Staff #503 verified the finding and stated that the wound should have been added to the patients plan of care.

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Item #1 Water Management Plan

Based on interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

b. Implement a water management program that considers the ASHRAE industry standard and/or the CDC toolkit, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and/or environmental testing for pathogens.

c. Specify testing protocols and acceptable ranges for control measures and document the results of testing and provide corrective actions taken when control limits are outside of acceptable ranges.

Findings included:

1. On 05/20/21 between the hours of 9:00 AM and 11:30 AM, Surveyor #1 and #4 interviewed Director of Maintenance (Staff #101) and Chief Operating Officer (Staff #102) regarding the hospitals water management plan titled, "Management Plan for the Prevention of Healthcare Acquired Infection Legionnaire's and/or other Waterborne Diseases," no policy number, effective date 10/18.

2. During the interview, surveyors determined that the plan was missing the following elements or included elements that were not applicable to the services and facilities provided by the hospital:

a) The plan indicated recommendations for disinfection for cooling towers and decorative fountains, the facility does not have these items.

b) The facility has not conducted a complete risk assessment to identify risks in the hospital, such as medical equipment. On 05/18/21 Surveyor #1 and #4 observed CPAP machines/ventilators in the emergency department that were not included in the water management plan.

c) The hospital had identified risks on a flow chart but had not provided control measures such as temperature management, flushing system of areas of stagnation and/or disinfection level controls.

d) The hospital did not specify protocols and acceptable ranges for control measures and action levels when control levels are outside of the acceptable ranges.

3. At the time of the review, Staff #101 confirmed the missing or unnecessary elements of the plan.

Item 2 Cleaning of Patient Care Equipment

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff cleaned patient care equipment according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable diseases.

Reference: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Last Update July 2019) (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee), Pgs. 62-63, Patient Care Equipment and Instruments/Devices.

Findings included:

1. Document review of the hospital's policy titled, "Cleaning Patient Equipment and Medical Devices," policy number 3992, effective 05/03/17, showed that a hospital approved detergent/disinfectant should be used to regularly clean soiled environmental surfaces or objects which may have contact with the patient. The policy showed all equipment in patient rooms are to be cleaned at least daily or upon discharge or transfer of the patient.

Document review of the hospital's policy titled, "Acute Care Outpatient Room Cleaning Procedure," policy number 1752, effective 02/16/19, showed nursing staff is responsible for disinfecting all equipment between patients.

2. On 05/18/21 between 10:00 AM and 10:30 AM, Surveyors #1 and #4 inspected the Acute Care Wing with the Facilities Director (Staff #401). Surveyors entered empty (previously cleaned) patient room #105 and observed a soiled blood pressure cuff attached to the blood pressure unit for patient use. Staff #401 wiped down the soiled cuff with a disinfecting wipe and confirmed the dirty cuff was not cleaned after patient discharge.

3. On 05/19/21 at 9:10 AM, Surveyors #1 and #4 observed a room cleaning after an outpatient discharge in Acute Care room #104. An Environmental Services (EVS) Technician (Staff #404) performed a room clean of high touch surfaces and the bathroom but did not clean/disinfect any patient equipment stored in the room.

4. At this time, Surveyors interviewed the EVS Manager (Staff #405) and an Acute Care Certified Nursing Assistant (CNA) (Staff #406) about the process for cleaning stored patient equipment. Staff #405 indicated that EVS did not generally clean the equipment after outpatient use and she believed nursing covered this. Staff #406 stated she was unaware of the outpatient room turnover and did not know to clean the patient equipment.
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Item # 1 Patient Care Services Evaluated

Based on interview and document review, the hospital's Quality Program failed to maintain oversight of analysis, evaluation, and quality activities for all the hospital's services including the hospital's Swing Bed program.

Failure to ensure that all patient care services are evaluated limits the hospital's ability to implement sustained improvements in care and improve patient outcomes.

Findings included:

1. Document review of the hospital's Quality Plan titled, "Quality Improvement Plan 2021," reference number 1142, effective date 04/07/21, showed that the plan applied to all services and sites of care provided at Columbia County Health System. Throughout the document the terms "hospital," "Clinics," and "nursing home," are used as locations of services, with "hospital" encompassing a vast majority of departments and services including the Wound Care Clinic. All departments within the Strategic Quality Support System (SQSS) report monthly to their performance improvement and quality assurance activities. The Quality Improvement Director is responsible to monitor progress via monthly data entry and reports actual or potential deficiencies to the Quality Committee and Executive Leadership for follow-up.

