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Based on observation, record review and staff interviews, the Critical Access Hospital failed to provide a safe and secure environment for the provision of patient care.

Findings:

The critical access hospital failed to assure patients were protected from fire hazards and failed to provide adequate response to deficiencies that the hospital had identified following an actual fire emergency on 10/24/2011 (see associated Life Safety Code survey dated 12/01/2011).

The hospital had failed to fully address these deficiencies that were identified by hospital administration following the 10/24/2011 fire:

1) Staff failed to activate the fire alarm upon noticing smoke in the patient care area
2) Lack of smoke detection in the hospital basement permitted smoke to penetrate the patient care areas without activation of the fire alarm
3) The hospital's HVAC system failed to prevent smoke from spreading between smoke compartments in the patient care area
4) Fire fighters did not have access to a master key and were unable to access the hospital
5) Staff failed activate the Hospital Incident Command System (HICS)
6) Firefighting equipment blocked egress routes for patient evacuation and ambulance
7) Not all relevant staff were notified of the emergency
8) The on-call administrator did not respond to calls


Additional life safety code violations included potential causes of ignition and spread of fire, including:

1) Failure to clean the hood ducts over the deep fat fryer in the kitchen
2) Failure to inspect the hospital fire sprinkler system and kitchen hood fire suppression system
3) Failure to ensure that smoke and fire doors shut and latch properly
4) Failure to ensure that emergency lighting operates properly
5) Failure to ensure that the hospital fire sprinkler system covers all required areas
6) Failure to ensure that exit signage directs people to a true exit

These and other violations of the Code are cited on the attached Life Safety Code survey.

These additional violations of the Code exacerbated the lack of effective response to failures identified after the earlier fire, by creating an increased risk of fire and decreased protection from the technologies designed to limit the spread of fire and smoke in the hospital.

There were 16 acute care patients in the hospital at 10:00 a.m. on 11/30/2011. 15 surgery cases were also scheduled for 11/30/2011. The patient census included 4 OB patients, including 2 undergoing C-section, 2 patients from surgery going to the acute care unit for overnight stay, 2 surgery patients going to the acute care unit for phase II recovery, 1 post-surgery patient and five acute care medical patients, one newborn under a bili-light with the mother rooming in, and one outpatient infusion patient.

Failure to maintain an environment that meets the requirements of the Life Safety Code creates a risk of serious injury or death for patients, staff and visitors in the hospital, and impairs the hospital's ability to provide quality care in a safe environment.

BECAUSE OF THE SEVERITY OF THE DEFICIENCIES, CONSULTATION WAS HELD WITH OFFICIALS OF THE WASHINGTON STATE PATROL, FIRE PROTECTION BUREAU AND WITH THE WASHINGTON DEPARTMENT OF HEALTH.

A STATE OF IMMEDIATE JEOPARDY WAS DECLARED ON 11/30/2011.

HOSPITAL CORRECTIVE ACTION:

The hospital administration was notified of the finding of Immediate Jeopardy on 11/30/2011.

The hospital initiated corrective action, consisting of:

1) Conducting remedial fire response training for all hospital personnel on shift on 11/30/2011 and 12/01/2011
2) Initiating a fire watch until the hospital fire sprinkler system was inspected on 12/01/2011
3) Obtaining a commitment from the contractor for submission of the basement smoke alarm plans to plan review at the state agency
4) Installing a locked box with hospital access badge and master key at the hospital entrance per the instructions of the local fire chief
5) Signing an attestation that HICS will be implemented per hospital policy
6) Informing the hospital Governing Body through the board chair of the findings of Immediate Jeopardy and corrective actions being taken to abate the state of Immediate Jeopardy
7) Cleaning the kitchen hood ducts by 12/01/2011
8) Obtaining a copy of the hospital fire alarm system inspection by 11/30/2011
9) Scheduling inspection of the kitchen hood fire suppression system on 12/01/2011

These corrections were completed by 3:45 pm on 11/30/2011.

Following verification of the corrective action, the hospital administration was informed that immediate jeopardy was removed at 4:00 pm on 11/30/2011. However, numerous Life Safety and other Environment deficiencies remained uncorrected at the time of the survey exit on on 12/01/2011.

Due to the scope and severity of deficiencies detailed in Tag C0231, the Condition of Participation for Physical Plant and Environment was NOT MET.

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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 include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 12/01/2011.

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Based on observation, record review and staff interviews, it was determined that the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual
The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment

Findings:

Due to the scope and severity of deficiencies detailed under the Conditions of Participation for Physical Plant and Environment, and for Periodic Evaluation and QA Review, the Condition of Participation for Organizational Structure was NOT MET.

Refer to Tags C0220, C0330, and C0342.

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1. Based on interview and review of patient rights information, the the Critical Access Hospital failed to develop a process for informing all patient's of their rights according to State hospital regulations.

Failure to inform all patients of their rights limits the patient's ability to exercise those rights

Reference: WAC 246-320-141 - Hospitals must: (2) Provide each patient a written statement of patient rights from subsection (1) of this section;

Findings:

a. On 11/29/2011 at 1:05 PM, an interview with the patient admissions supervisor (Staff Member #1) revealed that patients were given a brochure to read entitled "Understanding Your Rights" when admitted to the hospital for inpatient care and outpatient laboratory and radiology procedures. Review of the contents of this form revealed it did not include all of the patient's rights identified in current hospital regulations.

