HospitalInspections.org

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Based on observation, interview, and document review, the Critical Access Hospital failed to implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturer's expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Outdates Supplies: Monitoring and Disposal," PolicyStat ID #16990324, last approved 11/24, showed the following:

a. Supplies in Acute Care and Emergency Department (ED) will be checked on a monthly basis for outdates. The monthly checks will be documented each month. It is preferable that one staff member be in charge of this duty.

b. Areas that have individual monthly checklists to be completed include: crash cart in ED and Acute Care, Broselow cart in ED and the difficult airway cart in ED.

c. Disposal of supplies will be according to the type of item that it is. Sharps are to be disposed of in a sharps container. Other items can be disposed of in normal garbage.

2. On 11/18/24 between 9:15 AM and 10:55 AM, Surveyor #2 and Surveyor #3 and the Chief Nursing Office inspected the Emergency Department. The inspection showed the following:

a. One Glidescope B flex ultra slim 2.8 bronchoscope, with a manufacturer's expiration date of 09/24.

b. One Glidescope B flex slim 3.8 bronchoscope, with a manufacturer's expiration date of 09/24.

c. Two Glidescope B flex regular 5.0 bronchoscope, with a manufacturer's expiration date of 09/24 and 10/24.

d. Two Cook Medical pericardiocentesis set size 8.3 french with a manufacturer's expiration date of 08/24.

e. One Arrow pressure injectable arrow gard blue plus 4 lumen central venous catheter set, with a manufacturer's expiration date of 09/24.

On the Broselow cart:

a. In the blue drawer, one I-gel laryngeal mask airway (LMA) size 2.5, with a manufacturer's expiration date of 09/24.

b. In the orange drawer, one I-gel LMS size 2.5, with a manufacturer's expiration date of 09/24.

3. At the time of the review, Staff #201 verified the expired supplies and removed them from use. Staff #201 reported the supplies in the Broselow cart may be on back order. On 11/19/24 Staff #201 verified it was not the I-gel LMA's that were on back order but a different type of airway. Staff #201 reported they are in the process of ordering additional LMA's.

4. On 11/19/24 between 1:05 PM and 1:50PM, Surveyor #2 and Surveyor #3 and the Manager of the Surgery Department (Staff #202) inspected the Surgery Department. The inspection showed the following:

On the Malignant Hyperthermia cart:

a. Two purple blood tubes, with a manufacturer's expiration date of 06/24.

b. Two green blood tubes, with a manufacturer's expiration date of 05/24.

c. One blue blood tube, with a manufacturer's expiration date of 02/24.

d. One brown blood tube, with a manufacturer's expiration date of 09/24.

e. One gray blood tube, with a manufacturer's expiration date of 09/20.

f. Two ProVent arterial blood gas sampling kits, with a manufacturer's expiration date of 09/24.

5. At the time of the review, Staff #202 verified the expired emergency supply and removed it from use.
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Based on observation, interview and document review, the Critical Access Hospital failed to implement policies and procedures to ensure compliance with the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12).

Failure to follow the Washington State Retail Food Code and the U.S. Food and Drug Administration Food Code places patients, staff, and visitors at risk of foodborne illness.


Findings included:

1. Document review of the hospital's checklist titled, "Temperature Checks," no policy number or approval date, showed the proper range for nourishment room refrigerators is 34-41 degrees Fahrenheit (F).

2. On 11/19/24 at 9:45 AM, Surveyor #4 toured the emergency department (ED) with the Infection Preventionist (Staff #401) and the ED Manager (Staff #402). Surveyor #4 used a thin stemmed thermometer to assess the temperature of a mini refrigerator. The surveyor placed the open thermometer on refrigerator shelf and closed the door for a minute before assessing, the air reading was 45 F. The surveyor then tested the temperature of an applesauce cup stored in the refrigerator, the applesauce reading showed a temperature of 49.3 F.