2. On 05/20/21 at 10:00 AM, Surveyor #5, Surveyor #10, the hospital's Chief Executive Officer (Staff #507), the Quality Director (Staff #508), and the Quality Committee reviewed the hospital's Quality Program. The review showed the following:

a. Surveyor #5 found no evidence the hospital included its Swing-Bed Program into its Quality Improvement Program. Surveyor #5 found no evidence the hospital collected or analyzed quality data or implemented process improvement for their Swing-Bed Program.

b. Surveyor #5 found no evidence that the hospital's Fall Program included Swing-Bed patients. Quality documents showed that for Quarter 1, 2021 the Acute Care Department had 9 falls and the Booker Rest Home Long-Term Care Facility had 10 falls. Documents showed that for 2020 the hospital's Acute Care Department had 28 falls and the Booker Rest Home Long-Term Care Facility had 45 falls.

c. Surveyor #5 found no evidence that all Swing-Bed patient nosocomial wounds were tracked and analyzed as part of the Quality Program.

3. At the time of the review, the Quality Director (Staff #508), stated that the Plan, Do, Study, Act (PDSA) initiatives and activities for the Critical Access Hospital Swing-Beds located in the Acute Care area of the hospital were included in the Acute Care Department. She stated that the initiatives and activities for the Critical Access Hospital Swing-Beds located in the Booker Rest Home were included in the Booker Rest Home Long-Term Care PDSA's.

Item # 2 Medication Therapy Evaluation

Based on interview and document review, the Critical Access Hospital failed to implement a comprehensive and effective quality assurance program that included the evaluation of medication therapy for all Swing-Bed patients.

Failure to ensure evaluation of medication therapy for all Swing-Bed patients as part of comprehensive and effective quality assurance program limited the hospital's ability to identify issues and trends and implement effective interventions to improve patient outcomes.

Findings included:

1. Document review of the Critical Access Hospitals policy titled, "Pharmacy and Therapeutics Committee," policy number 1067, no date, showed the following:

a. It is the policy of Dayton General Hospital to establish a Pharmacy and Therapeutics Committee to oversee matters related to the use of medications, including, but not limited to, the development of drug formulary, therapeutic interchange protocols, and collaborative practice agreements for pharmacy dosing protocols.

b. The Pharmacy and Therapeutics Committee shall be composed of the following members, at minimum, with other health care personnel invited as appropriate;

-A medical staff member shall be the chairman of the committee

-Additional medical staff members assigned

-Pharmacy Manager

2. On 05/20/21, Surveyor #10 reviewed the Pharmacy Committee meeting minutes for Booker Rest Home for meeting dates 02/18/20, 08/18/20, and 03/16/21. The review showed that the Pharmacist (Staff #1017) who was contracted by the hospital to provide services for the Booker Rest Home attended the meeting. The review showed no evidence that a pharmacist with oversight over the CAH attended the meeting.

3. On 05/21/21 at 9:30 AM, Surveyor #10 interviewed the Director of Nursing for BRH (Staff #1009). During the interview Surveyor #10 and Staff #1009 reviewed the Pharmaceutical Services Committee minutes for BRH. Staff #1009 stated that there are two separate pharmacy committees, one for BRH and one for Dayton General Hospital. Staff #1009 confirmed that the pharmacist attending the BRH meeting was the contracted pharmacist for BRH (Staff #1017) and that the pharmacist (Staff #1008) for Dayton General Hospital did not attend these meetings.

4. At this same time, the Director of Nursing for Acute Care at Dayton General Hospital (Staff #1011) confirmed that the pharmacist (Staff #1008) did not attend the meeting at BRH and that they have a separate Pharmacy and Therapeutics meeting for Dayton General Hospital.

