HospitalInspections.org

Surveyor #1

Based on medical record review and administrative staff interview, the hospital failed to ensure that evidence existed to show that Medicare patients received a copy of the standardized notice "An Important Message from Medicare" upon or within two (2) days of admission and again within two (2) days of discharge for of Medicare patients reviewed for patient rights (S10).

Failure to ensure that patients receive their rights, as required, places these patients at risk of harm related to a discharge that may be accomplished prior to the patient being ready for discharge.

Findings:

1. Per review of Patient# S10's medical record, the patient was admitted on 1/7/2012 with medicare benefits. The record contained the notice titled "An Important Message from Medicare" that was dated upon admission. There was no evidence that an additional copy of the rights was given to the patient, prior to discharge.

Surveyor #1

Based on review of hospital provided agreements with outside providers, the Governing Body failed to ensure that its written agreement with the distant-site telemedicine entity, met all requirements for credentialing and privileging.

Failure to ensure that telemedicine providers are appropriately credentialed and privileged places all patients at risk of harm related to the unqualified providers potentially providing care to hospital patients.

Findings:

Per review of the "Remote Acute Telemedicine Services Agreement" entered into on 5/12/2011, the agreement does not include a proviso to ensure: a) The distant-site telemedicine entity's medical staff credentialing and privileging process and standards at least meet the standards at (c)(1)(i) through (c)(1)(vii); b) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides a current list to the CAH of the distant-site physician's or practitioner's privileges at the distant-site telemedicine entity; and c) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH whose patients are receiving the telemedicine services is located.
The First Amendment to the above cited agreement, entered into on 12/23/2011, was designed to include the above cited deficiencies.
However, as of 1/11/2012, the evidence of compliance had not been fully collected to be presentable during the inspection. It is anticipated that full compliance with the amendment will be accomplished in the near future.
The hospital had identified that they were not in compliance, prior to the inspection, but evidence of a system to collect the required information was noted.

Surveyor #1

Based on observations and administrative staff interview, the hospital failed to ensure that emergency supplies were monitored to prevent the use of supplies that were stored beyond the manufacturer's expiration date.

Failure to not ensure monitoring activities prevent the use of patient care supplies outside of the manufacturer's stated parameters places all patients at risk of harm related to the use of these supplies.

Findings:

During observational rounds in the North clinic laboratory room on 1/10/12 the following was noted: a) two (2) BD BBL Cultureswabs were found with an expiration date of 10/2009 and 12/2010 respectively; b) one BD Viral Transport tube that expired in 5/2011 and thirteen (13) tubes that expired in 8/2011; c) eight (8) culture swabs with an expiration date of 8/2011; d) a bottle of "Hibiclens" disinfectant with pump handle that had the expiration date obliterated on the bottom not allowing a determination of its expiration date; e) a "Coag Wipe" bleach towel had an expiration date on 4/2006; f) three (3) Nitro-test paper dispensers with expiration dates on 3/2010 and 3/2011 respectively; g) five (5) BD serum vacutainers (small red top) with an expiration date in 9/2006; h) a bottle of hydrogen peroxide with an expiration date in 10/2011; and i) fifteen (15) Microlet Multi-microbe Media containers with expiration dates in 3/2010, 3/2011 and 10/2011 respectively. These observations were verified by Staff #SS4.

Surveyor #3

Based on observation and review of records the hospital failed to maintain the interior surfaces.

Failure to maintain interior surfaces causes further damage and does not provide for cleanable surfaces.

Finding:

1. During a tour of the therapy pool on 1/12/2012 at 9:30 AM the surveyor observed that the metal window frames, the metal door frames and the ceiling vents were rusting from the moisture in the pool area. The plaster finish on the deck around the pool was chipping and flaking on three sides of the pool. The greatest damage to the pool deck was in the area of the pool chair lift and at the handrails into the pool.