3. At the time of the observation, Staff #401 confirmed the temperatures.

4. On 11/19/24 at 11:30 AM, Surveyor #4 toured the Acute Care Nourishment Room with Staff #401. The surveyor used a thin stemmed thermometer to assess the temperature of the full size refrigerator. The surveyor first tested a small butter tab, the reading showed 43.2 F. Additionally, the surveyor tested an applesauce cup, the reading was 46.6 F. Staff #401 confirmed the temperatures.

Cold held TCS food must be maintained at 41 degrees Fahrenheit or below.

Reference: Washington State Retail Food Code WAC 246-215-03525 Time/temperature control for safety (TCS) food, hot and cold holding
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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell MNLU21.
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Item #1 - Restraint orders

Based on record review, interview, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure providers orders for restraint contained the appropriate type of restraints to be utilized for 1 of 3 patients placed with provider orders for restraints reviewed (Patient #207).

Failure to place complete provider orders increases the risk of incorrect restraint application and risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints," PolicyStat ID #16990369, last approved 11/24, showed the following:

a. Restraint or seclusion must be used in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient as specified under CMS 482.12 (c ) and who is authorized to order restraint or seclusion by hospital policy in accordance with State law [CMS 482.13 (e)(7)].

b. Orders for restraint for the management of non-violent, non-self-destructive behavior must be renewed every 24 hours.

2. On 11/21/24 between 11:25 AM and 12:45 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Office (Staff #201) and the Clinical Informatics Specialist (Staff #203) reviewed the medical record of Patient #207 who was admitted to the hospital on 07/08/24 with a diagnosis of diabetic ketoacidosis and started in non-violent restraints at 2:00 PM. Surveyor #2 found no evidence of a provider order for non-violent restraints in the medical record.

3. At the time of the review, Staff #201 verified the missing provider order for non-violent restraints.

Item #2 - Restraint documentation

Based on interview, document review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff followed policies and procedures for restraint use and documentation for 1 of 2 patients reviewed in violent restraints (Patient #208).

Failure to follow hospital policies and procedures for restraint use puts patients at risk for injury or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints," PolicyStat ID #16990369, last approved 11/24, showed the following:

a. Face-to-face observation and documentation by the RN required at least every 15 minutes.

2. On 11/21/24 between 11:25 AM and 12:45 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Office (Staff #201) and the Clinical Informatics Specialist (Staff #203) reviewed the medical record of Patient #208 who had a provider order for violent restraints for violent and aggressive behavior. Patient #208 was placed in 4-point restraints on 07/30/24 at 4:37 AM. Patient #208 had face-to-face every 15-minute observation documentation at 5:35 AM by the RN and the next documentation was at 7:15 AM (missing a period of approximately one and a half hours).

3. At the time of the review, Staff #201 verified the missing face-to-face every 15-minute documentation.
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Item #1 - Pain Assessment and Reassessment

Based on interview, record review, and review of policy and procedure, the Critical Access Hospital (CAH) failed to ensure staff members completed and documented pain assessments/reassessments for each pain management intervention for 3 of 3 patients reviewed with orders for pain medication (Patient #204, #205, and #305).

Failure to assess/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, Reassessment, and Management," PolicyStat ID #16990340, last approved 11/24, showed the following:

a. It is the responsibility of all clinical staff to screen all patients for the presence or absence of pain.

b. If the screening assessment reveals pain is present in the patient, it is the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality (i.e., character, frequency, location and duration of pain), and response to treatment.

c. Any patient care provider from any department that has implemented a pain control mechanism will reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved.

d. As part of the reassessment, the multidisciplinary team should assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics. This ongoing reassessment should be done minimally every two (2) hours while active and during the night time hours when pain often becomes more intense and the patient's ability to sleep does not mean that there is absence of pain.

