HospitalInspections.org

.


Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a safe process for stocking and storing medications used during medical emergencies.

Failure to develop such a process risks medical errors and patient harm.

Findings included:

1. Document review of the hospital's policy titled, "Pharmacy: Emergency Crash Cart Security and Accountability," no policy number, revised 02/22, showed the following:

The Pharmacy Department will refill the crash cart medication trays as needed and replace outdating medications monthly.

Document review of the hospital's policy titled, "Emergency Department: Emergency Crash Cart Security and Accountability," no policy number, revised 01/22, showed the following:

a. Crash cart inventory will be completed monthly by nursing and pharmacy personnel.

b. Crash cart inventory includes:

i. Checking the expiration date on medications and supplies.

ii. Any medications that are expired or missing should be emailed to the current Pharmacist for replacement. Pharmacy will replace medications when on site.

iii. Replace any supply item with an expired date or missing.

Document review of the hospital's policy titled, "Pharmacy: Emergency Crash Carts," no policy number, revised 02/22, showed the following:

a. Pharmacy Procedures: All medications will be checked monthly for expiration dates and medications will be replaced prior to their expiration.

2. On 04/20/22 at 10:00 AM, Surveyor #5, and the Director of Pharmacy (Staff #503) reviewed Adult Emergency cart located in the hospital's North Wing. The review showed the following:

1-1,000 mL bag of D5W with ½ Normal Saline (NS) Intravenous Solution (IV) with a manufacturer's expiration date of 12/21.

1-1,000 mL bag of D5W Intravenous Solution (IV) with a manufacturer's expiration date of 02/22.

1-1,000 mL bag of NS IV with a manufacturer's expiration date of 02/22.

1-500 mL bag of Heparin 25.000 Units per 500 mL NS IV with a manufacturer's expiration date of 02/22.

1-250 mL bag of Dobutamine 400 mg in 250 mL with a manufacturer's expiration date of 02/22.

1-250 mL Nitroglycerin Drip bottle with a manufacturer's expiration date of 03/22.

3. At the time of the inspection, Staff #503 verified the finding and stated she did not know that medications were kept in those sections of the emergency cart and as a result she had not been checking them.
.

.

Item #1 Unusable Emergency Supplies

Based on observation, interview, and review of documents, the hospital failed to implement a quality control system to prevent the use of patient care equipment, supplies, and resources that were unusable or beyond the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies are appropriately processed and stored and that do not exceed their expiration dates risks deteriorated or potentially contaminated supplies being available for patient use.

Reference: "2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care)." 2020 Guidelines are a comprehensive revision of the AHA's guidelines for adult, pediatric, and neonatal resuscitation education science, and system of care topics. Updated in 2020.

Reference: "American Academy of Pediatrics states that 2019 Broselow Reference Tape will be the most compliant with current PALS standards."

Reference: "Guidelines for Preventing Health-Care--Associated Pneumonia, 2003" (Centers for Disease Control and HICPAC), Semi-Critical equipment including laryngeal scope blades must be cleaned using sterilization or high-level disinfection and then packaged and stored in a manner to prevent recontamination.

Findings included:

1. Document review of the hospital's policy titled, "Emergency Department: Emergency Crash Cart Security and Accountability," no policy number, revised 01/22, showed the following:

Emergency medications, supplies, and equipment for use in medical emergencies shall be immediately available in the emergency room and acute care areas.

b. The emergency crash cart will be secured with a numbered disposable lock at all times when not in use. The seal will only be broken when an emergency situation arises or by Pharmacy or Licensed Nurse to inventory contents.

c. Crash cart inventory will be completed monthly by nursing and pharmacy personnel. Lock changes will be documented in specific cart logbook and signed and dated by authorized personnel with reason for lock change.

d. Crash cart inventory includes:

i. Checking the expiration date on medications and supplies.

ii. Any medications that are expired or missing should be emailed to the current Pharmacist for replacement. Pharmacy will replace medications when on site.

iii. Replace any supply item with an expired date or missing.

iv. Ensuring all equipment is functional

v. Reporting any malfunctioning equipment

vi. Securing the crash cart.

Document review of the hospital's policy titled, "Pharmacy: Emergency Crash Carts," no policy number, revised 02/22, showed the following:

a. Following the use of the emergency crash cart, the Charge Nurse will place all used instruments on the cart, clear out disposable items and restock all non-medication and medication items and lock the cart.

b. Patient care staff will check the integrity of the seal on night shift and note the inspection on the crash cart check list.

c. Universal Pediatric Dosing Guidelines will be kept on every emergency cart in the facility. These guidelines will be updated and reviewed annually or as needed by the medical staff and pharmacy.

