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Based on observation and interview, the critical access hospital failed to ensure that all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition.

Failure to all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition risks injury to patients and staff by operation of clinical devices that have not been approved and tested for safety and effectiveness.

Findings include:

The following clinical equipment was found within the hospital without evidence of inclusion in the hospital clinical equipment inventory:

a) A cast cutter in the equipment storage room with a clinical engineering label reading "due 09"
b) A BiPAP machine in patient room 10 that had no inventory number
c) A pulse oximeter in the emergency department obstetrics room that had no inventory number
d) Ear/nose/throat instruments in the emergency department obstetrics with a clinical engineering label reading "due 10/03"
e) A portable suction unit in the clean utility room with a clinical engineering label reading "due 02/05"
f) A blanketrol warming unit in the clean utility room that had no inventory number
g) A Spacelabs monitor in the emergency department that had no inventory number

The hospital maintenance director stated that this equipment had entered the hospital without going through his department for inventory and clinical engineering approval before being made available in patient care areas.

He also confirmed that there was no policy regarding the placement of clinical equipment within the hospital without going through the clinical engineering process.

Based on observation and interview by Deputy State Fire Marshal, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the Critical Access Hospital Recertification Life Safety Code Survey.

Based on observation, interview, record review, and review of hospital policies and procedures, it was determined that the Critical Access Hospital's governing body failed to assume full responsibility for determining, implementing and monitoring policies governing the hospital's total operation.

The governing body failed to ensure that comprehensive assessments were completed and plans of care were developed and implemented for long-term care residents (Refer to C0388, C0389, C0395, C0396); failed to ensure that the hospital arranged for dental services as needed (Refer to C0406); and failed to ensure that residents were notified of their right to contest discharge from the hospital (Refer to C0377)..

The cumulative effect of these deficiencies resulted in the provision of substandard care to the hospital's long-term care residents. The Condition of Participation for Organizational Structure was NOT MET.
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Based on interview and record review, the critical access hospital failed to ensure that the medical staff were properly granted specific hospital privileges.

Failure to grant specific privileges risks medical staff performing diagnoses or procedures, or writing orders, for which they are not approved by the governing body.

Findings include:

1) The medical staff coordinator stated that a cardiology consulting group had not been granted privileges to read echocardiograms and vascular studies performed at the hospital, although the radiology department manager confirmed that the cardiology group did read and report on these studies.

2) 2 of 7 members of the medical staff whose credentialing files were reviewed requested specific hospital privileges that were simultaneously for independent practice and for practice with required consultation. The medical staff were: MD 1 and MD 2.

Based on observation and review of policies and procedures, the critical access hospital failed to follow its policy on pre-procedure time out.

Failure to follow the policy on pre-procedure time out risks procedural errors such as wrong patient or wrong procedure.

Findings include:

1) The hospital's policy and procedure entitled "Intravenous Procedural Sedation" (Revised 11/2012) read, in part, as follows: "Pre-Procedure time-Out. A pre-procedure time out should be conducted for 2-3 minutes in the ER/procedure room before the procedure/incision. It should involve the entire procedure team, use active communication, and documented on the outpatient sedation form or Electronic Medical Record (EHR)."

2) During a colonoscopy procedure on 11/07/2012, it was observed that only the nurse and patient participated in the pre-procedure time out. The physician and two NA-Cs were also present in the room, but there was no procedure team agreement on the procedure to be performed or the patient's identity.

Based on interview and record review, the Critical Access Hospital failed to develop a written policy and procedure referring 2 of 2 residents at nutritional risk to the dietician for a comprehensive nutritional assessment (Residents #1, #2).

Failure to assess, plan, and provide nutritional care for patients with inadequate intake risks malnutrition of patients and impaired healing.

Findings:

1. The hospital's policy and procedure entitled "Admission Assessment" (Ref. #2007-7; Effective 5/1/2007; Revised 4/20/2012) read in part as follows: "Upon admission to the patient care unit, each patient will be assessed by the admitting nurse to determine any immediate needs and appropriate assignment of the care and data collection...The patient assessment will include content regarding:... Nutritional needs...".

2. Review of the records of 5 long-term care residents residing in the hospital's patient care unit at the the time of the survey revealed that 2 of the 5 residents (Residents #1, #2) had not been assessed on admission for nutritional needs that may have indicated referral to the hospital's dietician for a comprehensive nutritional evaluation.

