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Based on observation of the emergency department (ED) and a staff interview, it was determined that the hospital failed to ensure that medications available for patient use in treating emergency cases were maintained according to accepted standards of practice.

Findings include:

Observation of the emergency crash cart and the "dressing cart" located in the ED on 09/09/2011 at approximately 1000 with the director of nursing revealed the following multi-dose medication vials available for patient use. None of the vials were dated when they were opened in order to ensure that they were discarded at or before 28 days in accordance with accepted standards of practice:

-one Labetalol HCl 100 mg/20 ml, 20 ml vial;
-two 1% Lidocaine HCl 10 mg/1 ml, 50 ml vials;
-two 2% Lidocaine HCl 10 mg/1 ml, 50 ml vials; and
-one 1% Lidocaine HCl and Epinephrine 1:100,000 vial

An interview was conducted with the director of nursing on 09/09/2011 at approximately 1000 and he/she affirmed that the above vials were multi-dose vials; and that multi-dose vials are normally dated when opened, and discarded within 28 days. He/she further said that hospital RN staff are responsible for checking the ED medication and supply carts for outdates. A phone interview was conducted with the director of nursing on 09/23/2011 at approximately 1300 and he/she said the hospital had no policy and procedure for the management of multi-dose vials in order to ensure they were discarded within 28 days of opening.

Based on a review of the medical records of 4 patients receiving transfusions of blood or blood products at the facility, it was determined that while the facility had blood and blood products available on a 24-hours a day basis, facility staff failed to follow facility transfusion policies while transfusing 3 of 4 patients (Records # 18, 19, and 22).

Findings are:

The facility had a policy titled "Administration of Packed Red Blood Cells" with an effective date of "07/07" and no additional date under the "Review/Revised" that stated under Patient Identification "Two members of the nursing department (one must be an RN) will verify the physician order. At the patient's bedside the same two people will verify the unit information matches with the patient(')s arm band and blood bank ID band #." Additionally, under "Upon Completion of Transfusion," the policy stated: "5. Complete documentation:....c. Review Post Transfusion Instructions with patient. Give patient copy of post transfusion instructions and place copy in the chart."

Patient # 19 received 3 units of packed red blood cells (PRBC) on 03/07/2011 and 3 units of PRBC on 03/09/2011. Unit # 21LQ61331 transfused from 2400 on 03/07/2011 to 0330 on 03/08/2011 lacked the signature of a second witness. Unit # 21KF77350, transfused from 1555 to 1905 on 03/07/2011, lacked the time for both signatures of witnesses to that transfusion. Unit # 21KE34820, transfused from 1955 to 2330 on 03/07/2011, lacked the time for one witnesses's signature. Unit # 21LT05753, transfused from 1430 to 1635 on 03/09/2011, and Unit # 21LZ5968, transfused from 1145 to 1415 on 03/09/2011 lacked an indication if a reaction occurred or did not occur. The latter unit's "Blood or Blood Component Transfusion Form" also lacked a time that the baseline vital signs were taken.

Patient # 18 received 2 units of PRBCs on 03/24/2011; Unit # 21LK79486 and Unit # 21N37493. The "Blood or Blood Component Transfusion Form" for both units lacked an indication if a reaction occurred or did not occur.

Patient # 22 received 3 units of PRBCs on 01/10/2011; Unit # 21LL82240. The "Blood or Blood Component Transfusion Form" for this unit lacked an indication if a reaction occurred or did not occur. This medical record lacked a "Blood Transfusion Discharge Instructions."

Based on observations, documentation review, and interviews with hospital staff, the State Fire Marshals determined that the hospital failed to test the fire alarm system monthly; failed to continuously maintain, inspect, and test the required automatic sprinkler system; and failed to continuously maintain, inspect, and weekly test the required emergency power generator. The cumulative effect of these systemic problems resulted in a threat to the health and safety of patients and staff. Findings include:

Refer to the detailed findings listed at K tags; K 52, K 62, and K 144.