2. On 04/20/22 at 10:00 AM, Surveyor #5, the Director of Pharmacy (Staff #503), and the Chief Nursing Officer (Staff #501) reviewed the Adult Emergency Cart located on the hospital's North Wing and the Adult and Pediatric Emergency carts located in the hospital's Emergency Department. The review showed the following:

a. Emergency Cart/Crash Cart on North Wing

i. Broselow Pediatric Equipment size and Medication Dosage tape dated 2007.

ii. 6-Commingled oral airways.

b. Emergency Department Emergency Cart/Code Cart

i. 4-commingled Miller Laryngoscope blades.

ii. 4- commingled MAC Laryngoscope blades.

iii. 6-commingled oral airways.

iv. MAD nasal: Intranasal mucosal atomization device with a manufacturer's expiration date of 02/05/22.

v. 1-I Gel® 90+Kg Supraglotic airway with a manufacturer's expiration date of
03/21.

vi. 1-Suction Catheter open and stored on side of cart

c. Pediatric Emergency Cart/Crash Cart

References:

i. Broselow Pediatric Equipment size and Medication Dosage tape dated 2017.

ii. Pediatric Life Support reference book dated 2017.

iii. Resuscitation and Emergency Infusions reference book dated 2009.

iv. Pediatric Life Support reference card dated 2016.

v. "Preemie-Newborn Med sheet by Kilogram" from Sacred Heart Medical Center dated 2011.

Equipment/Supplies:

vi. 1-I Gel® -5 Kg Supraglotic airway with a manufacturer's expiration date of 03/22.

vii. 1-I Gel® 10-25 Kg Supraglotic airway with a manufacturer's expiration date of 01/22.

viii. 10-commingled oral airways.

ix. 1-Blue Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 11/30/21.

x. 1-Blue Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 07/30/21.

xi. 1-10 French indwelling catheter with a manufacturer's expiration date of 02/28/21.

xii. 1-Vital Sign Laryngeal Blade with a manufacturer's expiration date of 06/20/18.

xiii. 1-package of 50 EKG Electrodes with a manufacturer's expiration date of 11/29/11.

xiv. 3-Red/Pink Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 03/31/22.

xv. 2-White Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 07/30/21.

xvi. 2-Purple Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 11/30/21.

xvii. 2-Orange Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 11/30/21

xiii. 1-Yellow Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 06/30/21.

xiv. 1-Yellow Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 07/30/21.

xv. 2-Green Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 01/31/22.

xvi. 3-Green Broselow Intravenous Delivery Kit with a manufacturer's expiration date of 03/31/21.

Item #2 Monitoring and Ensuring Availability of Supplies and Equipment

Based on observation, interview, and review of documents, the hospital failed to implement a system to ensure that required equipment and supplies were readily available for use.

Failure to monitor and establish a systematic process for ensuring emergency patient care supplies and equipment are available for emergency use risks patient harm and death.

Findings included:

1. Document review of the hospital's policy titled, "Emergency Department: Emergency Crash Cart Security and Accountability," no policy number, revised 01/22, showed the following:

Emergency medications, supplies, and equipment for use in medical emergencies shall be immediately available in the emergency room and acute care areas.

b. The emergency crash cart will be secured with a numbered disposable lock at all times when not in use. The seal will only be broken when an emergency situation arises or by Pharmacy or Licensed Nurse to inventory contents.

c. Crash cart inventory will be completed monthly by nursing and pharmacy personnel. Lock changes will be documented in specific cart logbook and signed and dated by authorized personnel with reason for lock change.

d. Crash cart inventory includes:

i. Checking the expiration date on medications and supplies.

ii. Any medications that are expired or missing should be emailed to the current Pharmacist for replacement. Pharmacy will replace medications when on site.

iii. Replace any supply item with an expired date or missing.

iv. Ensuring all equipment is functional

v. Reporting any malfunctioning equipment

vi. Securing the crash cart.

2. On 04/20/22 at 10:00 AM, Surveyor #5, the Director of Pharmacy (Staff #503), and the Chief Nursing Officer (Staff #501) reviewed the Adult Emergency Cart located on the hospital's North Wing and the Adult and Pediatric Emergency carts located in the hospital's Emergency Department. The review showed the following:

a. The Crash Cart checklist contained only a space to document the security lock number and that the lock was intact. The review showed the same lock number repeated demonstrating that the cart contents had not been accessed monthly (which would result in a lock change with a different lock number).

b. Surveyor #5 found no evidence on the exterior of the cart of expiration dates of equipment/supplies locked in the drawers.

c. Surveyor #5 found no evidence on the exterior of the cart of expiration dates of medications locked in the drawers.

Surveyor #5 found no evidence that staff were ensuring that equipment including oxygen and suction were available and functional.

3. At the time of the finding, Staff #501 verified the finding and stated that staff should be opening up the carts each month and check for expiration dates. Staff #501 verified that the checklist did not contain an area for staff to document equipment including oxygen and suction were available and functional.
.

.
Based on observation, interview, and document review, the hospital failed to ensure that all facility and medical equipment is listed in an inventory which includes a record of maintenance activities.

Failure to maintain a complete inventory of equipment deemed safe to use and with record of preventative maintenance puts patients and staff at risk of injury or harm.

Findings included:

1. Document review of the hospital's policy titled, "Patient Care Related Equipment Process," no policy #, revised 11/20, showed that any patient equipment will be inspected by the Maintenance Department prior to being placed into use.

2. On 04/20/22 at 10:30 AM, Surveyor #4 inspected the Beauty Salon room with the Director of Environmental Services/Maintenance (Staff #402) and the Chief Executive Officer (Staff #401). The surveyor observed 2 hooded style hair dryers that did not have any asset/ID tags or preventative maintenance (PM) stickers.

3. At the time of the observation, Staff #402 confirmed the items were missed on the inventory and had not had an initial safety check or PM done.
.

.
Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell RC2Q21.
.

.

Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

Failure to establish and implement policies and procedures for hospital services provided to all patients admitted to the hospital risks substandard and inconsistent care which can lead to negative patient outcomes.

Findings included:

1. Failure to follow best practices based on nationally recognized organizations for blanket warmer cabinets.

Cross Reference: C 1006

2. Failure to ensure guidelines addressing consultations were developed and implemented.

Cross Reference: C 1014

3. Failure to implement its process for medications review by a pharmacist prior to medication administration.

Cross Reference C 1016

4. Failure to ensure medication storage areas were devoid of outdated or otherwise unusable medications.

Cross Reference: C 1016

5. Failure to ensure that hospital staff members completed and documented an initial admission assessment.

Cross Reference: C 1048

6. Failure to ensure staff members completed and documented shift reassessments.

Cross Reference: C 1048

7. Failure to ensure that staff performed and documented a Triage Assessment for all patient's admitted to the hospital's Emergency Room.

Cross Reference: C 1048

8. Failure to ensure that assessment and reassessment of a patient wounds.

Cross Reference: C 1048

9. Failure to ensure staff members completed and documented daily pain assessments and pain assessments prior to pain medication administration.

Cross Reference: C 1048

10. Failure to assess pediatric patient's immunization status.

Cross Reference: C 1048


Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.635 Provision of Services was NOT MET.

.

43911

.
Based on observation, interview, and document review, the hospital failed to develop procedures for the safe use of patient care equipment.

Failure to establish procedures for patient care equipment places patient at risk for injury.

Reference: AORN GUIDELINES FOR PERIOPERATIVE PRACTICE - 2021 EDITION, Environment of Care, Warming Cabinets, 6.5: Have an interdisciplinary team conduct a risk assessment to establish and implement a maximum temperature limit for blanket-warming cabinets based on evidence and the cabinet manufacturer's IFU.

Findings included:

1. Document review of the Pedigo Elite Series Blanket Warming Cabinet manufacturer's operations and care manual, no date, indicated that the temperature range is 90-160 degrees Fahrenheit for the unit, no additional recommendations for set points were found for safe temperature settings for the prevention of patient burns.

2. On 04/19/22 at 2:10 PM, Surveyor #4 observed a Pedigo Elite Series blanket warmer, Model No. P-2230, in the clean utility room in the North Wing with a set temperature of 143 degrees Fahrenheit (F).

3. On 4/20/22 at 12:45 PM, Surveyor #4 discussed the recommendation for blanket warmer risk assessments with the Director of Environmental Services/Maintenance (Staff #402). Staff #402 confirmed the facility did not have a specific policy for blanket warmer settings and had not completed a risk assessment for acceptable temperature settings.
.

.

Based on document review and interview, the hospital failed to develop and implement policies and procedures for the medical management of health problems that included conditions requiring a medical consultation, situations and circumstances requiring consultations, and/or referral for care outside the hospital.

Failure to ensure guidelines addressing consultations are developed and implemented risks delayed care, inappropriate care, and poor patient outcomes.

Findings included:

1. Document review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 01/23/19, showed no language addressing the medical management of health problems that include conditions requiring a medical consultation, situations and circumstances requiring consultations, and/or referral for care outside the hospital.

2. On 04/20/22 from 10:00 AM until 11:30 AM, Surveyor #5 and the Chief Nursing Officer (Staff #501) inspected the hospital's Emergency Department. Surveyor #5 noted that the scheduled Emergency Room medical provider was a Nurse Practitioner. During discussion with the Staff #501, Surveyor #5 asked under what circumstances would a consultation with medical staff or other professional healthcare staff, or referral outside the hospital should occur and specifically, what types of medical conditions require mid-level providers to get a consultation.

3. At this time, Staff #501 verified that the Nurse Practitioners work in the Rural Health Clinic and come to the hospital if a patient presents to the Emergency Room. Staff #501 stated that she did not know the hospital's policy for consultations or referral outside the hospital, but she would look for the hospital's policy.

4. On 04/21/22 at 12:00 PM, Staff #501 stated that the hospital did not have a policy that defined conditions requiring a medical consultation, situations and circumstances requiring consultations, and/or referral for care outside the hospital.

.

.

Item #1 Storage, Handling, Dispensing, Procurement and Administration of Drugs and Biological's for the Entire Critical Access Hospital (CAH).

Based on observation, document review, and interview, the Critical Access Hospital (CAH) failed to implement its process for medications review by a pharmacist prior to medication administration.

Failure to ensure that medications management quality processes for control, preparation, distribution, and use are implemented puts patients at risk of serious harm.

Findings included:

1. Document review of the hospital's policy titled, Medication Orders (Tele-Pharmacy), no policy number, revised 03/22, showed the following:

a. All medication orders for remote hospital sites must be reviewed and verified by a pharmacist prior to dispensing and administration.

b. Only in emergencies situation may the review and verification of a medication order be carried out after a mediation is administrated.

c. A pharmacist must perform an order check, review and verification.

