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Based on record review and interview, the Critical Access Hospital failed to provide Medicare patients with a notice regarding their right to appeal being discharged as required by federal regulations for 4 of 5 patients reviewed (Patients #1, #2, #3, #4).

Failure to provide this notice to Medicare patients limits patients' ability to contest their discharge and to appeal their discharge to a Quality Improvement Organization.

Reference: 42 CFR 405.1205 - Notifying beneficiaries of hospital discharge appeal rights.
(b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:

(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital.

(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge

Findings:

1. Review of the records of five patients receiving Medicare Part A benefits revealed the following:

a. Patient #1 was admitted for an inpatient stay on 7/3/2014. The patient was discharged from inpatient status and readmitted to long-term care ("swing bed") status on 7/6/2014. The "Important Message From Medicare" information form had been signed by the patient on 7/6/2014. There was no documentation in the patient's record that the patient had received notification of their discharge rights within two days of the patient's admission.

b. Patient #2 was admitted for an inpatient stay on 6/12/2014 and was discharged on 6/19/2014. The "Important Message From Medicare" information form had been signed by the patient on 6/13/2014. There was no documentation in the patient's record that the patient had received second notification of their discharge rights within two days of discharge.

Similar findings were found in the records of Patients #3, #4.

2. During an interview with Surveyor #1 on 9/24/2014 at 3:00 PM, the hospital's Director of Nursing (Staff Member #2) confirmed the findings above.
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Based on observation and interview, the Critical Access Hospital failed to maintain a safe environment free of potential hazardous situations and/or conditions.

Failure to maintain a safe environment puts patients, staff, and visitors at risk of injury.

Findings:

1. On 9/23/2014 at 11:10 AM, Surveyor #2 noted that an electrical breaker panel located on the 2nd floor near the elevator was not locked to prevent unauthorized access and/or loss of critical electrical service.

2. On 9/23/2014 at 11:20 PM, Surveyor #2 noted that an electrical breaker panel located on the 1st floor across from 104 CT was not locked to prevent unauthorized access and/or loss of critical electrical service.

3. On 9/23/2014 at 2:45 PM, Surveyor #2 checked the water temperature at the hand wash sink in room A104 ProCare using a digital thermometer and noted a water temperature of 123.7 degrees Fahrenheit.

4. On 9/23/2014 between the hours of 3:00 and 3:30 PM, Surveyor #2 noted that single fixture light bulbs in Central Supply and in a single service storage room used for the Drip Line Cafe were not shielded or made of shatter proof materials .

5. On 9/24/2014 at 3:30 PM, Surveyor #2 reviewed preventive maintenance documentation and was informed by Staff Member #10 that an electrical equipment safety check of a defibrillator (property number 08879) had not been performed prior to placing the equipment into service as is required by facility policy. The hospital's policy entitled Electrical Equipment Safety (Policy Stat ID: 962516) stated in part: ". . . All new electrical equipment must be checked for safety by the Engineering Department and calibrated prior to use. . . ".
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Based on observation, the Critical Access Hospital failed to maintain air pressure relationships required for the protection of patients in clinical care areas of the facility.

Failure to maintain proper air pressure relationships in clinical care areas puts patients at risk of infection.

Findings:

On 9/23/2014 at 1:40 PM, Surveyor #2 used a light weight flutter strip (tissue) to evaluate the air relationships between the "Soiled Utility Room" near the Emergency Department and adjoining spaces (i.e. corridors). As a result it was determined that the utility was positive to adjoining spaces not negative as is required.
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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:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION LIFE SAFETY CODE inspection reports.
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Based on interview and review of hospital personnel records, the Critical Access Hospital failed to develop a systematic process for assessment of competency for 6 of 9 staff members reviewed. (Staff Members #1, #3, #4, #5, #6, #7,).

Failure to ensure all hospital staff members are competent when performing patient care risks patient harm due to improper care and treatment.

Reference: WAC 246-320-156 Management of human resources. Hospitals must (3) Assure qualified staff available to operate each department including a process for competency, skill assessment and development;

Findings:

1. On 9/25/2014, review of the personnel files for the hospital's discharge planner (Staff Member #1); an emergency department technician (Staff Member #3); the dietician (Staff Member #4); two surgery technicians (Staff Members #5 and #6); and a respiratory therapist (Staff Member #7) revealed that the files did not include information regarding competence of these employees when performing their assigned duties.