Resident #1 had been hospitalized following surgery for a fractured jaw and was on a pureed diet. Resident #2 was being treated for open wounds on his legs related to cellulitis. These conditions posed inherent nutritional risks to these patients.

3. On 11/6/2012 at 3:30 PM, an interview with the hospital's long-term care coordinator revealed that the hospital had no written policy and procedure for referring patients and residents at nutritional risk to the contract dietician for a comprehensive nutritional assessment.
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Based on policy review and interview, the critical access hospital failed to review all clinical policies annually, by failing to review the infection control program policy.

Failure to review and revise as necessary the infection control program policy risks management of the critical access hospital infection control program in a way that may not reflect the latest applicable concepts and procedures for hospital infection prevention.

Findings include:

Review of the critical access hospital infection control plan on 11/08/2012 found that it had not been reviewed since March, 2010. The infection control manager confirmed that no review had been performed since that date.

Based on observation, interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for "Special Requirements for CAH Providers of Long-Term Care Services ("Swing Beds").

The hospital failed to complete comprehensive assessments and develop and implement plans of care for long-term care residents (Refer to C0388, C0389, C0395, C0396); failed to arrange for dental services as needed (Refer to C0406); and failed to notify residents of their right to contest discharge from the hospital (Refer to C0377).

The cumulative effect of these deficiencies resulted in the provision of substandard care to the hospital's long-term care residents. The Condition of Participation for :Long-Term Care Services was NOT MET.
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Based on interview and review of resident rights information given to long-term care residents on admission, the hospital failed to develop and implement a process for providing written information to long-term care residents regarding the reason for their discharge or transfer; and of their right to contest the discharge or transfer.

Failure to provide this information to long-term care residents violates their right to appeal their discharge or transfer to the state's long-term care ombudsman.

Findings:

1. On 11/6/2012 at 11:00 AM, an interview with the hospital's long-term care coordinator revealed that long-term care residents were not notified in writing of the reason for their discharge or transfer and the process for appealing their discharge or transfer to the state's long-term care ombudsman.

2. On 11/6/2012 at 2:45 PM, an interview with the hospital's long-term care coordinator revealed that when long-term residents were admitted to the hospital they were given information entitled "Patient Rights".

This form stated, under item #16, that long-term care residents had the "Right to have written notification of transfer to another facility or discharge."
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to conduct an interdisciplinary comprehensive assessment of the healthcare needs of 5 long-term care residents residing in the hospital at the time of the survey that included assessment of dental and nutritional status and activity needs; and that included information obtained through communication with the resident as well as licensed and nonlicensed direct care staff members on all shifts (Residents #1, #2, #3, #4, #5).

Failure to perform a comprehensive assessment of a resident's healthcare needs and develop an individualized plan of care according to assessment findings can result in the inappropriate, inconsistent, or delayed treatment.

Findings:

1. Review of the records of 5 long-term care residents receiving treatment in the hospital's patient care unit at the the time of the survey revealed the following:

a. 5 of 5 residents had not been assessed on admission for dental needs, to include missing or damaged dentures (Residents #1, #2, #3, #4, #5).

b. 2 of the 5 residents had not been assessed on admission for nutritional needs that may have indicated referral to the hospital's dietician for a comprehensive nutritional evaluation (Residents #1, #2).

Resident #1 had been hospitalized following surgery for a fractured jaw and was on a pureed diet. Resident #2 was being treated for open wounds on his legs related to cellulitis. These conditions posed inherent nutritional risks to these patients.

c, 5 of 5 patients had not been assessed for meaningful activity interests (Residents #1, #2, #3, #4, #5). The hospital's policy and procedure entitled "Activities - Participation in the Interdisciplinary Team" (Ref. #14.04; Effective 5/21/2007) read in part as follows: "Activities will participate as a member of the Interdisciplinary Team that reviews and plans for the care of the resident. Resident care planning will be based on assessment for recreation needs, functional abilities, interests and past life style. The process will incorporate mutually agreed upon goals and specific recreation services as approaches to meeting the individualized goals."

2. An interview with the hospital's long-term care coordinator on 11/6/2012 at 10:15 AM revealed that the hospital did not have a written policy and procedure for completion of a comprehensive resident assessment that included information obtained through communication with the resident as well as licensed and nonlicensed direct care staff members on all shifts.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to complete an interdisciplinary comprehensive assessment of the healthcare needs of 5 long-term care residents residing in the hospital at the the time of the survey within 14 calendar days of admission to the hospital's long-term care unit (Residents #1, #2, #3, #4, #5)

Failure to complete a comprehensive assessment of a resident's healthcare needs and develop an individualized plan of care according to assessment findings can result in the inappropriate, inconsistent, or delayed treatment.