2. On 01/20/22 at 10:00 AM, Surveyor #5 and the Pharmacy Director (Staff #503) inspected the hospital's Pharmacy and North Medication Room. The inspection showed that Patient #516 with medications in a Patient Own Medication drawer labeled by Odessa Drug had not been check by the hospitals Pharmacist. Surveyor #5 reviewed the labels on the bottles of medications which showed no confirmation they were reviewed by a hospital pharmacist. These medications included the following:

a. Lactulose 10 g/15 mL (a non-absorbable sugar used in the treatment of constipation and hepatic encephalopathy).

b. Azthioprine 80 mg oral daily (a medication used with other medications to prevent transplant rejection).

c. Amlodipine Besylate 10 mg (a medication used to treat angina, high blood pressure and coronary heart disease).

d. Tacrlomis 1 mg oral every day (an immunosuppressive drug).

e. Carvedilol 3.125 mg (a medication used to treat high blood pressure, congestive heart failure, and left ventricular dysfunction).

3. At the time of the review, Staff #503 stated that the medications should have been reviewed by the hospital's Tele-Pharmacist on arrival to the hospital and prior to patient administration. Staff #503 logged onto the electronic system and verified that none of the medications had been reviewed by the Tele-Pharmacist.

Item #2 Unusable Medications

Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability or efficacy.

References:

Manufacturers Instruction for use for HUMALOG® (insulin lispro injection) revised 11/19, instructions for use state do not use HUMALOG past the expiration date printed on the label or 28 days after you first use it. Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.

Manufacturers Instruction for use for NovoLog® (insulin aspart injection), revised 12/12, showed that opened NovoLog® vials should be thrown away after 28 days, even if they still have insulin left in them.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Unusable and Outdated Drugs," no policy number, revised 03/22, showed the following:

a. All drug storage areas of the hospital will be inspected at least monthly for outdated drugs, contaminated drugs, improperly stored drugs, and containers with worn, illegible or missing labels.

b. Areas to be inspected include automated dispensing devices (ADD), satellite pharmacies, surgical drug storage areas, night medication lockers, and other patient care stock areas.

c. All unusable drugs will be removed from the areas by the person conducting the inspection.

2. On 04/19/22 at 10:45 AM, Surveyor #5 and the Chief Nursing Officer (Staff #501) inspected the medication area on the West Wing. The review showed 1 bottle of Novolg® insulin with an open date of 04/08/22 and an expiration date of 05/08/22 (a period of 30 days).

3. At this time, Surveyor #5 asked the Licensed Practical Nurse (Staff #504) how long the insulin was good for after opening. Staff #504 stated 30 days.

4. On 04/20/22 at 9:30 AM, Surveyor #5 and the Pharmacy Director (Staff #503) inspected the hospital's Pharmacy. The inspection showed expired medications in bins in the pharmacy medication storage area including the following:

a. 8-Ipratropium bromide with albuterol sulfate inhalation (a medication combination used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) with a manufacturer's expiration date of 03/22.

b. 1-bottle guaifenesin and dextromethorphan liquid (a medication used to relieve a cough and thin mucus to relieve chest congestion) with a manufacturer's expiration date of 03/22

c. 120 tablets-Magnesium Oxide 40 mg (a medication used to treat indigestion) with a manufacturer's expiration date of 03/22.

d. 1 vial of Humalog insulin (a rapid acting human insulin used to treat elevated blood sugars) that was opened and not dated.

5. At the time of observation, Staff #503 verified the expired medications and removed them from the storage area for disposal.

.

.
Item #1 Admission Assessment

Based on interview and document review, the hospital failed to ensure that hospital staff members completed and documented an initial admission assessment for 3 of 3 Swing Bed patients reviewed (Patient #502, #503, and #515).

Failure to perform an initial assessment of the patient created risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the Critical Access Hospital's policy titled, "Mandatory Documentation and Chart Checks," no policy number, revised 01/21, showed the following:

a. Mandatory documentation and chart checks are completed to ensure nursing assessments and documentation is completed. The mandatory documentation and chart checks prevent omissions of treatments, medications and assessments to ensure the patient in the facility are receiving the best care possible.

b. Mandatory documentation to be completed for all patient types on admission includes an "Adult Admission History".

c. Mandatory documentation for Certified-Swing to be completed throughout the patient's stay included a "Complete Systems Assessment" every 12 hours.

2. On 04/20/22 at 1:20 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital's Swing Bed Program on 04/06/22. The review showed the following:

a. The patient's admission assessment in the Electronic Health record was incomplete. Surveyor #5 found no documentation on the admission assessment screens addressing the following:

i. Functional Screening

ii. Learning

iii. Safety

iv. Systems Assessment

v. Communication Needs

vi. Suicide Risk

vii. Discharge Needs

viii. Management of pain

ix. Wounds

x. Skin

xi. Nutritional Screening

xii. Abuse/Neglect Screening

xiii. VTE prevention

xiv. Living Situation and Resources

xv. Religious preference and needs

xvi. Educational needs and barriers to learning

b. The System Assessment screens showed no documentation including:

i. Pain Assessment

ii. Fall Risk Assessment

iii. Wound documentation

iv. Braden Score Risk Assessment

v. Nutritional Screening.

3. At the time of the finding, Staff #501 verified that these sections of the admission assessment were not completed. Surveyor #5 asked for the hospital's policy related to admission assessments and what assessments and screening were required to be completed as part of the admission assessment. Staff #501 stated that the hospital did not have a policy that defined what assessments and screenings were to be completed in the admission assessment, but that the staff should have completed all the admission screens developed in the electronic admission assessment.

