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Based on policy review, observations, code cart documentation for 5 of 5 emergency code carts and staff interview, it was determined that the hospital failed to ensure that emergency code carts were maintained in accordance with its policy to ensure the integrity and availability of the contents of the carts.

Findings include:

1. A procedure titled "DAILY CODE CART INSPECTION AND TESTING ALL CAMPUSES," effective 10/25/2011 was reviewed. The policy reflected "6...A The code cart is inspected and defibrillator/monitor is tested every 24 hours...C. For each cart, items are checked and noted on the Code Cart Checklist. Confirm that the items are present and no supplies are beyond any printed expiration dates:...G. For each code cart, document that the daily inspection and testing were completed by initialing and signing on the appropriate date on form F10048, Code Cart Check Sheet..."

2. During a tour of the hospital's Radiology Department on 02/28/2012 at 1500 with the department's manager, an emergency code cart and a corresponding code cart check sheet were observed. Page 1 of the checklist reflected "St. Charles Health System - CODE CART CHECK SHEET" which identified items on the cart that were to be checked each day. The check sheet lacked documentation that checks had been completed on 02/07/2012, 02/11/2012, 02/12/2012, and 02/13/2012.

3. During a tour of the ICU on 02/29/2012 at 1500 with the nurse manager, an emergency code cart and corresponding code cart check sheet were observed. The check sheet lacked documentation that checks had been completed on 02/16/2012 per hospital policy.

4. During a tour of the Emergency Department on 02/28/2012 at 1500 with the nurse manager, the adult code cart and corresponding code cart check sheet were reviewed. The check sheet lacked documentation that checks had been completed on 02/10/2012 and 02/19/2012. Additionally, the pediatric code cart and corresponding code cart check sheet were reviewed. The check sheet lacked documentation that checks had been completed on 01/09/2012, 01/19/2012, 01/22/2012, 01/29/2012,02/10/2012, and 02/19/2012.

5. An interview with the nurse manager of the Emergency Department on 02/28/2012 at 1530 confirmed the staff had failed to complete the daily code cart checks as required by hospital policy.

Based on the review of documentation in 3 of 5 medical records of patients who received blood transfusion services (Record #s 1, 2 and 4) and policy review, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy. Vital signs, whether or not transfusion reactions were observed, and tasks to be completed prior to the start of the transfusion were not documented according to hospital policy.

1. The policy titled "Blood/Blood Components - Transfusion," dated 02/2005 reflected "Blood Bank form 'Transfusion Record' accompanies the blood/component from blood bank...Used as record of transfusion...Vitals signs taken/recorded on this form as per printed instructions...Observe for transfusion reaction(s) up to one (1) hour after infusion of blood/component...Two nurses (one must be an RN) check the blood/component at the patient's bedside, comparing information on the patient's arm band(s) with the label on the bag tag, blood unit, and blood transfusion record form...Verify the following...Physician's order...Patient's name...Unit number...'R' number...Blood component(s) to be given...Blood ABO group and Rh type...Expiration date..."

2. A "Transfusion Record" form was contained within each of the patient records reviewed. The form included a "Transfusion Record" section which reflected "(Must Complete Immediately Before Beginning Transfusion)" followed by a listing of tasks with corresponding checkboxes. The tasks included items such as "...Consent form signed...Blood product verified with physician order...Patient name, MRN & DOB are identical on blood bank band, bag tag & this form...Product is not expired..." The form had a "Transfusion Reaction" section with corresponding "Yes" and "No" checkboxes. The form also indicated time increments when vital signs were to be checked as follows "...Pre-transfusion...15 Minutes After Start..1 Hour After Start...2 Hours After Start...3 Hours After Start...Post Transfusion."

3. Patient record #1 was reviewed. The "Transfusion Record" form reflected the patient received one unit of blood on 11/02/2011 which was started at 1539 and stopped at 1805. Vital signs were documented at 1539 and 1554. The next set of vital signs were not completed until 1650, 71 minutes after the start of the transfusion. The record lacked documentation that vital signs were obtained one hour after the start of the transfusion as indicated on the "Transfusion Record" form and directed by hospital policy.

