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Based on medical record review, staff interview, and review of Federal law and policies and procedures, the facility failed to ensure notice of the facility's advance directives policy was provided at the time of admission or registration for 16 of 20 sample inpatients (#1, #4, #5, #6, #8, #10, #11, #13, #15, #16, #17, #18, #19, #20, #21, #24). The findings were:

1. Review of the following inpatient medical records showed no evidence the facility's advance directives policy was provided:
a. Patient #1 admitted on 12/14/19.
b. Patient #4 admitted on 12/14/19.
c. Patient #5 admitted on 12/16/19.
d. Patient #6 admitted on 12/13/19.
e. Patient #8 admitted on 12/14/19.
f. Patient #10 admitted on 12/15/19.
g. Patient #11 admitted on 9/4/19.
h. Patient #13 admitted on 11/29/19.
i. Patient #15 admitted on 7/17/19.
j. Patient #16 admitted on 8/8/19.
k. Patient #17 admitted on 9/9/19.
l. Patient #18 admitted on 11/25/19.
m. Patient #19 admitted on 11/21/19.
n. Patient #20 admitted on 2/11/19.
o. Patient #21 admitted on 12/5/19.
p. Patient #24 admitted on 12/17/19.

2. Review of the facility's policy "Advanced Directives" (revised 11/19) showed "Admissions personnel will document on the EMR whether the patient has completed an advanced directive and/or the educational material concerning advanced directives has been given to the patient or patient's representative."

3. During an interview on 12/18/19 at 3:20 PM the CNO and the Vice President of Quality and Patient Safety stated advance directives information was provided and documented for swing bed patients, but not for inpatients. They confirmed the medical records for the sample inpatients did not contain evidence the facility's advance directives policy was provided to the patient.

4. Review of 42 CFR 489.102 revealed critical access hospitals "...are required to: 1) Provide written information to such individuals concerning- i) An individual's right under State law (whether statutory or recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives...ii) The written policies of the provider or organization respecting the implementation of such rights, including a clear and precise statement of limitation if the provider cannot implement an advance directive on the basis of conscience..."

Based on observation, staff interview, and review of humidity logs, Survey and Certification letters, facility policy, and facility documentation, the facility failed to ensure the humidity level was appropriate for the medical equipment and supplies in 3 of 3 ORs. The findings were:

1. Observation on 12/19/19 at 10:18 AM in OR #1 showed the humidity level was 25%. Observation on 12/18/19 at 12:06 PM revealed the humidity in OR #2 was 27%.

2. Review of the humidity logs showed the following concerns:
a. Review of the humidity logs from 9/1/19 through 12/17/19 for OR #1 showed 10 days when the humidity level was below 30%.
b. Review of the humidity logs from 9/1/19 through 12/17/19 for OR #2 showed 20 days when the humidity level was below 30%.
c. Review of the humidity logs from 9/1/19 through 12/17/19 for OR #3 showed 64 days when the humidity level was below 30%.

3. Review of a letter to the State survey agency dated 12/7/16 showed the facility was selecting the categorical waiver permitting the facility's ventilation system to operate at a 20% or greater humidity level, related to a CMS Survey and Certification (C&S) letter (13-25-LSC) dated 4/19/13. However, review of a subsequent CMS S&C letter (15-27, Hospital, CAH & ASC) dated 2/10/15 revealed that a humidity level of below 30% was not compatible with the instructions for use (IFUs) for some sterile supplies and medical equipment used in ORs. The letter stated CMS expected facilities to follow the current IFUs for supplies and equipment used in their ORs.

4. During an interview on 12/18/19 at 10:30 AM the OR director stated she did not have evidence to show the humidity level in the ORs was appropriate for the equipment and supplies. She stated she had not reviewed the IFUs for equipment and supplies to determine the humidity requirements.

5. On 12/18/19 at 10:35 PM the lead sterile technician stated she had not reviewed the IFUs to determine the humidity requirements for equipment and supplies in the ORs.

6. During an interview on 12/18/19 at 2:35 PM, the maintenance director stated he thought the humidity level in the ORs was usually 30-60%. He stated he had no evidence to show that the humidity level below 30% in the ORs was appropriate for the equipment and supplies.

7. Review of the facility's policy "Operating Rooms- Temperature, Humidity, and Ventilation" (revised 1/2017) showed "...Relative humidity shall be maintained at 20 to 60 percent...Before establishing or re-establishing the low end design RH [relative humidity] below 30% in the OR, healthcare facilities should assess the impact of lower RH on the equipment and supplies being used."

8. Review of "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations," January 2015, (http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/News/Humidity_in_OR_Joint_Communication_to_HDOs_January_2015.pdf ) showed "...relative humidity can impact the shelf life and product integrity of sterile supplies. Some products, such as biological indicators and chemical indicators used for sterilization monitoring and EKG electrodes used for patient monitoring are very sensitive to humidity...It is important for personnel to know and understand the IFUs specific to all supplies and equipment, and in particular know what environmental humidity requirements are specified in the IFU...Relative humidity may affect the operation of some electro-medical equipment used in the OR...too low humidity may also impact calibration." Further, "Before establishing or re-establishing the low end design RH levels below 30% in the OR, healthcare facilities should assess the impact of lower RH on the equipment and supplies being used...Have you determined what the IFUs say about humidity levels for each item in the HDO's [Healthcare Delivery Organization] existing inventory of supplies and equipment used in the OR?...Note: Supplies that currently require minimum RH levels of 30% or higher are used throughout a healthcare facility (e.g., EKG electrodes). While this risk assessment is specific to the OR, the same process should be considered for other areas where RH levels are going below 30% by design or effect."

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to notify the organ procurement organization (OPO) of a death for 1 or 5 expired patients (#16) reviewed. The findings were:

1. Review of the medical record for patient #16 showed the date of death in the facility was 08/09/19. Further review of the medical record showed no evidence the OPO was notified.

2. Interview with the VP of Quality and Patient Safety on 12/17/19 at 3:20 PM revealed patient #16 had been placed on hospice shortly after admission to the facility. The staff assumed that the hospice agency would make the OPO contact. It was confirmed the facility did not make contact with the OPO.

3. Review of the facility's policy titled "Organ, Tissue, and Eye Procurement", Version 4, which was undated, showed in the section labeled "POLICY: It is the policy of Star Valley Health (SVH) to identify all potential donors of organs and tissues for transplantation according to the state and federal regulation." Further review of the same document, paragraph two showed "All deaths at SVH shall be reported to Intermountain Donor Services Hotline.....for evaluation of donation potential."