4. On 04/20/22 at 3:34 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), and the Assistant CNO (Staff #505), reviewed the medical record for a "Certified Swing Bed" patient (Patient #502). Surveyor #5 found no documentation on the admission assessment assessment screens addressing the following:

i. Functional Screening

ii. Learning

iii. Safety

iv. Systems Assessment

v. Communication Needs

vi. Suicide Risk

vii. Discharge Needs

viii. Management of pain

ix. Wounds

x. Skin

xi. Nutritional Screening

xii. Abuse/Neglect Screening

xiii. Infectious Disease Screening

5. At the time of the review, Staff #501 verified the finding that staff had not documented on the assessment screens.

6. On 04/21/22 at 11:00 AM, Surveyor #5 and Staff #501 reviewed the medical record for Patient #515 who was admitted to the hospital's Swing Bed Program on 10/18/21. The review showed similar findings that staff had not fully completed and documented the Admission/Initial Assessment.

7. At the time of the review, Staff #501 verified the finding that staff had not documented on the assessment screens.

Item #2 Reassessment

Based on interview and document review, the hospital failed to ensure staff members completed and documented shift reassessments for 2 of 3 Swing Bed patients reviewed (Patient #502 and #503).

Failure to perform assessments and reassessments appropriate to a patient's illness risks patients not receiving appropriate monitoring or care related to their unidentified health care needs.

Findings included:

1. Document review of the Critical Access Hospital's policy titled, "Mandatory Documentation and Chart Checks," no policy number, revised 01/21, showed the following:

a. Mandatory documentation and chart checks are completed to ensure nursing assessments and documentation is completed. The mandatory documentation and chart checks prevent omissions of treatments, medications and assessments to ensure the patients in the facility are receiving the best care possible.

b. Mandatory documentation for Certified-Swing to be completed throughout the patient's stay included a "Complete Systems Assessment every 12 hours.

2. On 04/20/22 at 1:20 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital's Swing Bed Program on 04/06/22. The review showed the patient did not receive shift reassessments for the following shifts including no reassessments for 12.5 continuous days:

a. 04/07/22 Day Shift

b. 04/08/22 Day Shift or Night Shift

c. 04/09/22 Day Shift or Night Shift

d. 04/10/22 Day Shift or Night Shift

e. 04/11/22 Day Shift or Night Shift

f. 04/12/22 Day Shift or Night Shift

g. 04/13/22 Day Shift or Night Shift

h. 04/14/22 Day Shift or Night Shift

i. 04/15/22 Day Shift or Night Shift

j. 04/16/22 Day Shift or Night Shift

k. 04/17/22 Day Shift or Night Shift

l. 04/18/22 Day Shift or Night Shift

m. 04/19/22 Day Shift or Night Shift

n. 04/20/22 Day Shift

3. At the tine of the review, Staff #501 confirmed the finding and stated that the patients in the "Certified Beds" should have been reassessed each shift and that she would follow up with the staff.

4. . On 04/20/22 at 3:34 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), and the Assistant CNO (Staff #505), reviewed the medical record for a "Certified Swing Bed" patient (Patient #502) who was admitted on 04/12/22. The review showed no shift reassessments for 16 of 16 possible shift assessments since admission including:

a. 04/12/22 Night Shift

b. 04/13/22 Day Shift or Night Shift

c. 04/14/22 Day Shift or Night Shift

d. 04/15/22 Day Shift or Night Shift

e. 04/16/22 Day Shift or Night Shift

f. 04/17/22 Day Shift or Night Shift

g. 04/18/22 Day Shift or Night Shift

h. 04/19/22 Day Shift or Night Shift

i. 04/20/22 Day Shift

5. At the time of the review, Staff #501 verified the finding and stated the shift assessments should have been completed.

6. On 04/21/22 at 10:25 AM, during follow up interview, Staff #501 stated that the staff did not know they needed to complete nursing reassessments.

Item #3 Emergency Room Patient Assessment

Based on document review and interview, the hospital failed to ensure that staff performed and documented a Triage Assessment for all patient's admitted to the hospital's Emergency Room for 3 of 3 patient's reviewed (Patient #517, #518, and #519).

Failure to perform a Triage Assessment for patients presenting to the Emergency Department created risk that patients would not receive timely medical treatment appropriate to their care needs.

Findings included:

1. Document review of the Critical Access Hospital's policy titled, "Admission to the Emergency Room," no policy number, revised 01/21, showed that the Registered Nurse will evaluate and provide triage assessment on all individual's presenting to the Emergency Department (ED).

2. On 04/21/22 from 12:00 PM until 1:00 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical records for 3 patients who received care in the hospital's Emergency Department. The review showed the following:

a. Patient #517 was admitted to the Emergency Department on 02/14/22 for the treatment of Ear Pain. Surveyor #5 found no evidence the patient received a Triage Assessment.

b. Patient #518 was admitted to the Emergency Department on 03/07/22 for the treatment of a Sore Throat. Surveyor #5 found no evidence the patient received a Triage Assessment.

c. Patient #519 was admitted to the Emergency Department on 04/02/22 for the treatment of right shoulder pain after a fall from a motor bike during a motor cross competition. Surveyor #5 found no evidence the patient received a Triage Assessment.