Findings:

1. Review of the records of 5 long-term care residents residing in the hospital's patient care unit at the the time of the survey revealed that a comprehensive assessment of their healthcare needs had not been completed within 14 days of admission.

2. An interview with the hospital's long-term care coordinator on 11/6/2012 at 10:15 AM revealed that the hospital did not have a written policy and procedure for completion of a comprehensive resident assessment within required timeframes.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop comprehensive care plans based on an interdisciplinary comprehensive assessment of the healthcare needs for 5 long-term care residents residing in the hospital at the time of the survey (Residents #1, #2, #3, #4, #5).

Failure to perform a comprehensive assessment of a resident's healthcare needs and develop an individualized plan of care according to assessment findings can result in the inappropriate, inconsistent, or delayed treatment.

Findings:

1. Review of the medical records of long-term care residents residing in the hospital at the time of the survey (Residents #1, #2, #3, #4, #5) revealed that comprehensive interdisciplinary plans of care had not been developed for these patients based on a comprehensive assessment that included measurable objectives and timeframes.

2. 2 of 5 residents (Resident #1 and Resident #2) were receiving physical therapy as part of their hospital treatment. Further review revealed that the physical therapy care plans for these residents had been written in individual progress notes and were not included in the care plan section of the residents' electronic medical records.

3. 5 of 5 residents (Residents #1, #2, #3, #4, and #5) had not been assessed for recreation needs, functional abilities, interests and past life style according to hospital policy. Their patient care plans did not include a plan for participation in the hospital's activities program.

4. An interview with the hospital's long-term care coordinator on 11/6/2012 at 10:15 AM revealed that 1 of 5 residents (Resident #5) had chipped his/her dentures during a fall in March 2012. The resident's care plan did not include a plan for assisting the patient to repair his/her dentures.

5. An interview with the hospital's long-term care coordinator on 11/6/2012 at 10:15 AM revealed that the hospital did not have a written policy and procedure for completion of a comprehensive resident care plan.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop interdisciplinary comprehensive care plans for 5 long-term care residents residing in the hospital at the the time of the survey within 7 calendar days after completion of a comprehensive assessment (Residents #1, #2, #3, #4, #5).

Failure to complete a comprehensive assessment of a resident's healthcare needs and develop an individualized plan of care according to assessment findings can result in the inappropriate, inconsistent, or delayed treatment.

Findings:

1. Review of the records of 5 long-term care residents residing in the hospital's patient care unit at the the time of the survey revealed that a comprehensive care plan had not been developed within 7 days of completion of a comprehensive resident assessment.

2. An interview with the hospital's long-term care coordinator on 11/6/2012 at 10:15 AM revealed that the hospital did not have a policy and procedure for completion of a comprehensive resident care plan within required timeframes.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to provide evidence that it referred Resident #5 to a dentist for evaluation of damaged dentures.

Failure to assist residents to obtain dental care risks oral injury and malnutrition related to impaired ability to eat.

Findings:

1. During an interview on 11/6/2012 at 2:00 PM, Resident #5 stated she had a "sore mouth" related to "broken teeth" that had occurred during a fall.

2. An interview with the hospital's long-term care coordinator on 11/6/2012 at 3:30 PM confirmed that Resident #5 had fallen in on 3/20/2012. The coordinator stated the resident had complained of a sore mouth after the fall. She stated that she examined the resident's dentures and had noted a "small chip". The coordinator stated that the resident's son was attempting to make an appointment with a dentist for evaluation of the condition of Resident #5's dentures.

3. Review of Resident #5's medical record at the time of the interview with the long-term care coordinator revealed the record lacked evidence that the hospital had taken an active part in referring the resident to a dentist.

4. The hospital's policy and procedure entitled "Long Term Swing Bed Dental Services" (Ref. #14.2.0013; Effective 1/2012) read as follows: "Policy: Ferry County Memorial Hospital will ensure that all long term swing bed patients obtain routine and emergency dental care... Procedure: ... Assure emergency dental services are obtained for the resident when needed. Promptly refer residents with lost or damaged dentures."
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