2. On 11/20/24 between 1:00 PM and 2:10 PM, Surveyor #2, Surveyor #3, the Chief Nursing Officer (Staff #201), and a Clinical Informatics Specialist (Staff #203) reviewed the medical records of 3 patients seen in the ED. The review showed the following:

a. Patient #204 was a 39-year-old male seen in the ED on 11/15/24 with a chief complaint of lower abdominal pain and diagnosed with diverticulitis. Patient #204 had a provider order for morphine (a narcotic medication used to treat pain) 4 milligrams intravenously that was given at 12:28 PM for a complaint of 8/10 pain. Patient #204 had nursing documentation indicating the patient was sleeping post morphine administration. Surveyor #2 found no evidence of a pain reassessment including the characteristics, intensity, or pain rating in the medical record.

b. Patient #205 was a 54-year-old female seen in the ED on 10/24/24 with a chief complaint of head injury and right knee injury after an accident with a horse. Patient #205 had a provider order for oxycodone (a narcotic used to treat pain) a one-time order of 5 milligrams orally and Tylenol (a medication used to treat pain) a one-time order of 975 milligrams orally. Patient #205 received Tylenol 975 milligrams orally at 9:29 AM and oxycodone 5 milligrams orally at 9:38 AM for a pain score rating of 7/10. Surveyor #2 found no evidence of a pain score reassessment in the medical record.

3. At the time of the review, Staff #201 verified the missing pain reassessment.

4. On 11/20/24 between 2:10 PM and 3:00 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302), and the Medical Surgical Manager (Staff #303) reviewed the medical surgical records of 3 patients. Staff #302 stated that the pain reassessment is completed in the medication effectiveness evaluation flow sheet. The review showed the following:

a. Patient #305 was admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home. The review showed that Patient #305 reported pain at 8:12 PM a 9 /10 on the number scale (0= no pain, 10= worse pain). At 9:35 PM the medication administration follow-up showed the RN documented that the provider prescribed oxycodone (a narcotic used for pain treatment) 5 milligrams administered orally for moderate pain was effective. The pain assessment review showed that Patient #305 reported 9/10 pain at 9:35 PM. Surveyor #3 found no additional interventions for the 9/10 pain at 9:35 PM.

b. Patient #305 had no pain reassessment from 9:35 PM on 10/25/24 until 8:00 AM on 10/26/24 (missing a period of approximately 10 hours).

c. Patient #305 reported 10/10 on 10/25/24 at 8:00 AM and oxycodone 5 milligrams was administered. The medication administration follow-up showed the RN documented pain medication administration was "effective".

d. Patient #305 was discharged on 10/26/24 at 2:15 PM. Surveyor #3 found no pain assessments after 8:00 AM on 10/26/24 (missing a period of approximately 6 hours).

5. At the time of the review, Staff #301 verified the missing pain reassessments and missing pain assessments every two hours for patients having pain

Item #2 - Initial Nursing Admission Assessment

Based on interviews, document review, and review of policies and procedures, the Critical Access Hospital (CAH) staff failed to complete an initial nurse admission assessment for 3 of 3 patient records reviews (#304, #305, and #306).

Failure to ensure hospital staff completes the nurse admission assessments patients at risk for inappropriate plans of care and treatment, delayed coordination of care needs, and adverse health consequences.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Adult Admission, Admission History and Daily Assessment Documentation Requirements," PolicyStat ID #16990192, last approved 11/24, showed that:

a. Factors that must be considered in the assessment include the patient and family's perception of the illness and how the patient should be treated, the degree of illness, cognition, communication challenges, cultural and religious needs, social and economic status, education and developmental level, activities of daily living, physical, emotional and physiological status. The result of the assessment is a personalized plan of care.

b. The registered nurse is responsible for assessing and completing the patient assessment within 6 hours of admission and the individualized plan of care is initiated.

c. Patients are screened during the initial assessment for psychiatric or substance abuse, and discharge planning (Patients at risk include psychological diagnosis, physical barriers at home, abuse and neglect, over the age of 70, elderly frail spouse or limited/adequate support), functional status (recent falls, elderly, swallowing difficulties).

d. The RN is required to complete allergy review, family history, social history, cultural/spiritual needs, discharge needs, functional assessment, vision, hearing and dental screening, and patient safety.

2. On 11/20/24 between 2:10 PM and 3:00 PM, the Surveyor #3, the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302) and the Medical Surgical Manager (Staff #303) reviewed the medical surgical patient records. The review showed the following:

Patient #304

a. Patient #301 was admitted from home after suffering speech difficulties due to a transient ischemia attack (TIA) on 8/13/24 at 4:10 PM. The review showed Patient #301 had a history of subarachnoid hemorrhage.

b. A review of the nurse admission assessment showed no screening or review completed for medication allergies, procedure history, psychosocial, cultural, spiritual, functional, or discharge needs.