3. At the time of the review, Staff #501 stated that nursing staff should have completed a Triage Assessment.

Item #4 Wound Assessment and Reassessment

Based on interview, document review, and review of hospital policy and procedure, the hospital failed to ensure that assessment and reassessment of a patient wound was completed for 1 of 1 patients with a wound reviewed (Patient #502).

Failure to ensure that staff accurately completed skin and wound assessments risks patient harm, injury, and delayed care.

Findings included:

1. Document review of the hospital's policy and procedure titled, Wound Assessment Documentation," no policy number, revised 11/21, showed the following:

a. Wound documentation will be weekly with daily monitoring for wound changes.

b. Staff are to conduct a focused wound assessment including:

i. Anatomic location.

ii. Wound size including length, depth, shape.

iii. Wound classification staging for pressure ulcers or full/partial thickness for all other etiologies.

iv. Wound base including viable and non-viable tissue with percent of each type of tissue, color, consistency, and adherence to wound bed.

iv. Wound edges and margins.

v. Clinical indicators of wound infection.

vi. Wound exudate.

vii. Condition of the Peri-Wound skin.

c. An initial photograph of the wound will be taken by the Licensed Nurse and then every week until the wound is healed to have a visual indicator for the healing process.

2. On 04/20/22 at 1:20 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital's Swing Bed Program on 04/06/22. The review showed the following:

a. Surveyor #5 found no evidence that staff completed a wound assessment on admission per hospital policy.

b. On 04/15/22 a Nurse's note stated that the wound was reassessed. Surveyor #5 found no evidence of the wound assessment.

c. Surveyor #5 found no evidence of weekly wound reassessments.

d. Surveyor #5 found no evidence of an initial wound photograph per hospital policy.

e. Surveyor #5 found no evidence of weekly wound photograph per hospital policy.

3. At the time of the review, Staff #505 verified the finding and stated that the hospital may not have implemented the weekly wound photograph yet.

4. Staff #501 stated that staff should be assessing and documenting wound assessments at least weekly.

Item #5 Pain Assessments

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented daily pain assessments and pain assessments prior to pain medication administration for 2 of 2 patient records reviewed (Patient #502 and #503).

Failure to assess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pain Management," no policy number, revised 11/21, showed the following:

a. Acute, Observation and Certified Swing bed patients will have their pain assessed upon admission, at the beginning of every shift, before and after each intervention for acute pain, and with any significant change in condition.

b. Documentation of pain management will be completed every shift in the electronic medical record.

c. Each time a scheduled or as needed pharmacological intervention has been initiated documentation will be completed on the electronic medication record.

d. The Licensed Nurse will document in the nurse notes at the end of the shift a brief summary addressing pain management.

2. On 04/20/22 at 1:20 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital's Swing Bed Program on 04/06/22. The review showed the following:

a. The patient did not received a daily shift pain assessment for 11 of 28 shifts including:

i. 04/06/22 Day Shift

ii. 04/07/22 Day Shift

iii. 04/08/22 Day Shift

iv. 04/09/22 Day Shift

v. 04/10/22 Day Shift

vi. 04/11/22 Day Shift

vii. 04/14/22 Day Shift

viii. 04/17/22 Night Shift

ix. 04/18/22 Day Shift

x. 04/19/22 Day Shift

xi. 04/20/22 Day Shift

b. The patient did not received a pain assessment prior to pain medication administration for 6 of 6 pain medication administrations reviewed including:

i. 04/07/22 at 10:01AM

ii. 04/14/22 at 8:02 AM

iii. 04/15/22 at 8:07 AM

iv. 04/19/22 at 5:30 AM, 7:49 PM, or 7:04 PM

3. At the time of the review, Staff #501 confirmed the finding and stated that it was the hospital's policy to assess for pain each shift and prior to pain medication administration.

4. On 04/20/22 at 3:34 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), and the Assistant CNO (Staff #505), reviewed the medical record for Patient #502 who was admitted to the hospital's Swing Bed Program on 04/12/22. The review showed the following:

a. The patient did not received a daily shift pain assessment for 6 of 16 shifts including:

i. 04/12/22 Day Shift or Night Shift

ii. 04/14/22 Day Shift

iii. 04/17/22 Night Shift

iv. 04/18/22 Day Shift or Night Shift

5. At the time of the review, Staff #501 confirmed the finding and stated that it was the hospital's policy to assess for pain each shift.

Item #6 Pediatric Immunizaton Assessment

Based on interview and document review, the hospital failed to assess the patient's immunization status for 2 of 3 pediatric patients treated in the Emergency Department (ED) (Patient #518 and #519).

Failure to obtain an immunization history creates a risk that immunization status may be overlooked and result in poor health outcomes for patients, staff and community members, including transmission and complications of infectious disease.

Findings included:

1. Document review of the Critical Access Hospital's policy titled, "Admission to the Emergency Room," no policy number, revised 01/21, showed that the immunization status for pediatric patients is assessed and documented in the medical record.

2. On 04/21/22 from 12:00 PM until 1:00 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical records for 3 patients who received care in the hospital's Emergency Department. The review showed the following:

a. Patient #518 was admitted to the Emergency Department on 03/07/22 for the treatment of a Sore Throat. Surveyor #5 found no evidence staff performed an immunization status assessment.

b. Patient #519 was admitted to the Emergency Department on 04/02/22 for the treatment of right shoulder pain after a fall from a motor bike during a motor cross competition. Surveyor #5 found no evidence staff performed an immunization status assessment.