5. On 05/20/21 at 10:00 AM, Surveyor #5, Surveyor #10, the hospital's Chief Executive Officer (Staff #507), the Quality Director (Staff #508), and the Quality Committee reviewed the hospital's Quality Program. The review showed the following:

a. The Quality Improvement Committee provided oversight including ongoing monitoring and evaluation for the Pharmacy Services provided by the CAH patients located in the Acute Care area which included 13 CAH Swing beds.

b. The Quality Improvement Committee did not provide oversight, ongoing monitoring, problem prevention, identification or analysis, or measures to improve quality for the pharmacy services provided at Booker Rest Home which included 12 CAH Swing Bed Patients.

6. At the time of the review, Staff #508 confirmed that the Quality Committee Pharmacy review did not include the 12 CAH patient's located at Booker Rest Hone.
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Based on interview and document review, the facility failed to identify, investigate, and report an adverse event.

Failure to identify, investigate, and report such events, limited the hospital's ability to implement interventions to prevent reoccurrence of the adverse event, potentially resulted in failure to submit information to the state to track and analyze in an effort to prevent similar recurrences, and put patients at risk of harm..

References:

RCW 70.56.020 (2) When a medical facility confirms that an adverse event has occurred, it shall submit to the department of health: (a) Notification of the event, with the date, type of adverse event, and any additional contextual information the facility chooses to provide, within forty-eight hours; and (b) A report regarding the event within forty-five days.

WAC 246-320-131: The governing authority must: (1) Establish and review governing authority policies including requirements for: (e) Reporting adverse events and conducting root cause analyses according to RCW 70.56.020.

WAC 246-320-146 : The National Quality Forum identifies and defines twenty-nine serious reportable events (adverse health events) as updated and adopted in 2011.(1) Hospitals must report adverse health events to the department.(2) Hospitals must comply with the reporting requirements under chapter 246-302 WAC.(3) Adverse health events are listed in chapter 246-302 WAC.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Occurrence Reporting Policy and Procedure," reference number 49, effective date 12/11/18, showed that any error or situation not consistent with established standards, routine operation of the facility, or routine care of a particular patient which causes or raises the risk of causing harm will be reported via the hospitals reporting system as soon as possible following the discovery of the incident. These types of incidents include reportable adverse events as listed by the Department of Health.

2. On 05/18/21 from 11:23 AM until 12:00 PM, and on 05/19/21 from 8:30 AM until 9:30 AM, Surveyor #5, the Booker Rest Home Social Worker Designee (Staff #504), and the Assistant Director of Nursing for the Booker Rest Home (Staff #503) reviewed the medical record for a Swing Bed patient, Patient #507. The review showed that the patient developed a 6 cm by 3 cm dark purple/maroon colored wound to the left inner buttock on or about 03/30/21. On 05/04/21 the wound measured approximately 6.5 cm by 5 cm with 2 small superficial open areas. On or about 04/28/21, the provider determined the wound was a deep tissue injury. At the time of the record review, the wound was still present.

3. At the time of the finding, Staff #503 verified the finding and stated that at the time of the discovery the hospital was not sure if the wound was a deep tissue injury or pyloderma granulosa (an ulcerative skin disease).

4. On 05/20/21 at 10:00 AM, Staff #503 verified that the wound had not been reported through the hospital's incident reporting system and had not been reported to the Department of Health as an adverse event. Staff #503 stated that as of this time, she had now reported the deep tissue injury as an adverse event.
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Item #1 Appropriate Utilization of Hospital Swing Bed Program

Based on interview and document review the hospital failed to ensure that patients were appropriately admitted to the hospital's Swing Bed program for 6 of 6 patients reviewed (Patient #505, #507, #510, #1001, #1002, and #1003).

Failure to ensure patients are admitted or transferred based on provider orders risk delay in care, inappropriate care, patient harm, or death.

Findings included:

1. Document review of the hospital's, "Medical Staff Rules and Regulations," dated 03/01/19, showed that a patient may be admitted to the Hospital for Acute Care, Observation, or Swing Bed (Skilled Nursing or Rehab Care) only by a physician order. All previous orders shall be reconciled when transferring level of care e.g. from Acute Care to Swing Bed. The receiving provider is responsible to enter new orders. Each reconciled or transferred order must either be continued, held, or canceled at the time of transfer.

Document review of the hospital's policy titled, Swing Bed Patients," reference number 469, effective date 05/04/17, showed that the Swing Bed patient is admitted from the acute hospital setting after a Physician order for continued skilled nursing care is received.