2. During an interview with Surveyor #1 on 9/25/2014 at 10:15 AM, the human resources director (Staff Member #8) and the human resources assistant (Staff Member #9) stated that the hospital did not have a systematic process for evaluating competency of hospital staff members who were not nurses.
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Item #1 - High Level Disinfection

Based on observation and interview, the Critical Access Hospital failed to ensure the control of potential infections by implementing nationally recognized standards of practice related to high level disinfection.

Failure to implement nationally recognized infection control standards puts patients at risk of healthcare acquired infections.

Reference: Centers for Disease Control, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008; Item 7 High-Level Disinfection of Endoscopes, sub-item (y) states: "Maintain a log for each procedure and record the following: patient's name and medical record number (if available), procedure, date, endoscopist, system used to reprocess the endoscope (if more than one system could be used in the reprocessing area), and serial number or other identifier of the endoscope used. Category II".

Findings:

1. On 9/25/2014 between the hours of 9:30 AM and 11:00 AM, Surveyor #2 noted that high level disinfection logs for endoscope reprocessing lacked sufficient information to allow for retrospective investigation of suspected infections associated with endoscopic procedures. Information currently logged was done using a form titled MV-1 Quality Assurance/Disinfectant Efficacy Log. This log included information on the liquid chemical germicide (LCG), the date the LCG was tested, test strip results (pass/fail) and various other machine parameters related to LCG.

Missing log data included but was not limited to the following: The model and serial number of the instrument associated with the reprocessing cycle; the patient's name and/or patient identifier linked to the scope used; and the name of the individual who processed the instrument and logged the results of efficacy testing.

Subsequent to this finding Surveyor #2 was informed by the Operating Room manager (Staff Member #11) that nothing in the patients' charts (endoscopic procedure) would show what scope was used during the endoscopic procedure.

2. On 9/25/2014 between the hours of 9:30 AM and 11:00 AM, Surveyor #2 noted that the surgical technician (Staff Member #6) engaged in the reprocessing of endoscopes was uncertain about the time required to properly test the efficacy of the liquid chemical germicide (LCG). The staff member indicated that the test strip results were to be read in one (1) minute but manufacture's instructions for use (IFU) printed on the test strip label indicates: "Wait for exactly (75) seventy-five seconds and then compare the test strip color with the color chart on the bottle to determine the glutaraldehyde level.

3. On 9/25/2014 between the hours of 9:30 AM and 11:00 AM, Surveyor #2 noted that the basin being used to mix "Intercept" detergent was not graduated so as to allow for a proper mixed detergent ratio meeting the manufacturer's directions for use (DFU).


Item #2 - Operating Room Cleaning and Disinfection

Based on observation, the Critical Access Hospital failed to properly disinfect environmental surfaces in the operating room in accordance with nationally recognized standards and practices.

Failure to follow recognized standards and practices for environmental surface disinfection puts patients at risk of healthcare acquired infections.

Reference: 2012 Perioperative Standards and Recommended Practices. for Inpatient and Ambulatory Settings of the Association of periOperative Registered Nurses (AORN), Recommended Practices for Environmental Cleaning in the Perioperative Setting, Recommendation II, item II.b.1 states: "Nonporous surfaces such as mattress covers, pneumatic tourniquet cuffs, blood pressure cuffs, and other patient equipment should be cleaned and disinfected with an EPA-registered hospital disinfectant between patient use".

Findings:

1. On 9/25/2014 at the conclusion of a surgical procedure, Surveyor #2 noted that during the post procedure cleaning of the operating room certain pieces of furniture (e.g., operating table and instrument sterile field table) were not thoroughly cleaned and disinfected as required.

Regarding the operating table: Prior to intervention by the surveyor, a surgical technician (Staff Member #6) had only applied disinfectant to the top and outermost side surfaces of the operating table pads and most other surfaces of the table. Disinfection of the surfaces not addressed prior to the surveyor's intervention was performed; e.g., bottom and missed sides of the table pads and the pedestal base of the table once the table was completely raised.

Regarding the instrument sterile field table: A thorough disinfection of missed vertical surfaces (e.g. table legs) and a portion of the table top was performed after the surveyor's intervention.

2. During the post surgical procedure cleaning of the operating room, Surveyor #2 noted that the surgical technician (Staff Member #6) was applying disinfectant to environmental surfaces by flooding surfaces from a spray type bottle.

Per 2012 AORN standards and recommended practice for environmental cleaning in the perioperative setting, Recommendation I, item 1.b.3 "Cleaning and disinfection methods that produce mist, aerosols, or dust (e.g., spray bottles containing disinfectant) should not be used".


Item #3 - Sterilization Efficacy Testing

Based on record review the Critical Access Hospital failed to adhere to nationally recognized standards of practice for steam sterilization efficacy testing.

