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Based on interview, observation, review of crash cart checklist documentation for 6 of 6 emergency crash carts, and policy review, it was determined the hospital failed to document that its emergency crash carts were maintained in accordance with its policy and to assure the integrity and availability of the contents of the carts.

Findings include:

1. A policy titled "Procedure For Crash Cart(s)-Checking and Locks," effective 06/2001 was reviewed. The policy reflected "A. Under the direction of the hospital pharmacist, NURSING will be responsible for checking the crash carts monthly. 1. The entire crash cart will be checked to assure all medications and equipment are clean, well supplied and ready for use. 2. The medication drawer: Remove the lock, remove ALL outdated medications and restock according to the check list. NO MORE AND NO LESS as specified by the check list...A new lock, in the appropriate numbered sequence will be applied to the medication drawer after each check. 4. The CRASH CART RECORD will be completed and signed by the R.N. OR L.P.N. who changes the lock...Nursing will make the appropriate staff assignments to assure the carts are checked on schedule...E. The defibrillator will be checked on each shift to make sure it is functioning by the charge nurse. This will be recorded on the defibrillator check sheet."

2. A policy titled "Code Cart Check," effective 06/2001 was reviewed and reflected "...2. A supply of locks is kept in the Pharmacy only. Locks are numbered and may be obtained from the Pharmacy. Include the lock number and reason why a new one was needed, i.e., and routine monthly check or replaced following code."

3. Tours of the hospital's medical/surgical unit, labor and delivery suite, and radiology department alcove areas were conducted with the Director of Nursing Services (DON) on 04/17/2012 at 0850. Crash carts were observed in the medical/surgical unit and the radiology department alcove area. Two crash carts were observed in the labor and delivery suite, one for adult patients and one for neonatal patients. Each crash cart had a corresponding crash cart checklist. The radiology and medical/surgical unit crash carts also had a corresponding defibrillator checklist.

The emergency crash cart checklist titled "Blue Mountain Hospital Med/Surg and Xray Code Carts" for the medical/surgical unit was reviewed. The checklist had columns with monthly checks for items which were contained within the cart such as medications and emergency care equipment. The checklists were reviewed for 12/2011, 01/2012, 02/2012 and 03/2012. No checks were documented for the month of 02/2012.

Further review of the medical/surgical checklists revealed that some individual items were not documented as checked. For example, the 12/05/2011 monthly check for "Procainamide [a drug used in the treatment of abnormal heart rhythms] 100 mg/ml...1 vial," "Suction Catheters...2 each," and "Flashlight...1 each" lacked documentation of a monthly check for that month. These findings were reviewed with the DON and he/she acknowledged that the crash cart checklist lacked documentation of monthly checks in accordance with hospital policy.

The emergency crash cart defibrillator checklist for the medical/surgical unit was reviewed. The checklist was titled "MED/SURG" and included a calendar with the months 01/2012, 02/2012, 03/2012 and 04/2012. During an interview with the DON on 04/17/2012 at 0850, he/she revealed that charge nurses worked 12 hour shifts and therefore there should be 2 defibrillator checks documented for each calendar day on the checklist. Review of the checklist revealed that many defibrillator checks were not documented each shift as directed by hospital policy. For example, only one check per day was documented 11 days out of 31 for the month of 01/2012; and no checks were documented 11 days out of 31 for that same month. Similar findings were identified for the months of 02/2012, 03/2011 (sic) and 04/2012. These findings were reviewed with the DON on 04/17/2012 at 0850 and he/she acknowledged that the defibrillator checks were not documented in accordance with hospital policy.


Similar findings were identified during review of emergency crash cart checklists for the labor and delivery, neonatal, and two emergency department ("Stemi Medication Drawer Check List" and "Pediatric Emergency Cart Checklist") crash carts; and review of the defibrillator checklists for the radiology department and emergency department (adult) crash carts.