Document review of the hospital's policy titled, "Acute Care and Booker Rest Home Swing Beds: Swing Bed Services," reference number 384, effective date 11/03/20, showed that patients located in the Swing Beds in the Acute Care Department will be seen by the attending physician at least once every 7 days. This will be documented in the record under physician progress notes in the Acute Care Department. All patients located in the Long-Term Care Swing Beds located in Booker Rest Hone will be seen by the attending provider on admission, every 30 days for 90 days and then every 60 days thereafter, and as needed.

2. On 05/20/21 at 9:00 AM, Surveyor #5 and the Booker Rest Home Director of Nursing (Staff #503) reviewed physician admission orders for Patient #505, #507, and #510 who were admitted for the Critical Access Hospital Acute Care to the hospital's Swing Bed program. The review showed the following:

a. Patient #505 was admitted to the hospital on 03/30/18. The patient was in room #202, a designated Critical Access Hospital bed. The patient had no admission orders to the hospital's Swing Bed Program.

b. Patient #507 was admitted to the hospital on 12/17/16. The patient was in room #210, a designated Critical Access Hospital bed. The patient had no admission orders to the hospital's Swing Bed Program.

c. Patient #510 was admitted to the hospital on 05/17/18. The patient was in room #212, a designated Critical Access Hospital bed. The patient's admission orders stated to admit to the Booker Rest Home.

3. At the time of the observation, Staff #503 verified that Patient #505, #507, and #510 were all "Booker Swing Bed" patients. She verified there were no admission orders for Patient #505 and #507. She verified that the orders for Patient #510 were for admission to the Booker Rest Home Long-Term Care Facility. Staff #503 stated that all the patients located in the Swing Beds in the Booker Rest Home were permanent "Custodial Care" patients and that patients moved back and forth between the Booker Rest Home Long-Term Care and the Swing Bed Program. Staff #503 stated that it was not the practice to write admission/transfer or discharge orders when patients were transferring back and forth between the Long-Term Care and the Swing Bed Program. She stated that any further patient record review would show the same findings.

4. On 05/18/21 at 2:15 PM, the hospital's Chief Executive Officer (Staff #507) stated that the patients located in the Booker Rest Home Swing Beds had depleted their 100-day Medicare Benefits. The hospital received financial reimbursement for the patients as "custodial swing bed patients" and these patients were placed in the hospital's Swing Beds located at the Booker Rest Home and care was provided based on Booker Rest Home Long-Term Care requirements.

5. On 05/19/21, Surveyor #10 reviewed the electronic medical record for 3 patients (Patient #1001, #1002 and Patient #1003). The review showed that Patient #1001was admitted on 03/21/12, Patient #1002 was admitted on 04/09/18, and Patient #1003 was admitted on 08/20/12. The admission orders for all 3 patients showed the patients were admitted to Booker Rest Home. Patient #1001, #1002 and #1003 were occupying beds in the Critical Access Hospital (CAH) Swing Bed Program for Dayton General Hospital.

6. On 05/19/21 at 11:30 AM, during an interview with a Licensed Practical Nurse (LPN) (Staff #1006). Staff #1006 stated that the patients are residents of Booker Rest Home and not CAH patients.

7. On 05/20/20 at 9:00 AM, Surveyor #10 interviewed the Director of Nursing for Acute Care (Staff #1011) and Director of Nursing for BRH (Staff #1009). Staff #1011 and Staff #1009 verified that there would not be admitting orders for swing bed patients who are residents of BRH. Additionally, Staff #1011 and Staff #1009 confirmed that the patients residing at BRH are permanent residents of BRH.

Item #2 Condition of Participation

Based on interview, record review and hospital policy review, the Critical Access Hospital failed to provide evidence of compliance with the Condition for Participation at 42 CFR 485.645: "Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds")" for 12 of 12 Swing-Bed patients admitted to Critical Access Hospital beds located in the Booker Rest Home (Patients #505, #506, #507, #508, #509, #510, #511, #512, #513, #514, #515, and #516).

Failure to comply with special requirements for CAH Long-Term Care Services (Swing-Beds) could lead to suboptimal care and services for patients placed in Swing-Bed status.

Findings included:

1. Failure to ensure that policies directing care of Swing-Bed patients were uniform for all Swing-Bed patients in the hospital.