At the time of the review, Staff #302 and Staff #303 verified the missing assessment areas.

Patient #305

a. Patient #305 was admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home. The review showed Patient #305 had a history of memory impairment and falls.

b. A review of the nurse admission assessment showed no review completed for procedure history, family, social, psychosocial, cultural, spiritual, functional, or discharge needs.

At the time of the review, Staff #302 and Staff #303 verified the missing assessment areas.

#306

a. Patient #306 was admitted from home while on hospice on 11/17/24 at 3:38 AM for breathing difficulties and end-of-life care. Patient #306 had a history of chronic obstructive pulmonary disease (COPD), mental health disorders, and substance abuse. The review showed that the nurse admission assessment was incomplete during Patient #306's hospitalization.

At the time of the review, Staff #302 and Staff #303, verified the missing admission history assessment. The interview showed that nursing staff had 24 hours to complete the patient assessment.
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Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infections places patients, staff, and visitors at risk of communicable illnesses.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Hand Hygiene," PolicyStat ID #16100831, last approved 06/24, showed the following:

Indication for handwashing and hand antisepsis include:

a. Decontaminate hands before having direct contact with patients.

b. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled.

Glove use:

a. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur.

2. On 11/20/24 between 10:35 AM and 10:50 AM, Surveyor #2 and Surveyor #3 and the Surgery Department Manager (Staff #202) observed a patient undergoing cataract eye surgery (Patient #206). Surveyor #2 observed a Surgery RN (Staff #206) administer eye drops to the surgical patient in the operating room who did not perform HH or wear gloves prior to the eye drop administration and no HH post eye drop administration.

3. At the time of the observation, Surveyor #2 verified the observation with Staff # 202.
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Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Findings included:

1. Document review of the hospital's policy titled, "Scheduled Maintenance and Inspections, EOC Systems," PolicyStat ID 14781054, approved 11/23, showed that the maintenance department was responsible for environment of care inspections at the facility that included checking utilities systems and general life safety items but did not include checking walls, floors or furnishings for damages.

2. On 11/19/24 at 9:30 AM Surveyor #4 toured the emergency department (ED) with the Infection Preventionist (Staff #401) and the ED Manager (Staff #402). During the tour, the surveyor observed several areas where the walls had been patched but not painted.

3. During the observation, Surveyor #4 discussed the damage to the walls as being a non-cleanable surface with Staff #401. Staff #401 confirmed the damage.

4. On 11/19/24 at 10:30 AM Surveyor #4 observed a discharge cleaning of Acute Care Room 9. During the observation the surveyor noted a small wood dresser next to the patient bed. The wood sealer on the dresser was worn and missing along the top corners. Staff #401 confirmed the wood dresser was losing its varnish/seal and no longer a cleanable surface in those areas.

5. On 11/20/24 at 4:00 PM, Surveyor #4 observed a colonoscope reprocessing with Staff #401 and a surgical technician (Staff #403). During the observation, the surveyor saw 3 areas of exposed drywall on the wall directly above the reprocessing sink. Staff #401 confirmed the wall was missing paint in those areas and was not a cleanable surface.
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Based on observation and interview, the Critical Access Hospital failed to have a certified food protection manager on staff to oversee the dietary needs of the hospital as required by the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12).

Failure to have the required certified food protection employee to manage the dietary services puts patients, staff, and visitors at risk of harm from food borne illnesses.

Findings included:

1. On 11/20/24 at 9:00 AM, Surveyor #4 inspected the hospital's dietary kitchen with the Dietary Manager (Staff #404) and the Infection Preventionist (Staff #401). During the inspection, the surveyor asked Staff #404 about her Food Protection Certification. Staff #404 stated that she had not completed a certified Food Protection Management course but thought the Registered Dietician (RD) may have completed this.