Based on observations, staff interviews, the review of policies and procedures, and a tour of the ED, it was determined that the hospital failed to maintain housekeeping and preventative maintenance programs to ensure that the physical environment was clean and supplies were stored properly in order for patients and staff to function safely.

1. Observations of the outdoor compressed gas storage area located outside the emergency department triage area were conducted on 09/06/2011 at approximately 1630 with the director or nurses; on 09/07/2011 at 1550 with the administrator; and on 09/09/2011 at 1030.

During all three observations, four tanks of unopened, compressed oxygen and one tank of unopened, compressed nitrous oxide were stored in an unsafe fashion; the oxygen tanks were not secured, positioned upright on top of a separate rack of oxygen tanks, and leaning against the outside facility wall. The nitrous oxide was also unopened and positioned in an upright position, not secured, and next to several other larger tanks of compressed gas that had a chain around them.

2. An interview and observation of a housekeeping cart was conducted with the housekeeping manager on 09/08/2011 at approximately 1530. The top section of the cart was open and held a container of odor eliminator spray. The bottom section of the cart was also open and held several containers of cleaning chemicals and supplies including a disinfectant spray. The middle section of the cart was enclosed with a locking door, also contained several types of cleaning chemicals and supplies, but was not locked. He/she acknowledged that the middle section of the cart had the capability of being locked, but was not normally locked. This was verified with a housekeeper at the time of the observation. The housekeeper said cleaning chemicals and/or supplies were routinely stored on the bottom section, and middle sections of the cart. He/she further said the carts were kept outside patient rooms in the hallway when housekeeping staff were cleaning the rooms, and therefore the cleaning chemicals and supplies contained on the carts were accessible to, and posed a safety risk to patients as it could not be assured they were in the housekeeper's line of vision at all times.

Housekeeping policies and procedures were reviewed with the housekeeping manager and he/she said the facility did not have policies and procedures for the security of chemicals/cleaning supplies that were stored on the housekeeping carts.

3. During a tour of the ED treatment room on 09/09/2011 at 1000 with the director of nursing, there were approximately five separate patched wall areas that included areas to the right upper side of the hallway ED entry door and above the "head" of the second patient bed. The patched areas had not been painted and therefore were uncleanable surfaces.

Based on the review of the Hospital's Quality Assurance Committee meeting minutes, review of the hospital's Quality Improvement plan, and interviews of hospital staff, it was determined that the facility administrator failed to ensure that all contracted services were furnished in a manner to enable the CAH to comply with Federal regulations and state rules as required by this regulation.

Findings are:

A review of the Hospital's Quality Assurance Committee meeting minutes on 09/08/2011 determined that those minutes lacked a number of quarterly reports for the pharmacy department. An interview of the director of nursing occurred at 10:00 and the pharmacist supplying pharmacy services and oversight was called to the facility, arriving at 11:05. The pharmacist provided additional quarterly reports but failed to provide reports for the fourth quarter of 2009 and the first quarter of 2010.

Refer to E Tag 505, OAR 333-520-0020 Dietary Services; the facility lacked a process for the submission of quarterly reviews to the administrator of services furnished by the hospital's contracted dietician.

In an interview with the hospital administer on 09/08/2011 at 16:00, the administrator affirmed that the facility lacked a process for scheduled, systematic reviews of the services provided through contracts.

Based on the review of policies and procedures, the review of documentation, and a staff interview, it was determined that the CAH failed to ensure that each individual designated by the CAH to initiate requests to the families of potential organ, tissue, or eye donors was an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology for approaching potential donor families and requesting organ or tissue donation. Additionally, based on the review of the CAH's organ, tissue and eye procurement policies, it was determined that the CAH also failed to define "imminent death" within those policies.