Cross reference: C 1006

2. Failure to ensure Providers wrote admission or transfer orders for patients admitted to/transferring to the hospital's Swing Bed program.

Cross reference: C 1600

3. Failure to provide hospital swing bed patients with a complete list of their patient rights.

Cross reference: C 1608

4. Failure to inform Swing Bed patients of their rights to be free from physical and chemical restraints.

Cross reference: C 1612

5. Failure to develop and implement a discharge plan with measurables goals and objectives for patients admitted to the hospital's Swing Bed program.

Cross reference: C 1620

The cumulative effect of these deficiencies resulted in the provision of substandard care to the hospital's swing bed patients. The Condition of Participation for: Long-Term Care "Swing-Bed" Services was NOT MET.

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Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights and failed to ensure there was a process in place to update patients on their rights every 24 months as directed by hospital policy.

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital's Admission Agreement document titled, "Exhibit 3 Resident's Rights,'" no date, showed that patients in the hospital's Swing Bed program must receive notification of their Patient Rights prior to or upon admission and they must be reviewed at least every 24 months in writing and in a language the resident and legal representative understands.

2. On 05/18/21 at 10:00 AM, Surveyor #5, the Booker Rest Home Social Worker Designee (Staff #504), and the Assistant Director of Nursing for the Booker Rest Home (Staff #503) reviewed the medical record for 3 "Swing Bed" patients (Patient #505, #507, and #510). The review showed the following:

a. The medical record for Patient #507 contained a document titled, "Booker Rest Home Long Term Care Facility Resident Admission Agreement." The document contained a listing of the Patient's Rights under "Exhibit 3". The document was signed by the patient on 12/17/16.

Surveyor #5 found that the document did not include a complete list of patient rights as required including the following:

§483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician.

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

The Surveyor found no evidence that the Patient Rights were reviewed at least every 24 months in writing.

3. At the time of the observation, Staff #504 verified the findings as stated that the patients only received their Patient Rights on admission to "Booker."

4. On 05/19/21, Surveyor #5 and Assistant Director of Nursing for the Booker Rest Home (Staff #503) reviewed the medical records for Patient #505 who was admitted to the hospital on 03/30/18 and Patient #510 was admitted to the hospital on 05/17/18. Surveyor #5 found the same omissions as listed above

5. On 05/19/21 at 11:00 AM, during discussion with Surveyor #5 about Patients in the hospital who have been admitted to the Swing Bed Program for greater than 2 years and up to 10 years and the hospital's process for updating patient on their Patient Rights, Staff #504 stated that the residents received their Patient Rights on admission and that there was not a process in place to provide updated Patient Rights for Long-Term Care Patients.

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Based on interview and review of the hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights to be free from chemical and physical restraints.

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal outcomes.

Findings include:

1. Document review of the hospital's policy and procedure titled, "Patient Bill of Rights," policy number 1223, last reviewed 01/11/21, showed no evidence that the facility informs their swing bed patients that they have a right to be free from physical and chemical restraints.

Surveyor #10 found that the document did not include a complete list of patient rights as required including the following:

483.13 (a) Restraints. The resident has the right to be free from physical and chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical condition.

2. On 05/19/20 at 11:10 AM, Surveyor #10 and a Licensed Practical Nurse (LPN) (Staff #1006) reviewed the medical record of 4 "Swing Bed" patients. The medical record review showed that 3 of 4 patients (Patient #1002, #1003, and #1004) had no evidence that they received information regarding their rights to be free from physical restraint.

3. At the time of the review, Staff #1006 verified the findings as stated that the patients did not receive information about their right to be free from physical and chemical restraints.

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Based on interview, medical record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a discharge plan with measurables goals and objectives for patients admitted to the hospital's Swing Bed program for 6 or 6 patients reviewed (Patient #505, #507, #508, #1001, #1002, and #1003).

Failure to complete a discharge plan with measurable goals and objectives impairs the ability for the patient to be discharged back into the community.

1. Document review of the Critical Access hospital's policy and procedure titled, "Discharge Planning for Booker Residents", policy number 190, effective 11/11/19, showed that the facility will develop a discharge plan for effectively discharging Booker Rest Home (BRH) and Long term Care Custodial Residents residing in Hall One Swing Beds back into the community.

