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Based on interview and review of patient rights information, the hospital failed to provide written notice to patients that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week.

This information assists the patient to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"In the case of a hospital as defined in Sec. 489.24(b), to furnish written notice to all patients at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with Sec. 482.13(b)(2) of this subchapter. The notice must indicate how the hospital will meet the medical needs of any patient who develops an emergency medical condition, as defined in Sec. 489.24(b), at a time when there is no physician present in the hospital. For purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service."

Findings:

An interview with the Director of Nursing Services (Staff Member #1) on 11/2/2011 revealed that the hospital had not developed a process to provide patients with written notice informing them that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week. In addition, there was no process for giving patients written notice indicating how the hospital would meet the medical needs of any patient who develops an emergency medical condition when a physician is not present.

Based on observation and interview, the critical access hospital failed to provide appropriate backflow prevention at points of potential cross-contamination.

Failure to provide appropriate backflow prevention risks contamination of the hospital potable water supply or clean surfaces by chemical or sewage backflow.

Findings include:

During a tour of the hospital on 11/01/2011, it was observed that plumbing in the following locations did not meet the cross-connection control standards of the Department:

a) Chemical dispensors at the kitchen produce sink and in the kitchen housekeeping closet, and
b) Three washing machines in the hospital linen department.

Based on review of pharmacy refrigerator logs, the critical access hospital failed to ensure that pharmaceuticals were stored at appropriate temperatures.

Failure to ensure that pharmaceuticals are stored at appropriate temperatures risks lack of efficacy of the medications.

Findings include:

During a tour of the critical access hospital on 11/01/2011, it was observed that the medication refrigerator located in the medication room behind the acute care nurses' station had a log sheet for October, 2011. The log sheet indicated that during 15 shifts in October, the temperature of the refrigerator was not documented. According to the chief nurse executive, there were two nursing shifts per day in October, so approximately half of the nursing shifts had not shown a documented medication refrigerator temperature.

Based on observation and interview, 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 MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 11/03/2011.

Based on record review and interview, the critical access hospital failed to follow its policy regarding medical staff appointment processes, by appointing a member of the medical staff in the incorrect category.

Failure to ensure that medical staff are appointed in the correct categories risks provision of patient care services by medical staff who are not qualified or legally permitted to provide such services.

Findings include:

During review of medical staff credentialing records on 11/03/2011, it was noted that a member of the medical staff (MD 1) was appointed on 01/07/2011, in the category of "Temporary Medical Staff." According to the hospital Medical Staff By-Laws (Revised 09/28/1995), medical staff may be granted Temporary Privileges "...for up to 180 days, provided, however, that in exercising such privileges, the applicant shall act under the supervision of the physician(s) which the chief of staff assigns to monitor his practice."

The critical access hospital Chief Executive Officer confirmed that MD 1 has been a member of the medical staff under Temporary Privileges for more than 180 days, and has no supervising physician designated by the hospital chief of staff. The Chief Executive Officer stated that he believes the category of appointment for MD 1 should have been "Provisional," rather than "Temporary."

Based on record review, review of policies and procedures, and interview, the hospital failed to implement a process for referring patients at nutritional risk to a dietician for a nutritional assessment in 1 of 2 records reviewed (Patient #1).

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

Findings:

1. Review of the hospital's policy entitled "Inpatient Dietician Consult Protocol" (Dated 5/12/2008) read as follows:

"Upon admission to Acute Care, Swing Bed, and Observation status, the attached nutritional assessment will be completed by the admitting nurse or delegated nurse. This assessment will be complete within 8 hrs of admission."

"If the assessment triggers one or more, yes, answer for any of the Dietary Consult Screening questions, the nurse and/or ward clerk will write a referral to the dietician as well as writing a standing order in the physician ' s orders for a provider signature."

"The dietician will complete an inpatient dietary consult and provide a written dietary plan for the physician and nursing staff as soon as possible once the order is received."

Review of the form entitled "Inpatient Nutritional Assessment Form" (Dated 5/12/2008) revealed that patients were screened for six different nutritional risk triggers including no oral intake for greater than three days, unintentional weight loss, low albumin levels, pressure sores or wounds, a malnutrition diagnosis, and poor intake or poor appetite.

2. Review of 2 patients for nutritional risk screens revealed the following:

a. Patient #1 was a 64 year-old patient admitted on 10/15/2011 for treatment of a skin infection and wound healing. Review of nursing documentation and laboratory results on 11/1/2011 revealed that the patient had multiple skin issues including a Stage IV pressure ulcer and a skin infection as well as a low albumin level. A nutritional assessment (screen) completed by nursing was not found in the patient's medical record. There was no dietary consult in the patient's medical record.

3. An interview with the Dietician (Staff Member #2) and a Registered Nurse (Staff Member #3) on 11/1/2011 revealed that the nutritional assessment form used to be included in an admission packet that nursing was responsible for completing when a patient was admitted to the unit. Recently the facility switched to an electronic medical record that included a similar nutritional assessment form however the electronic form was not used on every patient. The Dietician and RN thought this was due to the change in process and loss of the "paper" admission packet. The electronic medical record does not indicate which forms staff must complete when admitting a patient to the unit.

Based on interview and review of hospital policy and procedures, the hospital failed to ensure that hospital policy and procedures were reviewed annually according to facility policy.

Failure to review policies and procedures risks implementation of procedures that do not meet current standards of practice.