2. On 11/21/24 at 10:00 AM, Surveyor #4 reviewed personnel files and training records with the Human Resources Manager (Staff #405). The review showed the hospital's Dietary Manager has a food handlers permit but is not a certified Food Protection Manager. The surveyor discussed the requirement with Staff #405. Staff #405 confirmed that currently no hospital staff are Certified Food Protection Management as required.

Reference: Washington State Retail Food Code WAC 246-215-02107 Certified food protection manager (FDA Food Code 2-102.12).
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Based on the interview, document review, and medical record review, the Critical Access Hospital (CAH) staff failed to implement policies and procedures for transferring patients from the facility to another acute care hospital for 2 of 5 patient records reviewed (Patients #302 and #303).

Failure to ensure hospital staff implement guidelines for patient transfers places the patient at risk for delay in care, inappropriate level of care, and poor outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled "(EMTALA) Medical Screening Examination, Stabilization and Treatment," PolicyStat ID 1537074, last approved on 03/24, showed "Request for Transfer/Consent for Transfer/Certification for Transfer" is required and fully completed for patients. The patient or representative's written consent/request is on this document.

2. Document review of the hospital's policy and procedure titled "Suicide Precautions" PolicyStat ID 16487782, last approved 08/24, showed that patient transfers required the completion of the transfer certificate.

3. On 11/19/24 between 1:50 PM and 3:15 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Officer (Staff #301), and a Health Informatics Specialist (Staff #302) reviewed the medical records of patient transfers to another acute care hospital. The review showed the following:

a. Patient #302 was transferred to another acute care hospital on 11/12/24 at 11:37 PM. Review of the Consent to Transfer form showed the patient or representative's written consent blank.

b. Patient #303 was transferred to a psychiatric facility on 10/29/24 at 2:48 AM. The review showed there was no Consent to Transfer form in the electronic medical record.

4. At the time of the reviews, Staff #302 verified the blank Consent to Transfer form and the missing transfer.
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Based on interviews, document review, and review of policies and procedures, the Critical Access Hospital (CAH)failed to identify or screen for discharge planning needs in 3 of 3 patient records (Patients #304, #305, and #306).

Failure to ensure hospital staff screens all at-risk patients for post-discharge needs during the nurse admission assessment places patients at risk for delayed coordination of care needs and adverse health consequences.

Findings included:

1. Document review of the CAH's policy and procedure titled "Discharge Planning," PolicyStat ID #17014727, last approved 11/24, showed:

a. Initial identification/screening for discharge planning needs shall be conducted during the nursing admission assessment.

b. An automatic referral to the discharge planner is made for all high-risk patients (homeless, long-term intravenous infusions, suspected abuse, unable to perform activities of daily living by themselves, terminal diagnosis).

2. Document review of the hospital policy and procedure titled "Admissions," PolicyStat ID #17014605, last approved 11/24, showed that:

a. The registered nurse (RN) is responsible for assessing and completing the patient assessment within 6 hours of admission and the individualized plan of care is initiated.

b. Patients are screened during the initial assessment for psychiatric or substance abuse, and discharge planning (Patients at risk include psychological diagnosis, physical barriers at home, abuse and neglect, over the age of 70, elderly frail spouse or limited/adequate support), functional status (recent falls, elderly, swallowing difficulties).

3. On 11/20/24 between 2:10 PM and 3:00 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302), the Medical Surgical Manager (Staff #303) reviewed the medical surgical patient records. The review showed the following:

a. Patient 304 was an 88-year-old patient admitted from home after suffering speech difficulties due to a transient ischemia attack (TIA) on 8/13/24 at 4:10 PM. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs.

b. Patient #305 was a 75-year-old patient admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home, and Patient #305 had a history of memory impairment and falls. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs.

c. Patient #306 was a 55-year-old patient admitted from home while on hospice on 11/17/24 at 3:38 AM for breathing difficulties and end-of-life care and had a history of chronic obstructive pulmonary disease (COPD), mental health disorders, and substance abuse. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs.

4. At the time of the review, Staff #302 and Staff #303, verified missing the nurse admission screening for discharge needs and incomplete nurse admission assessment.
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