4. An observation of the emergency crash cart for the medical/surgical unit was conducted with the DON on 04/17/2012 at 0850. The observation revealed the cart was "locked" with a break away lock numbered 6487331. The DON indicated that break away lock numbers for emergency crash carts were recorded in a log book located in the pharmacy department. He/she said that each time a break away lock was removed from a cart, the lock number and the number for the replacement lock was to be recorded on the log. The log book was reviewed with the DON. The log had columns which reflected "DATE," "TIME," "NURSE," "LOCK NO," "EXPLANATION AS TO WHY LOCK WAS REMOVED," and "NEW LOCK NO." Review of the log documentation reflected the last new lock was placed on the "Med/Surg Code Cart" on 03/24/2012 at 0320. The "NEW LOCK NO." was documented 6497318. No further lock numbers were documented on the log for the medical/surgical unit emergency crash cart. The DON acknowledged that lock number 6487331 on the medical/ surgical unit crash cart did not correspond with the last recorded log book number 6497318. Lock number 6487331 was not recorded on the log including the reason why a new lock was needed in accordance with hospital policy. Therefore the integrity of the contents of the cart could not be assured.

Based on documentation in 3 of 3 medical records reviewed of patients who received blood transfusion services (Record #s 7, 8 and 9) and policy review, it was determined the hospital failed to ensure documentation of all of the elements for blood transfusions as required by hospital policy. Vital signs were not documented according to hospital policy. Blood was not transfused within time frames as directed by hospital policy.

1. The policy titled "Standard of Care - Administration of Blood," effective 05/01/2001 reflected "Blood or blood products are administered under the following guidelines...Obtain and document baseline vital signs, then 15 min. after transfusion is started then 1 hour after the transfusion is completed...The maximum time for infusion of one unit is four hours..."

2. Patient record #s 7, 8 and 9 were reviewed. A form titled "Blood Bank" was contained within each of the patient records. The form included a "SIGN OUT RECORD" with the blood transfusion date, "TIME BEGUN [time transfusion begun]" and "TIME COMPLETED [time transfusion completed]." The form also had a section for recording "vitals signs" at designated time frames as follows: "BEFORE TRANSFUSION," "15 MIN. AFTER START," "1 HOUR AFTER START," and "60 MIN. POST COMPLETION." Each of the time frames were followed by columns for documenting temperature, pulse and blood pressure readings. There were was no column for documenting respiratory rate.

3. Patient record #7 was reviewed. The "BLOOD BANK" form reflected the patient received one unit of blood on 04/02/2012. The "TIME BEGUN" was 1245 and "TIME COMPLETED" was 1730, more than the maximum of four hours after the transfusion was started in accordance with hospital policy. Temperature, pulse and blood pressure readings were documented on the form following the time frames "15 MIN. AFTER START," "1 HOUR AFTER START," and "60 MIN. POST COMPLETION." However, review determined the form lacked a documented time when the temperature, pulse and blood pressure were completed, and there was no documented respiratory rate. Review of the electronic medical record reflected temperature, pulse, respirations and blood pressure readings were not recorded until 04/02/2012 at 1418, more than an hour after the blood transfusion was started. The record lacked documentation that vital signs were completed in accordance with hospital policy.


The record reflected Patient #7 received another unit of blood on 04/02/2012 which was started at 1730 and completed at 2000. Temperature, pulse and blood pressure readings were documented on the "BLOOD BANK" form following the time frames "15 MIN. AFTER START," "1 HOUR AFTER START," and "60 MIN. POST COMPLETION." However, review determined the form lacked a documented time when the temperature, pulse and blood pressure were completed, and there was no documented respiratory rate. Review of the electronic medical record reflected temperature, pulse, respirations and blood pressure were recorded on 04/02/2012 at 1730, 1747, 1840 and 2000. The next set of vital signs were not documented until 2120, 80 minutes after the blood transfusion was completed.


Similar findings were identified in Patient record #s 8 and 9.