2. On 1/12/2012 the surveyor reviewed the pool repair bid from Northwest Hot Springs dated 2/4/2010 and observed the same conditions. The report stated the following: 1.) "The coating ( which was applied approx. 7-8 years ago) is separating and peeling off in some areas. 2.) The old tile ( under the coating ) and tile grout mid-bed directly under the tile is separating around the original poured cement flooring (3 layers down). 3.) The bottom wall tile (where it meets the original floor tile) is cracked in many areas. 4.) The tile backer board on the vertical walls to the rear and left of the therapy pool is buckling and therefore causing the tile to separate. 5.) The metal door and window frames are rusting."

3. These findings were confirmed on 1/12/2012 during an interview by the surveyor with hospital staff L2, L3, and L4.

Surveyor #3

Based on observation and interview with hospital staff the hospital failed to maintain air pressure relationships consistent with industry standards for ventilation.

Failure to maintain the correct environment and air pressure to support medical procedures performed places the patients at risk for the spread of infections.

Finding:

1. On 1/11/2012 at 3:00 PM the surveyor measured the air pressure in operating rooms #1, #2, #3 and endoscopy room #4. The air pressure was positive to the corridor for the four rooms and the air pressure was positive to the "Substerile" core for operating rooms #2 and #3. This allowed for air mixing in the "Substerile" core between operating rooms #2 and #3.

2. During an interview by the surveyor with staff (L1) the staff person reported to the surveyor that operating room #2 was used to perform both surgery and bronchoscopy procedures.

3. Staff (L2) reported to the surveyor that operating rooms #1, #2, #3,and #4 were designed for positive pressure and recirculated air, but later the air pressure in room #4 was changed to be negative pressure to accommodate endoscopy procedures.

4. A bronchoscopy procedure room requires a negative air flow with exhaust to the outside to prevent the possible spread of infection during a procedure.

Surveyor #3

Based on observation the Critical Access Hospital (CAH) failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Refer to the Fire Life Safety report for deficiencies found during the survey on 1/10/2012.

Surveyor #2


Based on interview, observation and review of policy and procedure the facility failed to don surgical attire in a manner to optimally assure asepsis.

Failure to do so creates a risk for patients to acquire nosocomial infection including, but not limited, to surgical site infection.

Findings:

1. During an observation of the surgery located in the operating room suite of Patient #LS4, 3 of 3 members of the surgical team were observed wearing surgical attire not properly donned and/or affixed.
a. The surgeon, (MD #LS10) was wearing cloth head coverings with a significant number of strands of hair that were hanging outside the head attire in front of his/her ear and from his/her neck hairline to the bottom of the neck.
The above provider was also noted to have the lower strings of his/her surgical mask loosely tied with a few inches of laxity on each side. This donning technique created venting of the mask on each side over the facial contours. At one point during the surgery, the surgeon stepped away from the surgical field to sneeze while wearing his/her vented mask with his/her gloved hands were within 3 feet of his/her nose/mouth. The nose/mouth to hand/surgical garb proximity was adequate for droplet transmission, considered to be approximately 3 feet from where they are generated. Surgical gloves/garb was not changed prior to proceeding to the next step in surgery.

b. Circulating nurse, Staff Member LS# 4, was observed to be wearing a cloth head covering and it was donned so that a significant number of strands of hair were hanging outside of it and down the base of the neck.

c. Another RN staff member, Staff Member #LS1, was observed wearing a facility provided head covering in restricted and semi-restricted areas. However, the nurse was observed on numerous to be wearing the covering in a manner that fully exposed hair from the forehead hairline to the crown of the head.

2. 4 of 4 staff members were observed wearing jewelry that was not confined within scrub attire.
a. Staff members # LS 4&5 and MD #s LS8&LS10 were observed in the semi-restricted area and restricted areas wearing earrings (ranging in size from small to large) outside of surgical head coverings.