Failure to adhere to nationally recognized standards of practice for steam sterilization efficacy testing puts patients at risk of surgical site infection from potentially contaminated surgical instruments.

Reference: 2002 Association for the Advancement of Medical Instrumentation; ANSI/AMMI ST46:2002; Chapter 7.5.3.3 Test procedure sub-item (e) states: Each day that a test BI is incubated, at least one BI that is from the same lot and has not been exposed to the sterilant should be incubated as a control to verify the presterilization viability of the test spores, the ability of the media to promote growth of the test spores, and the proper incubation temperature. Upon completion of the incubation period, the test and control results should be read and recorded. If the control BI from a lot fails to grow, it should be assumed that the test BIs from that lot are nonviable or that improper incubation occurred. Therefore, the results from the test BIs should be considered invalid and the test repeated. Note - If several test BIs from the same lot are run on the same day, only one control BI from that lot need be used.

Findings:

On 9/25/2014 at 10:45 AM, Surveyor #2 noted that biological indicator (BI)control results were not being logged with the results of biological indicators. The surveyor was informed by the operating room manager (Staff Member #11) that BI controls were utilized primarily during the scheduled weekly efficacy testing and not with each load in which a BI was utilized.
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Based on interview and review of hospital staffing schedules, the Critical Acess Hospital failed to develop and implement a systematic process for orienting nursing personnel hired through staffing agencies to their work environment and assigned job duties, as demonstrated by 2 of 2 agency workers reviewed (Staff Members #8, #9,).

Failure to develop a systematic method for ensuring temporary workers are oriented to their assigned job duties risks patient harm due to improper care and treatment.

Findings:

1. On 9/25/2014, review of hospital's nursing staff schedules revealed that the hospital had employed two registered nurses through a staffing agency during the previous two months. Staff Member #8 worked 3 hospital shifts in August 2014. Staff Member #9 worked 6 hospital shifts from 9/1/2014 through 9/25/2014 and was scheduled to work during 2 shifts on 9/26/2014 and 9/27/2014.

2. On 9/25/2014 at 9:30 AM during an interview with Surveyor #1, the Director of Nursing (Staff Member #2) stated temporary nurses hired through staffing agencies were verbally oriented to their work environment and job duties. The director stated there was no systematic process for orienting these nurses or a method for documenting completion of the orientation.
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Based on interview and record review, the Critical Access Hospital failed to ensure that outpatient treatment records contained essential information regarding the patient's medical condition and discharge instructions for 2 of 2 patients reviewed (Patients #5, #6)

Failure to ensure essential information is present in patient records risks patient harm due to improper care and treatment.

Findings:

1. Review of the records of 2 patients who were given blood transfusions during an outpatient stay revealed the following:

a. Patient #1 was a 76 year-old patient who was transfused with two units of blood on 7/11/2014. The physician's transfusion order in the patient's record indicated the patient's stools had tested positive for blood prior to the transfusions. The order did not include the patient's diagnosis.

The patient's outpatient treatment records did not include a nursing admission history with information regarding the patient's current medications, and whether the patient had a medical condition such as congestive heart failure that might be adversely effected by an increase in the patient's blood volume.

There was no evidence in the record that the patient received discharge instructions that included actions to take in case symptoms of a transfusion reaction occurred after the patient left the hospital.

b. Similar findings were found in the records of Patient #2, an 86 year-old patient who was transfused with two units of blood on 7/17/2014.

2. On 9/24/2014 at 1:30 PM during an interview with Surveyor #1, the Director of Nursing (Staff Member #2) stated that nurses did not obtain a medical history from or provide discharge instructions to outpatients who received blood transfusions and/or medications.
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Based on interview and document review, the Critical Access Hospital failed to provide long-term care ("swing bed") patients with written notice of transfer or discharge from the hospital and to document this notice in the patient's clinical record.

Failure to provide written notice of transfer or discharge and to inform the patient of the discharge appeal process limits the patient's right to appeal this discharge to the state's long-term care ombudsman.

Findings:

1. A hospital document entitled "Swing Bed Contract - Standards of Care and Conditions of Participation" (No effective date) read as follows: "Statement of Patient Rights: The patient has the right to: ... Be transferred or discharged with advance notice to ensure that the transfer is orderly and actions are documented properly in his or her medical record. The transfer or discharge will only occur for medical reasons or for the welfare of the patient or others."

2. On 9/23/2014 at 1:45, during an interview with Surveyor #1, the hospital's discharge planner (Staff Member #1) and Director of Nursing (Staff Member #2) stated the hospital did not provide written notice to swing bed patients when they were transferred or discharged from the hospital.
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