HospitalInspections.org

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Based on document review, the critical access hospital failed to ensure that the telemedicine contractor agreement specified that the telemedicine entity provided services in a way that allows the hospital to comply with all applicable conditions of participation for Medicare.

Failure to have contract language specific to compliance with all conditions of participation for Medicare puts patients at risk of receiving inadequate care from telemedicine contractors.
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Findings:

On 1/8/2015 at 9:00 AM, Surveyor #2 reviewed the document titled "Professional Services Agreement between Online Radiology Medical Group Inc. and Cascade Medical Center" dated 2/2/2010. The document did not contain any language specifying that the contractor would provide teleradiology services in a way that allowed the hospital to be in full compliance with all conditions of participation for Medicare.

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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure that medications used in emergency carts were maintained so that expired items were not available for patient use.
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Failure to properly maintain emergency carts places patients at risk of having an outdated drug available for patient use.
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Findings:
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1. The hospital's policy and procedure titled "Pharmacy Medication Management" (Revised 11/2014) read in part: "2. Pharmacy shall remove all expired, damaged, contaminated or otherwise deteriorated medications from patient care areas and/or regular pharmacy stock."
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2. On 1/6/2015 at 10:45 AM in the acute care unit, Surveyor #1 found three 1ml vials of heparin 5000 units/ml with an expiration date of 1/1/2015 in the crash cart.
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3. On 1/7/2015 at 10:35 AM in the emergency room, Surveyor #1 found three 10ml syringes of sodium chloride 0.9% with an expiration date of 11/2014 in the precipitous delivery cart.
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4. An interview on 1/7/2015 at 11:30 AM with the Director of Nursing (Staff Member #1) confirmed the observations.

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Based on document review and interview, the critical access hospital failed to ensure that all facility and medical equipment is listed under their inventory and included in the facility's preventive maintenance program.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk from equipment malfunction.
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Findings:

On 1/7/2015 at 10:20 AM, Surveyor #2 interviewed the Facilities Director (Staff Member #8) about the hospital's bio-engineering program. S/he indicated that all equipment is subject to preventive maintenance through a contracted service. The surveyor asked to see the preventive maintenance history for the autoclave (Model Name: M11 Ultracave) located in the central supply department. The facilities director was unable to locate any maintenance history for this item and concluded that it was not part of the current facility inventory.
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Based on document review, the critical access hospital failed to ensure that its patient care policies received an annual review by the hospital's professional health care staff.

Failure to conduct an annual policy review puts patients at risk of unsafe or inadequate care.

Findings:

On 1/6-7/2015 Surveyor #1 reviewed the hospital patient care policies and found several policies had not been reviewed within the last year. Examples of the out-of-date policies include:

a. Hospital nursing policy titled "Patient Identification Bands and Special Bands" last reviewed 9/22/2005.

b. Hospital nursing policy titled "Fall Prevention" last reviewed 11/2011.

c. Hospital nursing policy titled "Swing Bed Activity Program" last reviewed 10/2011.

d. Hospital nursing policy titled "Discharge Planning Swing Bed" last reviewed 9/2006.

e. Hospital nursing policy titled "Patient Restraints and/or Seclusion" last reviewed 11/2007.
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Based on interview, the critical access hospital failed to ensure that patient diet orders sent to the dietary department are only changed as a result of written physician orders.

Failure to require written orders for changes to patients' therapeutic diets puts patients at risk for receiving inadequate or inappropriate nutrition.
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Findings:

On 1/7/2015 at 10:50 AM, Surveyor #2 interviewed the Dietary Manager (Staff Member #7) about the procedure for staff members to receive patient's dietary orders. S/he stated that the diet orders or changes to diet orders are taken over the phone, and may be processed without first having a written order from the patient's physician.
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Based on record review, review of hospital policies and procedures, and interview, the critical access hospital failed to ensure admission falls assessments were complete according to facility policy for two of three patients (Patients #1, #2).
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Failure to assess patients for falls at time of admission places patients at risk of injury from falling.
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Findings:
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1. The hospital's policy and procedure titled "Falls Prevention" (Revised 11/2011) read in part: "2. The nurse admitting the patient will assess the patient and assign a fall risk level."
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2. Review of the records of 2 swing bed patients revealed the following:
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a. Patient #1 was an 93 year old patient who had been admitted on 12/29/2014 for left pelvic fracture. The initial falls assessment had not been completed on admission. During interview on 1/6/2015 at 11:30 AM, Staff Member #2 confirmed these findings.
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b. Patient #2 was an 80 year old patient who had been admitted on 12/15/2014 for respite care and pain control. The initial falls assessment had not been completed on admission. During interview on 1/7/2015 at 2:00 PM, Staff Member #3 confirmed these findings.