4. Patient record #2 was reviewed. The "Transfusion Record" form reflected the patient received one unit of blood on 11/14/2011 which was started at 1545 and stopped at 1955. The section of the form with the listing of tasks to be completed before the start of the transfusion was blank. The "Transfusion Reaction" yes/no checkboxes were blank.

The record reflected Patient #2 received a second blood transfusion on 11/14/2011 which was started at 2015 and stopped on 11/15/2011 at 0010. Vital signs were documented at 2010 and 2030. The next set of vital signs were not documented until 2130, 75 minutes after the start of the transfusion. The record lacked documentation that vital signs were obtained one hour after the start of the transfusion as indicated on the "Transfusion Record" form and directed by hospital policy.

5. Patient record #4 was reviewed. The "Transfusion Record" form reflected the patient received one unit of blood on 12/30/2011 which was started at 1920 and stopped at 1950. The section of the form with the listing of tasks to be completed before the start of the transfusion was blank. Vital signs were documented at 1920. The next set of vital signs were not documented until 1950, 30 minutes after the start of the transfusion. The record lacked documentation that vital signs were obtained 15 minutes after the start of the transfusion as indicated on the "Transfusion Record" form and directed by hospital policy.

The record reflected Patient #4 received a second blood transfusion on 12/30/2011. The "Transfusion Record" form reflected the transfusion was started at 1955. Vital signs were documented at 1952 and 2010. The record lacked a documented completion or "stopped" time for the transfusion in order to determine whether or not vital signs were completed in accordance with the hospital policy. The section of the form with the listing of tasks to be completed before the start of the transfusion was blank. The "Transfusion Reaction" yes/no checkboxes were blank.

6. These findings were reviewed with the Med Surg/ICU Manager on 02/28/2012 at 1230.

29709

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group as required by this regulation.

Findings include:

1. During the CAH recertification and State relicensure survey, it was determined that many policies had not been reviewed or revised on an annual basis per this regulation. Listed below is a sample of patient care policies that had not been reviewed for more than a year:

· "Advance Directive/Patient Rights," on approval route, 8/17/05;
· "Blood/Blood Components - Informed Consent," Originated: 12/04;
· "Blood/Blood Components - Refusal of Blood/Blood Components," Originated 12/04;
· Cascade Healthcare Community, "Patients' Rights and Responsibilities," Reformatted 3/5/09;
· "Mandatory Overtime in Patient Care Units - CHC," sent on approval route 6/12/07;
· "Patient/Patient Representative Complaint/Grievance Resolution Process," no date listed;
· PIONEER MEMORIAL HOSPITAL DEPARTMENT OF NURSING, "PRACTICE GUIDELINES FOR HOSPITAL DISCHARGE," last approved 1/03;
· "PIONEER MEMORIAL HOSPITAL STAFFING COMMITTEE CHARTER," Adopted June 2, 2009;
· Procedure, "RESTRAINTS - Non-violent, non-self-destructive behavior," no revision date;
· "STAFFING OF ALL NURSING UNITS," revised 11/07;
· "STAFFING PLAN FOR ALL NURSING UNITS," revised 2/07;
· St. Charles Medical Center "HEALING HEALTH CARE and PATIENT RIGHTS and RESPONSIBILITIES,"12/06;
·

Based on interviews with hospital staff and the review of contracted services documentation, it was determined that in 3 of 4 contracted services, the hospital lacked documentation confirming all contracted services enable the CAH to comply with Federal regulations and state rules as required by this regulation


Findings include:

On 02/28/2012 at 1035 a list of all 130 contracted services was provided to the surveyors. From this list, annual evaluations of four random patient care service contracts were requested for further review and proof that the services met the CAH conditions of participation.

On 03/01/2012 at 0840 the CEO provided a thorough evaluation of the contracted services for emergency department physician coverage.