4. An interview was conducted with the Compliance and Quality Improvement Coordinator on 04/18/2012 at 0930. The "BLOOD BANK" forms contained within Patient record #s 7, 8 and 9 were reviewed. He/she acknowledged that although the forms reflected time frames for documenting temperature, pulse and blood pressure readings as "15 MIN. AFTER START," "1 HOUR AFTER START," and "60 MIN. POST COMPLETION" there was no actual time when the vital signs were documented on those forms.

Based on policy review, hospital board by-laws, and medical staff by-laws, and review of 2 of 7 credential staff files (C5 and C7), it was determined that the hospital failed to document compliance with the certification requirements for physicians who take call for the Emergency Department (ED) per hospital policy and by-laws.

1. A review of an Emergency Services policy titled "Blue Mountain Hospital District EMERGENCY SERVICES, "STAFFING," last reviewed 12/17/2009, reflected "One Advance Trauma Life Support [ATLS] credentialed physician per 24 hours shift."

2. A review of the "BLUE MOUNTAIN HOSPITAL DISTRICT BY-LAWS," ARTICLE IX, Section 1. f. reflected "The applicant shall sign a statement furnished to him/her by the DISTRICT CHIEF EXECUTIVE OFFICER acknowledging that he/she has read and understood the by-laws, rules and regulations and that he/she specifically agrees to the following undertakings: 1. An obligation as member of the Medical Staff to provide continuous care and supervision to all patients in the hospital for whom he/she has responsibility. 2. An obligation as a member of the Medical Staff to provide timely emergency care to any individual seeking such care through the hospital's Emergency Department while assigned emergency call duty as outlined in the by-laws, rules and regulations of the Medical Staff."

3. A review of the "BLUE MOUNTAIN HOSPITAL MEDICAL STAFF RULES AND REGULATIONS" reflected "A...4. Emergency Admission...If a patient is admitted to the Hospital through the emergency room, then the attendant Physician in the emergency room is and shall remain the responsible attending Physician until there is written notice recorded on the order sheet of the patient's medical record which states that transfer of care has been made to and accepted by another Member of the Medical Staff...F. EMERGENCY SERVICES 1. Procedure (1) The Medical Staff shall adopt a method of providing medical coverage in the emergency services area."

All physicians who practice at the hospital take turns being on call for the ED and providing ongoing care for the patients they admit as inpatients.

4. A review of credentialed staff's files on 04/18/2012 at 1230 revealed the hospital failed to document ATLS certification for 2 of 7 (C5 and C7) randomly chosen physicians per Hospital Board By-Laws, Medical Staff By-laws and hospital policy.

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. During the CAH recertification and State relicensure survey, it was determined that many policies were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of patient care policies that have not been reviewed for more than a year:

-BLUE MOUNTAIN HOSPITAL, "COMPLAINT/GRIEVANCE GUIDELINES," last reviewed 08/02/2005;
-Blue Mountain Hospital District, "CPR CERTIFICATION," last reviewed 08/02/2005;
-BLUE MOUNTAIN HOSPITAL DISTRICT, "POLICY: EMERGENCY MEDICAL TREATMENT and ACTIVE LABOR ACT (EMTALA) CONSOLIDATED OMNIBUS BUDGET RECONCILIATION LABOR ACT (COBRA), last reviewed 08/02/2005;
-Blue Mountain Hospital District, "E.R. Staff Orientation," last reviewed 08/02/2005;
-BLUE MOUNTAIN HOSPITAL DISTRICT, "OBSTETRIC ORIENTATION," last reviewed 08/09/2002;
-BLUE MOUNTAIN HOSPITAL, "SANE RESPONSE POLICY AND PROCEDURE," last reviewed 11/2009;
-BLUE MOUNTAIN HOSPITAL DISTRICT, "STAFFING PLAN," last reviewed 08/02/2009;
-Blue Mountain Hospital District, "STAFFING," last reviewed 12/17/2009;
-Blue Mountain Hospital Surgery Department, "CARDIOPULMONARY RESUSCITATION TRAINING REQUIREMENTS," last reviewed 07/01/2010

2. During an interview with the DON on 04/17/2012 at 1200, he/she confirmed that the patient care policies and procedures were not being reviewed annually. He/she confirmed the hospital hired a consultant to assist in the revision of policies and procedures and with making the policies and procedures electronically available to all staff.