3. At the time of the review, Staff #501 stated that nursing staff should have completed an assessment of immunization status for the pediatric patients.
.
.

.
Based on interview and document review, the hospital failed to develop and implement policies and procedures to approve requests for religious exemptions from COVID-19 vaccination.

Failure to develop and implement policies and procedures for exemptions from vaccination for COVID-19 places patients, visitors, staff, and the community at risk of harm.

Findings included:

1. Record review of the hospital policy titled, "COVID-19 Vaccination Accommodation Compliance Policy," no policy #, last revised "12/22," showed that staff may request an exemption from COVID-19 vaccination based on sincerely held religious beliefs. The employee would fill out the hospital vaccine exemption request form for approval by human resources. The human resources director would review the requests, document appropriate accommodations for approval or denial and document discussion with staff regarding accommodations.

2. Record review of 8 employees with religious exemptions showed 7 of 8 were approved and 1 of 8 was missing documentation (Staff #406).

3. On 04/21/22 at 9:00 AM, Surveyor #4 interviewed the Director of Human Resources (Staff #403) about the process for COVID-19 vaccine exemption, the facility's policy and documentation process. Staff #403 confirmed the request for exemption documentation was missing for 1 of the 8 exempted staff reviewed (Staff #406). Staff #403 also confirmed Staff #406 had been employed since 09/21/21.

4. During the interview with Staff #403, Surveyor #4 used the CMS Staff Vaccination Formula and Table to determine that the overall staff vaccination rate for the facility was 98%.
.
.

.

Based on interview and review of the hospital's quality program and quality documents, the hospital failed to implement, monitor, and evaluate performance improvement action plans as directed by its quality plan for quality indicators consistently not meeting hospital defined targets.

Failure to implement corrective action plans for identified problems and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.


Findings included:

1. Document review of the hospital's Quality Plan titled, "Quality Assurance/Performance Improvement Plan (QAPI)," dated 2022/2023, showed the following:

a. QAPI is intended to communicate an organization-wide philosophy and process to regularly identify and implement constructive and cost-effective opportunities to improve performance,

b. The organizational-wide QAPI process includes identifying and implementing opportunities to improve the quality of patient care and quality of life, as well as other measures of organizational performance. This includes, but is not limited to, all of the mandatory requirements from the Department of Health, but any fundamental process the hospital implements to ensure effective communications, environment of care, quality of the work environment and most of all, safe and effective patient centered care.

c. The objectives of QAPI include:

i. Ongoing monitoring and data collection,

ii. Investigation and resulting action regarding identified concerns,

iii. Problem prevention, identification, and data analysis,

iv. Development of corrective action plan(s),

v. Implementation of corrective action plans(s),

vi. Evaluations of corrective action plan(s), and

vii. Measures to improve performance on a continuous basis.

d. The Board of Commissioners has the ultimate responsibility and authority for the resource, support, development, and implementation of an effective QAPI program.

e. The QAPI committee is responsible for:

i. Reviewing committee and departmental findings and assuring corrective measures are implemented to improve outcomes

ii. Ensuring that the quality, safety, and appropriateness of patient care/services provided are monitored and evaluated and ensure appropriate action is taken when indicated.

iii. Re-evaluating the QAPI process in order to "close the loop". QAPI issues are not considered to be closed until the re-evaluation process demonstrates a measure of quality or change at an acceptable level has been achieved.

iv. Recommend and implement remedial action to correct deficiencies.

f. The Odessa Memorial Healthcare Center (OMHC) Model for Process improvement and analysis of data and information is Plan, Do, Study, Act (PDSA).

2. On 04/21/22 from 2:35 PM until 4:15 PM, Surveyor #5, the Chief Nursing Officer (Staff #501) and the Chief Executive Officer (Staff #502) reviewed the hospital's Quality Improvement Program. Surveyor #5 and Staff #501 reviewed Quality Committee Minutes and documentation for dates 02/22/21, 03/29/21, 04/26/21, 05/24/21, 04/26/21, 05/24/21, 06/28/21, 07/26/21, 10/25/21, 11/29/21, 12/20/21, 01/31/22, 02/28/22, and 03/28/22.

Surveyor #5 and Staff #501 reviewed the hospital's dashboards titled, "2021 OMHC Quality Improvement Dashboard Performance Measures" and "2022 OMHC Quality Improvement Dashboard Performance Measures." The review showed the following indicator data reported on the dashboards.

a. Aspirin administered to all suspected cardiac patients did not meet the hospital defined target for compliance for 7/12 months of data collection.

Surveyor #5 found no evidence that hospital staff developed or implemented process improvement initiatives related to the identified deficiencies.

b. Swing Bed patients with new orders for psychotropic medications will have a diagnosis in the order did not meet the hospital defined target for compliance for 8 of 10 months of reported data.

c. Percentage of documentation not completed within 24 hours of patient visit had not data reported for a continuous period of 10 months from 06/21 to 03/22.

d. Emergency Transfer Communication Tool (EDTC) did not meet the hospital defined target for compliance for 10 of 15 months from 01/21-03/22.

e. Eliminating the amount of medication error by changes in the process did not meet the hospital defined target for compliance for 12 of 15 months of data reported from 01/21 through 03/22.