An interview with the Administrator on 03/01/2012 at 1315 confirmed the hospital lacked documentation of an annual review for the remaining three contracted services. He/she stated that the computerized contract tracking system identified each of these contracts to be reviewed every three years instead of yearly. He/she confirmed that there was no annual review of the services to confirm they comply with the conditions of participation.

Based on the review of documentation contained in 2 of 4 medical records of patients who expired in the hospital (Record #s 7 and 8), review of hospital policy, and organ procurement contract review, it was determined that the hospital failed to ensure documentation of a timely notification of the donor referral organization as required. The hospital donor referral policy did not include a clearly defined timeframe for a "timely" referral. The date and time of the donor referral notification was not documented in all cases in order to determine whether or not the referral was timely.

Findings include:

1. The "Contract For Pacific Northwest Transplant Bank Organ Procurement Services" signed/dated 09/01/2011 was reviewed and reflected "ENTITY shall refer all ventilated patients for which death is imminent to the donor referral line...ENTITY must make the referral in a timely manner in order to allow PNTB to adequately evaluate the patient for medical suitability. A timely referral is one that occurs as soon as the patient meets the mutually agreed upon clinical trigger/imminent death criteria and prior to the withdrawal or deceleration of life sustaining therapies as set forth in more detail in ENTITY policy."

2. The policy titled "Organ Donation, including Donation after Cardiac Death," revised 08/20/2010 reflected "When death occurs in the hospital...Call the donor referral line...Ideally if death is imminent, contact the donor referral line in advance to determine if patient is medical [sic] suitable for eye/tissue donation...The Life-Death Transition Form remains in patient's chart...Documentation...Life, Death Transition Form." The policy lacked a clearly defined timeframe of a "timely" referral. This was reviewed with the Clinical Practice Coordinator on 02/28/2012 at 0810.

3. The medical record for Patient #7 was reviewed. The "Life/Death Transition" form reflected the date/time of death was 10/20/2011 at 0540. The record reflected the patient was released to a funeral home on 10/20/2011 at 0635, nearly an hour later. The record reflected the donor referral line had been called by an RN, however, it lacked a documented time in which the donor referral line had been called in order to determine whether or not a timely referral had occurred. This was reviewed with the Med Surg/ICU Manager on 03/02/2012 at 1330.

4. The medical record for Patient #8 was reviewed. The "Life/Death Transition" form reflected the date/time of death was 11/03/2011 at 0640. The the record reflected the patient was released to a funeral home on 11/03/2011 at 0855, over two hours later. The record reflected the donor referral line had been called by the RN, however it lacked a documented time when the donor referral line had been called in order to determine whether or not a timely referral had occurred. This was reviewed with the Med Surg/ICU Manager on 03/02/2012 at 1330.

Based on the review of documentation contained in 3 of 4 Swing-bed records of patients who were discharged from the hospital (Record #s 10, 12 and 13), the review of Swing-bed documentation, and interviews with hospital staff, it was determined that the hospital failed to ensure the provision of a written notice before discharge with all of the elements required by this regulation.

Findings include:

1. Swing-bed patient record #12: Review of the record reflected the patient was admitted to a hospital Swing-bed on 09/16/2011 and discharged on 09/26/2011. The record lacked documentation that a written discharge notice with all of the required elements had been provided to the patient prior to discharge.

2. Swing-bed patient record #10: Review of the record reflected the patient was admitted to a hospital Swing-bed on 09/24/2011 and discharged on 09/30/2011. A document titled "Pioneer Memorial Hospital Notice of Transfer or Discharge" reflected "You have the right to appeal this decision as explained on the back of this form." The back of the form was blank. The notice did not include the name, address and telephone number of the State long term care ombudsman or a statement that the patient had the right to appeal the action to the State as required.