Based on interview, review of documentation in 3 of 3 records of patients who underwent a surgical procedure with general anesthesia (Record #s 10, 11, and 13), and policy review, it was determined that the hospital lacked documentation that all patients were discharged in the company of a responsible adult following their procedure in accordance with hospital policy.

Findings include:

1. The Surgical Services department policy titled "Discharge Orders & Patient Instructions," effective 07/01/2010 was reviewed and reflected "...Discharge RN ascertains that the patient has a responsible person to transport the patient home and stay with the patient during the day and overnight...Discharge RN records the following information in the patient record...Who patient is accompanied by...Type of transportation to private vehicle (ambulatory, wheelchair, etc.)..."

2. Patient record #10 was reviewed. The record reflected the patient underwent a left elbow surgery on 12/16/2011 and received general anesthesia for the procedure. The procedure was started at 0849 and completed at 0914. The patient was discharged at 1047 the same day. The record lacked documentation of who accompanied the patient upon discharge in order to ensure that the patient had a responsible person to transport him/her home upon discharge as directed by hospital policy.

3. Patient record #11 was reviewed. The record reflected the patient underwent an umbilical hernia surgical procedure on 12/06/2011 and received general anesthesia for the procedure. The procedure was started at 0819 and completed at 0941. The patient was discharged home at 1115 the same day. The record lacked documentation of who accompanied the patient upon discharge.

4. Patient record #13 was reviewed and reflected that the patient underwent a gallbladder surgery on 12/20/2011 and received general anesthesia for the procedure. The procedure was started at 0806 and completed at 0941. The patient was discharged at 1300 the same day. The record lacked documentation that the patient had a responsible person to transport him/her home upon discharge.

5. An interview and review of Patient record #s 10, 11, and 13 was conducted with the Operating Room Manager on 04/19/2012 at 1540. He/she acknowledged that none of the records reviewed contained documentation of who accompanied the patient upon discharge in order to ensure the patient had a responsible person to transport him/her home as directed by hospital policy.

Based on the review of documentation contained in 3 of 4 records of patients who expired at the hospital (Record #'s 3, 4, and 6), policy review, and review of organ procurement contract documentation, it was determined that the hospital failed to ensure documentation of notification of the donor referral organization as required. The hospital policy did not include a definition of imminent death in accordance with hospital policy.

Findings include:

1. The "Contract For Pacific Northwest Transplant Bank Organ Procurement Services" signed/dated 09/02/2011 was reviewed and reflected "ENTITY shall refer all ventilated patients for which death is imminent to the donor referral line...ENTITY must make the referral in a timely manner in order to allow PNTB [Pacific Northwest Transplant Bank] to adequately evaluate the patient for medical suitability. A timely referral is one that occurs as soon as the patient meets the mutually agreed upon clinical trigger/imminent death criteria and prior to the withdrawal or deceleration of life sustaining therapies as set forth in more detail in ENTITY policy."

2. The policy titled "Organ/Tissue/Eye Donation-Nursing Staff Responsibilities," effective 07/01/2012 was reviewed and reflected "Designated hospital staff will notify the Organ Donor Association of an individual's death or imminent death in the hospital in a timely manner. The ODA [Organ Donor Association] will establish protocols to designate those deaths or imminent deaths that will be reported...The hospital and the ODA will determine the criteria for imminent death (approved by the medical staff) and when the ODA should be notified (ideally within one [1] hour)...Procedure...Cardiac Death...The nurse will notify the Nursing Supervisor immediately upon the patient's death...The Nursing Supervisor or Registered Nurse will call the death into the [ODA]..." Review of the policy revealed it did not include a criteria or definition for determining "imminent death."