Findings:

1. The hospital's policy and procedure entitled "Policy for Updating Procedure Books" (Approval date 1/2000) stated that all policy and procedure books within the facility were to be reviewed and updated on an annual basis by both assigned nurses, administrators and physicians.

2. Review of two policy and procedure books entitled "Nursing Procedure Manual #1" and "Nursing Procedure Manual #2" on 11/2/2011 revealed that there was no face sheet at the front of the book indicating that the policies and procedures had been reviewed and/or updated.

3. An interview with the Director of Nursing Services (Staff Member #1) revealed that the nursing policies and procedures in the two books were purchased in 2007. The policies and procedures have not been reviewed or updated since purchased by the hospital.

Based on interview, record review, and review of policy and procedure, the hospital failed ensure that orders for patient medications were reviewed and authenticated by a physician as required by chapter 246-873 WAC, PHARMACY - HOSPITAL STANDARDS and hospital policy and procedure.

Failure to follow pharmacy hospital standards and hospital policies and procedures places patients at risk for harm due to medication errors.

Reference:

WAC 246-873-080 (6) Medication Orders. Drugs are to be dispensed and administered only upon orders of authorized practitioners. A pharmacist shall review the original order or direct copy thereof, prior to dispensing any drug, except for emergency use or as authorized in WAC 246-873-050.

Findings:

1. The hospital policy and procedure entitled "Medication Reconciliation and Medication Ordering" (Ref No. PHA 077; Review date 6/1/2006) read as follows: "Orders at admission or new orders after admission will only be transcribed to the MAR and administered if the provider has given a verbal order for each medication, or he/she has signed the MR [Medication Reconciliation] form."

2. Patient #2 was a 61 year-old patient who was admitted on 11/2/2011. On 11/2/2011 nursing staff were observed entering medications listed on a medication reconciliation form into the electronic medical record. The medication reconciliation form did not have a physician's signature.

An interview with a Registered Nurse (Staff Member #4) on 11/2/2011 revealed that the physician wrote an order to continue patient's current home medications. Staff Member #4 stated that she/he pulled the patient's list of medications from a previous hospitalization and reviewed the medications with the patient to ensure the list was up-to-date.

Review of the patient's medical record confirmed that the physician's (MD #1) medication order dated 11/2/2011 read as follows: "continue her current home meds." The order did not list the medications individually.

3. An interview with MD #2 on 11/10/2011 revealed that after this issue was brought to his/her attention he/she talked to the other physicians and found that two never order medications this way and two sometimes ordered medications this way. MD #2 stated that this was a process problem. If nursing staff enter medications into the system the physician is not notified by the system to review and authenticate the orders. MD #2 stated that all physicians have been instructed to review and sign the Medication Reconciliation form (paper form) prior to entering the medications into the electronic Medication Administration Record.

Based on document review, the hospital failed to provide documentation that the comprehensive evaluation contained information from a review of a representative sample of open and closed patient records.

Findings:

Review of the document presented as the Critical Access Hospital annual evaluation on 11/2/2011 revealed the evaluation did not include information about the review of both open and closed patient records.

Based on document review and interview, the hospital failed to include a review of health care policies as part of the Critical Access Hospital's (CAH) annual evaluation.

Failure to include review of hospital policies and procedures in the annual CAH evaluation places patients at risk of harm related to the potential of receiving inappropriate care and services.

Findings:

Review of the document presented as the CAH annual evaluation on 11/2/2011 revealed that the evaluation included a general statement that changes and updates were made to several policies. The evaluation did not include detailed information about the evaluation, review and/or revision of hospital policies and procedures

Based on interview, the critical access hospital failed to ensure that its quality assurance and performance improvement (QAPI) processes included systematic review of contracted patient care services.

Failure to ensure that the critical access hospital QAPI processes include systematic review of contracted patient care services risks provision of clinical services not meeting hospital expectations.

Findings include:

During an interview on 11/03/2011, the critical access hospital QAPI manager, Director of Information Systems and Chief Executive Officer all stated that contracted services were reviewed by senior executives or by department managers as needed, in the course of contract renewal. However, there were no objective, pre-established criteria reported for the review of contracted services, and no documentation was available describing the quality review of contracted services.

Based on interview and record review, the hospital failed to inform swing bed patients and family or surrogate decision makers of certain patient's rights outlined in this regulation.

Failure to do so impedes the patient's ability to be aware of and exercise these rights.

Reference:

42 CFR ?483.10 Residents Rights

Findings:

Review of patient records on 11/1/2011 to 11/3/2011, both acute care and swing bed (long term care patients), revealed that swing bed patients placed on the Acute Care Unit were given the same patient rights handout entitled "Patient Bill of Rights". The handout did not include all items listed under ?483.10(a-m) that are specific to swing bed patients.

The handout entitled "Patient Bill of Rights" did not address the swing bed patient's right to:

? Access his/her records and photocopies thereof within the defined time frames
? Be fully informed in a language that he/she can understand
? Formulate an advance directive
? Choose a personal attending MD/DO
? Perform services for the facility if the facility has documented the need or desire in the plan of care; nature of services performed; compensation for services
? Personal privacy including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups
? Access to stationery, postage, and writing implements at the residents own expense

In addition, the handout stated that the resident had the right to refuse visitors and the "doctor may restrict visitors as he/she sees fit." This does not comply with ?483.10 (j).