An eye donor agreement titled "AFFILIATION AGREEMENT FOR EYE DONOR PROCUREMENT Between LIONS VISIONGIFT And PIONEER MEMORIAL-HEPPNER" signed/dated 08/08/2011 was reviewed and reflected "LIONS VISIONGIFT will...Provide periodic education for designated requestors...PROCUREMENT HOSPITAL will: 1. Refer all patients who are deceased or whose death is imminent to the donor referral line..."

A "MORROW COUNTY HEALTH DISTRICT" ED policy titled "Organ Donation" dated effective 06/02 was received on 09/07/2011 by the director of nursing. The policy reflected "All deaths or pending deaths within the [ED] will be reported to the OREGON ORGAN DONOR PROGRAM...the [ED] must have documentation stating family acceptance or denial of donation." On 09/08/2011 at 1225, a policy titled "Special Facilities Organ Procurement" dated effective 05/01/02 was received and reviewed. The policy reflected "The DONOR REFERRAL LINE...is notified of all deaths...On the rare occasion, the donor can be transported to Hermiston, Oregon for organ harvesting..." None of the documentation in the policies and procedures identified which staff were "designated requestors." The policies further failed to include a definition of "imminent death."

An interview was conducted with the director of nursing on 09/08/2011 at 1110. He/she said that the CAH did not have the capabilities for organ procurement, but were able to facilitate eye donations. He/she further said that all charge nurses were "designated requestors" for potential donor families. On 09/09/2011, he/she provided documentation that included staff training pertinent to organ, tissue and eye donation, however he/she further acknowledged that the documentation failed to include all of the hospital's current charge nurses that were "designated requestors" as required by this regulation.

Based on a staff interview, the review of hospital swing-bed patient rights documentation, and the review of 5 of 5 medical records (Record #s 9, 10, 11, 12 and 21) of hospital residents who had received swing-bed services, it was determined the hospital failed to ensure that each resident was informed of all of his/her swing-bed resident rights contained in the regulations; it was also determined that the hospital failed to document that each resident received his/her rights orally as required.

Findings include:

Review of the Resident Rights document titled "SWING BED PROGRAM PATIENT'S RIGHTS" provided to the swing-bed residents lacked identification of all of the rights listed in the regulations. The list of Resident Rights provided to the resident by the hospital failed to identify the following rights:

-The resident has the right to refuse treatment;
-The resident has the right to formulate an advanced directive;
-Access and visitation rights - The resident has the right and the facility must provide immediate access to any resident by the following: Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident;
-Married couples - The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement; and
-Abuse - The resident has the right to be free from verbal and sexual abuse, corporal punishment, and involuntary seclusion.

Five hospital swing-bed medical records were reviewed:
All 5 swing-bed medical records contained a form titled "PATIENT RIGHTS ACKNOWLEDGEMENT." Review of the form reflected "I have read and understand my Patient Rights and Responsibilities in Pioneer Hospital's Swing Bed Program, and I agree to abide by these program obligations." Review of the form did not include that resident's were informed of their rights orally as required.

Record #s 10 and 11 - The patient rights acknowledgement form was not signed or dated by the resident; the records lacked documentation of whether or not the resident was informed of his/her resident rights in writing and orally.

Record #s 9, 12, and 21 - The records lacked documentation that the residents were informed of their rights orally as required.

An interview was conducted with an office clerk on 09/07/2011 at 1530. He/she explained the process he/she uses to provide resident rights to swing-bed residents. The process did not include providing residents with their rights orally.

Based on a staff interview and the review of 3 of 5 medical records (Record #s 9, 10 and 12) of residents who were discharged from the hospital following the provision of swing-bed services, it was determined that the facility failed to notify the resident of the discharge before the facility discharged the resident in writing including all of the required elements.

Review of medical record #s 9, 10, and 12 lacked documentation that the facility had notified the resident and, if known, a family member or legal representative of the resident of the discharge and the reasons for the move in writing, including all of the required elements.