2. On 05/19/21 at 10:43 AM, Surveyor #5, the Director of Nursing for Booker Rest Home (Staff #503), and the Social Services Designee for the Booker Rest Home (Staff #504) reviewed the hospital's discharge plans for 3 current Swing Bed Patients (Patient #505, #507, and #510). The review showed the following:

a. Patient #505 was admitted to the hospital on 03/30/18. On 04/17/20, a Social Services note stated that there was no plan for discharge and the resident preference is not to be asked about discharge and the patient will let Social Services know if a new plan is made. On 03/24/21, a Plan of Care note showed that the patient was independent except she is not able to transfer without total assistance and she also needs reminded to turn and reposition related to poor circulation and skin issues every 2 hours. The note stated that there were no plans for discharge, and the resident's preference is to not be asked all the time, and the resident prefers only to be asked about discharge during the annual assessment period.

b. Patient #507 was admitted to the hospital on 12/17/16. Social Service notes dated 03/06/19, 04/29/20, and 04/15/21 showed that there were no plans for discharge as the resident needed 24-hour care, supervision, and medication management.

c. Patient #510 was admitted to the hospital on 05/17/18. Document review of the patients care plan showed that the potential for discharge was not feasible and the hospital was no longer actively pursuing discharge plans as all available options were refused by the patient. On 05/07/21, an Interdisciplinary note showed that there were no plans for discharge as the patient needed 24-hour care, supervision and medication management. The note stated the patient would like to discharge home, but he had refused all available alternatives and the patient would potentially be discharged to the hospital's Assisted Living facility when construction was complete.

Surveyor #5 found no evidence the hospital developed measurable discharge goals or objectives aimed at transitioning the patients from the hospital's "Swing Bed" program to home, Assisted Living, Long-Term Care, or other alternate discharge.

3. At the time of the observation, Staff #504 confirmed the finding and stated that it was not feasible to discharge most of the long-term patients because they needed 24-hour care, supervision, or medication management. She stated that the Swing-Bed Patients located at Booker Rest Home were "Custodial Care Patients' who were permanent residents. She stated that the plans were to discharge most of these patients to the hospital's Assisted Living when it was completed.

4. At the time of the observation, Staff #503 stated that the Patients located in beds #201 through #212 in the Booker Rest Home were referred to as "Booker Swing Patients." Staff #503 verified that the patients were located in the hospital's licensed "Swing Beds Program." Staff #503 stated that the 13 "Swing Beds" located in the hospital were Supervised by the Director of Nursing for Acute Care (Staff #501), and the "Swing Bed" patients located in the 12 rooms in the Booker Rest Home were Supervised by the Director of Nursing for Booker Nursing Home (Staff #503). Staff #503 stated that the Booker Rest Home Swing patients were "Custodial Care Patients," and were long-term care residents without plans to discharge.

5. On 05/19/20 from 11:10 AM to 12:00 PM, Surveyor #10 and a Licensed Practical Nurse (LPN) (Staff #1006) reviewed the medical records for Patient # #1002, #1003, and #1004 who had been admitted to the hospital's Swing Bed program to beds #201 through #212 in the Booker Rest Home. The review showed the following;

a. The Care Plan for Patient #1001 dated 03/01/21, showed that the patient was not safe for independent discharge. The patient's goal is to remain in the facility and the intervention/tasks showed that the family is unable to provide care at home and there are no plans for discharge at this time.

b. Patient #1002 was admitted on 01/01/18 to Dayton General Hospital for right sided weakness. The family requested that she stay at the hospital for on-going care. The patient was discharged and transferred to a swing bed on 01/05/18. On 04/09/18, the patient was admitted to Booker Rest Home for on-going care. There was no evidence in the patient's medical chart related to discharge goals and objectives.

c. Patient #1003 was admitted on 08/20/12 to the Booker Rest Home for custodial care. There was no evidence in the patient's medical chart of a discharge plan that included measurable discharge goals and objectives.

6. On 05/19/20 from 11:10 AM to 12:00 PM, Surveyor #10 and a Licensed Practical Nurse, (LPN) (Staff #1006) reviewed the medical record of 3 patients who had been admitted to the swing bed program. The review showed that 3 of 3 (Patient #1001, #1002, and #1003) medical records did not provide evidence of discharge plans with measurable goals and objectives.

7. At the time of the review, Staff #1006 verified the findings.

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