Surveyor #5 found no evidence in review of Quality minutes that the hospital developed or implemented process improvement to address data or process improvement not meeting hospital defined targets.

3. At the time of the review, Staff #501 verified the finding and stated that the hospital's minutes should be more robust.

.

.
Item #1 Complete List of Patient Rights

Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights for 3 of 5 patients reviewed (Patient #502, #509, and #512).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital's document titled, "Know Your Rights,'" updated 08/19, showed that Odessa memorial Healthcare Center must provide patients' with a written description of patients legal rights.

2. On 04/19/22 at 11:07 AM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for 2 "Swing Bed" patients designated by the hospital as Long-Term Care/Non-Certified Swing patients (Patient #509 and #512). The review showed that the Patient Right's document signed by each patient did not include the right to:

a. §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care.

b. §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research.

c. §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician including (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment.

d. §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (ii) Access to stationery, postage, and writing implements at the resident's own expense.

§483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.

§483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law

5. On 04/19/22 at 11:15 AM, Surveyor #5 and Staff #501 discussed the hospital's policies and processes for ensuring Patient's receive information about their Rights in writing when admitted to the hospital's Swing Bed Program, either through direct admit or from the hospital's Acute Care. Staff #501 verified the finding and stated that patients receive their hospital Patient Rights on admission and that the hospital did not have a policy or procedure for providing Swing Bed Patient Rights specific to the Long-Term Care Swing-Bed patient.

6. On 04/20/22 at 3:34 PM, Surveyor #5 and Staff #501 reviewed the medical record for a "Certified Swing Bed" patient (Patient #502). The review showed that the patient's rights document (updated 08/19) signed by the patient did not include all swing bed patient rights.

7. At the time of the review, Staff #501 verified the finding and stated that the hospital did not have a specific policy for Swing Bed Patient Rights.

Item #2 Written Copy of Patient Rights

Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a written list of their patient rights for 2 of 5 patients reviewed (Patient #503 and #512).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital's document titled, "Know Your Rights,'" updated 08/19, showed that Odessa memorial Healthcare Center must provide patients with a written description of patients legal rights.

2. On 04/20/22 at 1:20 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital's Swing Bed Program on 04/06/22.

Surveyor #5 found no evidence the patient received a written copy of his Swing Bed Patient Rights.

3. At the time of the review, Staff #501 verified the finding and stated that the patient should have received a copy of his patient rights.

4. On 04/21/22 at 11:00 AM, Surveyor #5 and Staff #501 reviewed the medical record for Patient #515 who was admitted to the hospital's Swing Bed Program on 10/18/21.

Surveyor #5 found no evidence the patient received a written copy of his Swing Bed Patient Rights.

5. At the time of the review, Staff #501 verified the finding.

.




.

.

Based on interview, medical record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a discharge plan with measurable's goals and objectives for patients admitted to the hospital's Swing Bed program for 2 or 4 patients reviewed (Patient #509 and #512).

Failure to complete a discharge plan with measurable goals and objectives impairs the ability for the patient to be discharged back into the community.

Findings included:

1. Document review of the hospital's policy titled, "Discharge Planning," no policy number, revised 01/21, showed the following:

a. Discharge Planning begins on admission and is conducted in an ongoing manner by an interdisciplinary team.

b. All patients admitted to a Swing Bed will have an initial care plan meeting, where discharge potential/planning is addressed within 14 days of admission.

c. Medicare Swing Beds will have regular care plan meetings, occurring initially by 14 days and then at least every 30 days thereafter until discharged or transferred.

d. All Long-Term patients in Swing Beds will have a care plan every 90 days and discharge potential is discussed.

e. A patient's Care Plan, with discharge planning, is developed to address needs/outcomes perceived by the patient, family/significant others, and staff.

2. On 04/19/22, Surveyor #5 and The Chief Nursing Officer (Staff #501) reviewed the open medical record for 2 Swing Bed patients. The review showed the following:

a. Patient #509 was admitted on 06/11/20. Discharge planning documents showed the following:

i. Discharge planning documents dated 11/02/21 stated, "(Patient #509) will remain in Long-Term Care. No plans for discharge at this time."

ii. Discharge planning documents dated 12/02/20 stated, "(Patient #509) will remain in Long-Term Care at OMHC (Odessa Memorial Healthcare Center)."

iii. Discharge planning documents dated 11/02/21 stated, "(Patient #509) will remain in Long-Term Care. No plans for discharge at this time."

iv. Discharge planning documents dated 01/24/22 stated, "(Patient #509) would like to remain at OMHC in the Long-Term Care. There are no plans for discharge at this time."

b. Patient #512 was admitted on 09/17/20. Discharge planning documents showed the following:

i. Discharge planning documents dated 12/18/20 stated, "to remain at OMH." Discharge planning documents dated 03/12/21 stated, "No plan to discharge."

ii. Discharge planning documents dated 02/09/22, stated "No plan to discharge."

3. Document review of hospital policies and procedures showed that the hospital had developed and initialed policies specific to 3 types of patients including, "Emergency Room patients," "Acute, Observation and Certified-Swing bed patients," and "Long Term Care Residents."

4. At the time of the finding, Staff #501 verified the finding and stated that the there was no discharge planning and no discharge plans as these patients were Long-Term Care patients and not being discharged.
.