An interview was conducted with the director of nursing on 09/08/2011 at 1225. He/she said a written discharge notice with all of the required elements was not normally provided to a swing-bed resident unless the resident was being discharged or transferred involuntarily.

Based on the review of 2 of 5 medical records (Record #s 9 and 12) for residents receiving swing-bed services, it was determined that the hospital failed to develop a comprehensive care plan for each resident that included services furnished to attain or maintain the resident's highest practicable physical and psychosocial well-being; additionally, care plan interventions were not individualized to meet the resident's needs and manage their risk factors.

Findings include:

The record for patient #9 was reviewed and revealed that the resident was admitted to the hospital swing-bed program on 07/06/2011 at 1330. The resident had diagnoses that included quadriplegia, diabetes mellitus, multiple decubitus ulcers and a urinary tract infection. The patient was discharged on 08/03/2011.

The admission database and health questionnaire revealed the patient had no movement to his/her legs, "very limited movement" to his/her arms but was able to use a trapeze, had a foley catheter, a colostomy, and was receiving decubitus wound care and intravenous antibiotic therapy.

The treatment care plan had a section designated for the resident's functional status and included feeding, bathing, toileting, oral care, positioning, transferring, [wheelchair] wheeling and walking. None of the areas were marked in order to describe the amount of assistance the resident required to maintain his/her highest practicable physical abilities.

Review of the nursing care plan included the following problems "Impaired skin integrity...Potential for skin integrity impairment...Altered peripheral tissue perfusion." The care plan included the following interventions and information "...Note any [complaints] of leg pain while walking...Wear shoes or durable slippers when ambulating...Encourage client to turn frequently or reposition themselves frequently with or without assistance per client needs...Trapeze, Alternating pressure mattress...Use convoluted (Eggcrate) mattress...Catheter...Ostomy..." The care plan lacked documentation of individualized interventions and services necessary to attain or maintain the resident's highest practicable physical and psychosocial well-being. For example, although the care plan included that the patient had a foley catheter and an ostomy, there was no information that specified the amount and frequency of assistance the resident required in order to manage those appliances and to reduce the risk for functional and medical declines related to their use; the care plan included two specialized mattresses and did not specify which mattress was appropriate in order to manage the resident's risk factors including his/her decubitus ulcers; and the care plan lacked documentation that included individualized interventions for the management of the resident's immobility and paraplegia.

The record for resident #12 was reviewed and revealed that the resident was admitted to the hospital swing-bed program on 07/18/2011. The resident had fallen and sustained a pelvic fracture and a right wrist fracture. Further review of the record revealed the resident had chronic lung disease and required oxygen therapy. The resident was discharged on 08/25/2011.

A physical therapy evaluation was completed on 07/15/2011 and revealed the resident had a splint to the right wrist, decreased range of motion to the right shoulder, used a walker for gait, and a trapeze for scooting up in bed.

The treatment care plan had a section designated for the resident's functional status and included feeding, bathing, toileting, oral care, positioning, transferring, [wheelchair] wheeling and walking. None of the areas were marked in order to describe the amount of assistance the resident required to maintain his/her highest practicable physical abilities.

Review of the nursing care plan included the following problems "Mobility, Impaired," "Potential for injury" and "[Alteration] in comfort: pain related to trauma." Interventions included "...Provide splinting/supportive Devices as ordered...Provide passive ROM [range of motion]...Assess independent ambulation and provide assistance as needed...Perform/provide:-immobilization and elevation of limb." The care plan lacked documentation of individualized interventions and services necessary to attain or maintain the resident's highest practicable physical and psychosocial well-being. For example, although the care plan directed to provide and perform immobilization and elevation of the resident's limb, there was no documentation that explained which limb was to be treated; although the care plan directed to assess independent ambulation and provide assistance as needed, there was no documentation that designated the amount and type of ambulation assistance that was needed.

This was discussd with the director of nursing on 09/08/2011 at 1225.