3. Based on a Surgical Services department policy titled, " Dress Code " , (reviewed June 2003), item B. stated " All possible head and facial hair including sideburns and neckline should be covered while in semi-restricted and restricted areas of the surgical suite. B1 stated. " The surgical hat or hood should be clean, free of lint, and should confine the hair. " Item D2 stated, "Masks should cover the mouth and nose completely' and item D3 stated "Masks should have facial compliance to prevent venting."
These facility policies were aligned with current national guidelines of the American College of Surgeons and standards of AORN related to surgical attire.
The facility failed to follow its own policy, as well as adhere to nationally recognized standards of care, related to surgical attire. These findings were discussed accordingly with the Interim Director of Surgical Services, Staff Member #LS2.

Surveyor #2

Based on interview and record review the facility failed to assure that registered nurses administered medications for conscious sedation solely subsequent to obtaining a physician order.

Failure to do so creates a risk that patients may receive medications administered by a professional health care provider that was not also licensed to prescribe medication. This further creates a risk for a medication error and harm including, but not limited to, disability and death.

Reference: WAC 246-873-080(6) Medication Orders. Drugs are to be dispensed and administered only upon orders of authorized practitioners.

Findings:

1. In review of 3 of 3 records for Patient # (LS1, LS2, LS3), it was noted that patients received Fentanyl and Versed for conscious sedation on 7-7-11, 7-1-11 and 7-28-11, respectively, for short stay gastrointestinal procedures.
The total amounts for Fentanyl and Versed are as follows for each patient respectively:
? Fentanyl 150 mcgs and Versed 5mg
? Fentanyl 100 mcgs and Versed 4mg
? Fentanyl 100 mcgs and Versed 7mg
There were no physician orders preceding the administration of the above medications on a form titled "Physician's Minor Procedure Perioperative Orders (11-2009) in the section titled "Pain Control" or in any other section.

2. On 1-12-12 in an interview with registered nurse, Staff Member LS# 6, he/she stated that the "Physician's Minor Procedure Perioperative Orders" (11-2009) was no longer being used in the facility. It was verified with that individual that the form titled, "Intraoperative Monitoring" (for conscious medication administration recording) was signed by the RN and physician at the end of the procedure. Nowhere on that form were verbal orders recorded. The physician and RN signatures at the bottom of the form were not timed in reference to the start of the procedure.

3. The same day it was subsequently verified with the Interim Surgical Services Director, Staff Member #LS 2 that the facility changed order forms in September 2011 and was now using an order form titled, "Procedural Sedation Orders" (09-2011) prior to registered nurse medication administration. The more recent form specified options for conscious sedation with "FULL" or "HALF" doses and there was an area at the bottom of the form for writing additional orders. He/she stated that the sedation orders were to be entered on the form prior to registered nurse administration of medication. This change was implemented to help prevent administration of conscious sedation medication prior to a physician order.

Surveyor #1

Based on interview and record review, the hospital failed to provide each out-patient with a written statement of patient rights.

Failure to educate patients regarding patient rights risks patients not having the knowledge required in order to exercise their rights.

Findings:

1. Per record review, Patient #S1 was a 41 year-old patient receiving out-patient wound care. A review of the patient's record did not provide evidence that he/she had received a copy of the hospital's patient rights information.

2. Per record review, Patient #S2 was a 54 year-old patient receiving out-patient wound care. A review of the patient's record did not provide evidence that he/she had received a copy of the hospital's patient rights information.

3. Per record review, Patient #S3 was a 58 year-old patient receiving out-patient chemotherapy services. A review of the patient's record did not provide evidence that he/she had received a copy of the hospital's patient rights information.

4. Per record review, Patient #s S4 and S5 were receiving out-patient chemotherapy services. A review of their records did not provide evidence that they had received a copy of the hospital's patient rights information.

Surveyor #1

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information showing an evaluation of its total program.

Failure to document an evaluation of the total program places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

The hospital had not completed and finalized the annual program evaluation for September 2010 to September 2011, so a review was accomplished of the Critical Access Hospital (CAH) Program Evaluation for the months of September 2009 to September 2010. The document listed the areas of admission numbers, deliveries, out-patient visits, observation patient numbers, surgical and medical patient numbers.
The program evaluation document did not include all other areas of the total program. Some examples would include: laboratory; imaging; dietary and nutrition services; rehabilitation; out-patient infusions; and wound care services, etc.
The program evaluation document did not contain an evaluation of any of these services, just a listing of patient numbers.