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Based on record review and interview, the critical access hospital failed to establish a method to identify the author of entries into the medical record for three out of three records reviewed (Patient's # 7, 8, and 9).
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Failure to properly identify the clinician documenting patient care puts patients at risk for adverse outcomes resulting from errors in communication and documentation
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Findings:
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1. On 1/7/2015 at 4:15 PM and 1/8/2015 at 8:00 AM, review of the medical records of three patients who visited the emergency department (ED) revealed the following:
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a. Patient #7 was a 79-year-old patient who was seen on 11/11/2014 with a chief complaint of altered mental status. A staff member, identified only as "Nurse, Agency-RN1" completed both the ED nursing note and ED disposition summary.
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b. Patient #8 was a 66-year-old patient who was seen on 11/12/2014 with a chief complaint of nosebleed. A staff member, identified only as "Nurse, Agency-RN1" completed the ED nursing assessment, vital signs, and triage note.
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c. Patient #9 was a 55-year-old patient who was seen on 11/23/2014 with a chief complaint of abdominal pain. A staff member, identified only as "Nurse, Agency-RN1" completed the ED nursing assessment and vitals.
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2. On 1/7/2015 at 09:50 AM, Surveyor #1 interviewed the hospital's clinical informatics officer (Staff Member # 5). S/he acknowledged that "Nurse, Agency-RN1" was a generic title assigned to agency nursing personnel for the purpose of documenting patient care and treatment into the electronic medical record. S/he confirmed the hospital did not have a written policy or procedure for authentication of signatures for clinical contracted personnel. S/he reported that the hospital had used an "agency personnel access request log" to identify contracted staff members who had access to the electronic medical record. S/he indicated the log was no longer available and missing all records between July and November 2014.
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3. On 1/7/2015 at 1:00 PM Surveyor #1 interviewed the Director of Nursing (Staff Member #1). S/he confirmed two different health professionals provided care to Patient's #7, #8, and #9.

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Based on interview and document review, the critical access hospital failed to conduct an annual program evaluation of its total program, including number of patients served and number of services provided.

Failure to conduct an annual program evaluation leaves the hospital unable to determine if utilization of services is appropriate for the population served and if current policies and practices are effective.
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Findings:

On 1/8/2015, Surveyors #1 and #2 conducted a review of the hospital's quality program with the Chief Operating Officer (Staff Member #6). S/he was able to produce an annual program review for 2011 and 2012, but s/he stated the hospital had not conducted a review for 2013.

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Based on record review, review of hospital policies and procedures, and interview, the critical access hospital failed to ensure that hospital staff completed swing bed admission activity assessments and associated activity plans for five of six patients reviewed (Patients #2, #3, #4, #5, #6)

Failure to develop and implement an activity plan for long-term care puts patients at risk of physical, mental, and psychosocial impairment.

Findings:

1. The hospital's policy and procedure titled "Swing Bed Activity Program" (Revised 10/2011) read in part: "2. Upon admission to the Swing Bed Program, the Activity Director shall do an assessment of activity needs and develop the activities plan within 24 hours of admission . . . 3. The Activity Director shall document the Activity Plan on the Patient's Care Plan and the nurses and the activity director will document all offers and denials in the nursing notes. Participation in all activities will be documented in the nursing notes."


2. On 1/7/2015 at 12:45 PM, Surveyor #1 interviewed the hospital's activity program director (Staff Member #4). Staff Member #4 confirmed that it was facility policy to assess swing bed patients for activity interests, and have the Activity Director develop an activity plan for these patients.

3. On 1/7/2015 at 1:00 PM, a review of the medical records of six swing bed patients revealed five of six records with no documentation of a comprehensive activities assessment and no evidence that staff members developed a patient activity plan.

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Based on review of policy and procedures and administrative staff interview, the critical access hospital failed to develop and implement written policy and procedures addressing patient visitation rights.
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Failure to develop a policy and procedure for patient visitation rights risks denying a patient the therapeutic care needs of open visitation.
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Findings:
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1. Review of the hospital's policy and procedures on 1/6/2015 revealed the hospital did not have a written policy and procedure for patient visitation rights which outlines the limitations or restrictions which may be clinically necessary.
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2. An interview on 1/6/2015 at 2:00 PM with the Director of Nursing (Staff Member #1) confirmed the above findings.