3. Swing-bed patient record #13: Review of the record reflected the patient was admitted to a hospital Swing-bed on 10/18/2011 and discharged on 10/25/2011. The record contained a discharge notice which reflected "The Person at the Swing Bed/Nursing Facility who can help you with relocation or with sending in your request for a meeting as described on the back of this form is..." The form was signed/dated by an RN on 10/25/2011. The record lacked documentation that the notice was provided to the patient in writing as required.

4. These findings were reviewed with the Med Surg/ICU Manager on 03/02/2012 at 1345.

Based on the review of documentation in 4 of 4 records of patients who received hospital Swing-bed services (Record #s 10, 11, 12, and 13), the review of Swing-bed program documentation and staff interview, it was determined the hospital failed to provide an on-going program of activities that was directed by a designated staff person who meets the requirements of this regulation, or a qualified individual as required.

Findings include:


1. The Med Surg/ICU Manager was interviewed on 02/29/2012 at 1245. He/she indicated that he/she was primarily responsible for the hospital Swing-bed program. A job description for the Swing-bed program Activities director was requested. The manager revealed that although the hospital had developed and implemented a plan to offer activities to Swing-bed patients, the hospital lacked a defined ongoing program of activities directed by a designated staff person or qualified individual.

2. Swing-bed patient record #s 10, 11, 12 and 13 were reviewed. Although each record contained an Activities assessment and plan, none of the records included documentation that the Activities program was directed by a designated staff person or qualified individual.

3. A hospital Swing-bed program admission folder was reviewed and contained a document titled "Hello and Welcome to the Pioneer Memorial Hospital Swing Bed Program!" Review of the documentation reflected "...The team working with you may include nurses, physical therapists, occupational therapists, speech therapists and a discharge planner to assist with the transition back to your place of residence." None of the documentation contained within the "Welcome" notice or the Swing-bed admission folder included information regarding an on-going program of activities that was directed by a designated staff person or qualified individual.

Based on review of documentation contained in 4 of 4 records of patients who received hospital Swing-bed services, interviews and policy review, it was determined the hospital failed to ensure documentation that acceptable nutrition was maintained. Nutrition screening and consults were not completed as required by hospital policy. Daily weights were not documented in accordance with physician orders.

Findings include:

1. A policy titled "Swing Bed Nutrition Services," undated reflected "...Nutrition and diet are a part of the patient's initial comprehensive assessment and ongoing daily assessments. Examples of identifiable nutritional risk factors may include but are not limited to...Unintentional weight loss of more than 10% body weight...Diagnosis of anorexia nervosa or cachexia...Presence of pressure ulcers...Patient consistently refused meals or consumes less than 50% of meals for three (3) days...Nutrition screening is documented in the medical record and incorporated to the plan of care. If a patient is deemed to be at nutritional risk an order for Dietician consult is obtained." During an interview with the Med Surg/ICU Manager on 02/29/2012 at 1400, he/she said although the policy had not yet been officially approved, it reflected the hospital's process. He/she further said the nutrition screening was to be completed by the patient's admitting nurse during the Swing-bed admission process.

2. A policy titled "Nutrition Screening, Assessment, and the Nutrition Therapy Plan," revised 10/29/2009 reflected "...Nutrition screening will be used to identify patients with potential nutrition risk for dietician referral or further RD intervention...Step 1: Nursing Screen. The nurse completes the nutrition screen via the Electronic Medical Record (EMR) within 24 hours of admission, unless there are extenuating circumstances. The presence of nutrition risk, cues nursing to enter a consult to Dietician...Step 2. Nutrition Assessment Within 48 hours of notification, a nutrition assessment is completed on patients identified at nutrition risk and documented..."

3. An interview was conducted with the Registered Dietician/Dietary Manager on 02/27/2012 at 1500. During the interview the manager revealed that nursing staff completed a nutrition screening for all Swing-bed patients during the admission process. If risk factors were identified during the nutrition screening, the manager was informed and he/she would then complete a nutrition assessment.