Surveyor #1

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information showing the utilization of CAH services, including at least the number of patients served and the volume of services.

Failure to document an evaluation of the total program places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

The hospital had not completed and finalized the annual program evaluation for September 2010 to September 2011, so a review was accomplished of the Critical Access Hospital (CAH) Program Evaluation for the months of September 2009 to September 2010. The document listed the areas of admission numbers, deliveries, out-patient visits, observation patient numbers, surgical and medical patient numbers.
The program evaluation document did not include an evaluation of the volume of services for all hospital programs.

Surveyor #1

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information from a representative sample of "open and closed" patient records.

Failure to document the inclusion of open records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

The hospital had not completed and finalized the annual program evaluation for September 2010 to September 2011, so a review was accomplished of the Critical Access Hospital (CAH) Program Evaluation for the months of September 2009 to September 2010. The document stated on page 4, "A representative sample of both active and closed clinical records is used for evaluation purposes".
The program evaluation document did not present any evidence that this was actually accomplished. No evidence was presented to show how many open or closed records were reviewed. There was no evidence presented to show what the outcome of the record reviews identified and what was done with this information.

Surveyor #1

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that health care policies had been reviewed, as a result of annual program evaluation findings.

Failure to document the review of policies that were found to need updating, as a result of the program evaluation, places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

The hospital had not completed and finalized the annual program evaluation for September 2010 to September 2011, so a review was accomplished of the Critical Access Hospital (CAH) Program Evaluation for the months of September 2009 to September 2010. The document stated on page 6-7, "... policies, procedures and practices are added, deleted or revised as a result of review at the Committee level or during periodic evaluation as applicable".
The program evaluation document did not identify which policies and procedures were evaluated, reviewed and/or revised as part of the annual program evaluation?

Surveyor #1

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that utilization of services were appropriate, established policies were followed, and any changes were needed.

Failure to document the review of comprehensive evaluation for services used and any identified changes to policies, procedures or facility practices places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

The hospital had not completed and finalized the annual program evaluation for September 2010 to September 2011, so a review was accomplished of the Critical Access Hospital (CAH) Program Evaluation for the months of September 2009 to September 2010. The document stated on page 6-7, "... policies, procedures and practices are added, deleted or revised as a result of review at the Committee level or during periodic evaluation as applicable".
The program evaluation document did not provide evidence that the utilization of services were appropriate, established policies were followed, and any changes were needed.

Surveyor #1

Based on review of the quality assurance program plan, review of committee minutes and administrative staff interview, the hospital failed to ensure that the quality plan included the provision to collect, measure and assess data related to all patient care services, such as: contracted services; dietary and nutrition; respiratory therapy; family birth center; and out-patient infusion therapies.

Failure to include data related to all patient care services that affect patients places patients at risk of harm related to potential care and treatment issues not being identified and corrected.

Findings:

1. Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to contracted services related to patient care.

2. Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to the following: dietary service; nutrition service; respiratory therapies; family birth center; and the out-patient cancer treatment and infusion center.

Per interview with staff #SS1 on 1/11/2012, during the quality assessment and performance improvement review, no evidence could be provided to show that the hospital quality assurance system had been collecting, measuring and assessing data regarding the above mentioned issues.

Surveyor #1

Based on review of the quality assurance program and minutes, and administrative staff interview, the hospital failed to ensure that the quality plan included the provision to collect, measure and assess data related to the efficacy of the medication therapy provided to patients with identified infections requiring antibiotics.

Failure to include the above identified data places patients at risk of harm related to potential care and treatment issues not being identified and corrected.

Findings:

Per review of the hospital quality plan and related documentation, no information was found that the plan included a way to collect, measure and assess data related to contracted services related to patient care.

Per interview with staff #SS3 on 1/11/2012, during the infection control program review, no evidence could be provided to show that the hospital quality assurance system had been collecting, measuring and assessing data regarding the above mentioned issue.