3. Patient record #3 was reviewed. The patient was admitted to the hospital on 12/21/2011 at 1625. The patient expired at the hospital on 12/28/2011. Review of the record revealed it lacked documentation that the ODA had been notified in accordance with hospital policy.

Patient record #4 was reviewed. The patient was admitted to the hospital on 10/17/2011 at 1930. The patient expired at the hospital on 10/20/2011. Review of the record revealed it lacked documentation that the ODA had been notified in accordance with the hospital policy.

4. The medical record for Patient #6 was reviewed. The patient was admitted to the hospital on 02/20/2012 at 1330. The hospital's "RELEASE OF DECEASED PATIENT" form reflected the patient expired at the hospital and was released to a mortuary on 02/23/2012. Review of the record revealed it lacked documentation that the ODA had been notified.

5. An interview was conducted with the Swing-bed Coordinator on 04/18/2012 at 1045. He/she reviewed Patient record #s 3 and 4. The coordinator acknowledged that both records lacked documentation of ODA notification as directed by hospital policy.

Based on documentation contained in 1 of 1 Swing-bed record reviewed of a patient who was discharged from the hospital following Swing-bed services (Record # 1) and the review of hospital Swing-bed policies and forms, it was determined the hospital failed to ensure the provision of a written notice before discharge with all of the elements required by this regulation and in accordance with hospital policy.

Findings include:

1. The policy titled "Transfer & Discharge Requirements" approved 12/15/2010 was reviewed and reflected "...Swing Bed...Before BMH [Blue Mountain Hospital] transfers or discharges a patient, the facility must...1. Notify the patient and, if known, a family member or legal representative of the patient of the transfer or discharge and the reasons for the move in writing ain [sic] in a language and manner they understood...3. Include in the notice the items described in "Contents of the Notice", Below.
CONTENTS OF THE NOTICE
The written notice must include:
1. The reason for transfer or discharge.
2. The effective date of transfer or discharge.
3. The location to which the patient is transferred or discharged.
4. A statement that the patient has the right to appeal the action to the State.
5. The name, address, and telephone number of the State long term care Ombudsman.
6. In the case of patients with developmental disabilities, the mailing address and telephone number of the agency of the Developmental Disabilities Assistance and Bill of Rights Act.
7. For patients who are mentally ill, the mailing address and telephone number of the agency responsible for protection and advocacy of the mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act."

2. Review of the hospital's Swing-bed policies reflected that the hospital had developed a form titled "Notice of Intent to Discharge." The form did not include the name and address of the State long term care Ombudsman, the mailing address of the agency responsible for the protection and advocacy of developmentally disabled individuals for nursing facility residents with developmental disabilities, and the mailing address of the agency responsible for the protection and advocacy of mentally ill individuals.

3. Swing-bed patient record #1: Review of the record reflected the patient was admitted to a hospital Swing-bed on 02/06/2011 and discharged home on 02/10/2011. The record lacked documentation that a written discharge notice with all of the required elements had been provided to the patient prior to discharge. The record contained a "Notice of Intent to Discharge" form which had not been filled out. The "Notice of Intent to Discharge" form lacked the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the patient was transferred or discharged, and the name and address of the State long term care Ombudsman.

4. An interview was conducted with the hospital's Swing-bed Coordinator on 04/18/2012 at 1110. He/she reviewed Patient record #1 and acknowledged that the "Notice of Intent to Discharge" form was not completed and there was no other documented transfer or discharge notice with all of the required elements contained within the record. He she further acknowledged that although the "Notice of Intent to Discharge" form reflected "...Address for these agencies are available from the hospital staff," the notice lacked the name and address of the State long term care Ombudsman, the mailing address of the agency responsible for the protection and advocacy of developmentally disabled individuals for nursing facility residents with developmental disabilities, and the mailing address of the agency responsible for the protection and advocacy of mentally ill individuals.