4. Swing bed patient record #11: Review of the record revealed the patient was admitted to a hospital Swing-bed on 02/24/2012 and discharged 02/28/2012. Review of the record reflected the patient had risk factors which placed him/her at nutritional risk. The history and physical dated 02/24/2012 reflected the patient had diagnoses which included anemia, diverticulitis, edema to both legs, and left leg cellulitis requiring intravenous antibiotics. Documentation on the Med-Surg flow sheet dated 02/24/2012 at 1800 reflected the patient experienced "green liquid stool, nausea & vomiting..." The record lacked documentation that a nutrition screening or assessment had been completed in accordance with hospital policy.

5. Swing bed patient record #13: Review of the record revealed the patient was admitted to a hospital Swing-bed on 10/18/2011 and discharged 10/25/2011. Review of the record reflected the patient had risk factors which placed him/her at nutritional risk. The discharge summary transcribed 10/19/2011 at 1844 reflected "Reason for Admission: Recovery from acute encephalopathy, left pubic ramus fracture, resolved dehydration, a recent [urinary tract infection], underlying dementia, diabetes mellitus type 2 and hypothyroidism." The "Swingbed Admission Orders" dated 10/18/2011 indicated the patient was to be weighed daily. Review of the "Daily Weight Flow Sheet" reflected weights were not documented on 10/19/2011 and 10/20/2011. Further review reflected the patient weighed 176.1# on 10/18/2011 and 170# on 10/25/2011, a loss of approximately 6# in 7 days. The "Swing Bed Nursing Admission and Assessment" dated 10/18/2011 at 1030 reflected "...Appetite: poor..." The "Swing Bed Discharge Summary" dated 10/25/2011 reflected "Weight Trend: decreasing." A "Nutrition Screening and Referral" was contained in the record and reflected "To be completed on admission and [whenever] a change in nutritional status noted." The form listed 7 nutrition risk factors. Two risk factors were identified: "...Resident consumes less than 1500cc per day unless fluids are restricted by physician's order" and "...Resident regrets therapeutic diet restrictions." The bottom of the form reflected "If the answer to any of the above is positive, notify physician (if needed) and leave a message for...Registered Dietician...." The screening form lacked a completion date, time and signature/title. Further review of the record revealed it lacked documentation that a dietary consult had been obtained as required by the hospital policy.

This was reviewed with the Med Surg/ICU Manager on 03/02/2012 at 1400 and he/she reviewed the record and verified that there was no documented dietary consult.

6. Swing-bed patient record #12: Review of the record revealed the patient was admitted to a hospital Swing-bed on 09/16/2011 and discharged 09/26/2011. Review of the record reflected the patient had risk factors which placed him/her at nutritional risk. The RN "Swing Bed Discharge Summary" dated 09/26/2011 reflected the patient had admission diagnosis of peptic ulcer disease and "hemorrhage." The "Nutrition Screening and Referral" reflected the following nutrition risk factors: "...Resident and/or family report a recent weight loss...Resident consumes less than 1500cc per day..." The screening form lacked a documented completion date, time, and signature/title. Further review of the record revealed it lacked documentation that a dietary consult had been obtained as required by the hospital policy.

This was reviewed with the Med Surg/ICU Manager on 03/02/2012 at 1400 and he/she reviewed the record and verified that there was no documented dietary consult.

7. Swing-bed record #10: Review of the record revealed the patient was admitted to a hospital Swing-bed on 09/24/2011 and discharged 09/30/2011. Review of the record reflected the patient had risk factors which placed him/her at nutritional risk. The discharge summary dictated 09/30/2011 and transcribed 10/01/2011 reflected the patient had diagnoses which included stasis ulcerations with cellulitis and congestive heart failure. The patient required intravenous antibiotics and wound debridement during his/her hospital Swing-bed stay. "Swingbed Admission Orders" dated 09/24/2011 reflected that daily weights were ordered. The record lacked documentation that a nutrition screening or assessment had been completed in accordance with hospital policy.

This was reviewed with the Med Surg/ICU Manager during an interview on 03/02/2012 at 1400. He/she reviewed the record and verified that there was no documentation of daily weights or a dietary consult.