The form did not inform patients that they had the right that they had the right for security, complaint resolution, and communication [WAC 246-320-141(1)(b)]; the right to be protected from neglect [WAC 246-320-141(1)(c)]; the right to access protective services WAC 246-320-141(1)(d)]; the right to complain about their care without fear of retribution or denial of care [WAC 246-320-141(1)(e)]; the right to timely complaint resolution [WAC 246-320-141(1)(f); the right to be involved with all aspects of their care, including resolving problems with care decisions [WAC 246-320-141(1)(g)(ii)]; the right to be informed of unanticipated outcomes of care according to RCW 70.41.380 [WAC 246-320-141(1)(h)]; the right to family input in care decisions [WAC 246-320-141(1)(j)]; the right to end of life care [WAC 246-320-141(1)(m)]; and the right to donate organs and other tissues according to RCW 68.50.500 and 66.50.560, including medical staff input and direction by family or surrogate decision makers [WAC 246-320-141(1)(n)(i)(ii)].

b. On 11/29/2011 at 1:15 PM, an interview with an emergency department registration clerk (Staff Member #2) revealed that the patient rights brochure was not offered to patients admitted for care in the emergency department.



2. Based on record review and review of policies and procedures, the Critical Access Hospital failed to follow its policy and procedure for restraining patients in accordance with State hospital regulations for 6 of 7 patient records reviewed (Patients #1, #2, #3, #4, #5, #6).

Failure to follow established utilization guidelines for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

References:
WAC 320-246-226 - Hospitals must: (3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with CFR 42.482.

42 CFR 482.13(e) Standard: Restraint or seclusion - (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

(4) The use of restraint or seclusion must be--
(ii) Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law.

(5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under Sec. 482.12 (c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings:

Review of the records of seven patients who had been restrained during their hospitalization revealed the following:

a. Patient #1 was a 16-year old individual that had been brought to the hospital's emergency department on 2/12/2011 at 10:35 PM by a law enforcement officer for medical clearance to be taken to a juvenile detainment facility. According to the patient's medical record, the patient was initially calm until staff requested that he provide a urine specimen.

The "Emergency Room Report" completed by Physician #1 states he became "combative and belligerent, yelling profanely and calling us all names." He became "acutely agitated" whenever anyone was in the room with him other than the police officer. The report read: "He is placed in leg restraints and left arm restraint as well as a 4-point manual restraints by staff and the police officer to obtain his blood, as well as to perform a catheterization in his urethra to obtain a urine specimen. He had repeatedly refused to cooperate with providing a specimen and had been advised multiple times that he would have to have a catheterization to obtain the specimen. He continued to refuse despite the police officer telling him that he did not have a choice. As noted, he had a constant, steady stream of profanities and cursing all of us repeatedly."

The hospital's policy and procedure entitled "Restraints" (ID #124017; Effective 5/2010, Revised 10/2011) read in part as follows: "The patient has the right to be free from any form of restraints (physical restraint or drug being used as a restraint) that is not medically necessary or is used if it is means of coercion, discipline, convenience, or retaliation by staff." The use of restraints would be "selected only when other less restrictive measures have been found to be ineffective to protect the patient and others from harm."

The patient's record did not include evidence that hospital staff had attempted less restrictive alternatives to restraint, including de-escalation techniques.

The policy identified "Correctional Restraints" as handcuffs or restraints used for patients under arrest or incarcerated to prevent elopement. The policy did not identify the hospital's legal responsibilities and liabilities for restraining patients for the forced collection of blood and urine under the direction of law enforcement officers.

b. Patient #2 was a 77 year-old patient who had been admitted on 10/4/2011 for treatment of a post-operative ileus. The patient was confused on admission and had a diagnosis of dementia with delirium. The patient was placed in bilateral soft wrist restraints at 4:30 PM to prevent him from pulling out his nasogastric tube. The patient remained in these restraints until 10/5/2011 at 10:25 AM. The record indicates the patient was unrestrained until 10/5/2011 at 5:15 PM, when he began to attempt again to remove his nasogastric tube. The patient was again placed in bilateral soft wrist restraints until 10/6/2011 at 8:00 AM.

The patient's record included a physician's order written on 10/5/2011 at 8:30 AM that authorized the initial use of the restraints. The record did not include a physician's order authorizing the reapplication of the restraints on 10/5/2011 at 5:15 PM.

The hospital's policy and procedure entitled "Restraints" (ID #124017; Effective 5/2010, Revised 10/2011) stated that the use of a restraint would "never be used as a standing order or on an as-needed basis." Nursing staff had used the initial restraint order on an "as needed" basis.

c. Patient #3 was a 54 year-old individual who had been brought to the hospital's emergency department on 2/12/2011 at 10:03 PM by a law enforcement officer for a mental health evaluation. According to the patient's medical record, the patient was confused related to lithium toxicity and was placed in 2 point locked restraints at 10:17 AM "to prevent elopement". The record indicated the patient was in restraints from 10:17 AM to 2:40 PM.

The hospital's policy and procedure entitled "Restraints" (ID #124017; Effective 5/2010, Revised 10/2011) stated that restrained patients would be observed by nursing staff at intervals of every 30 minutes with attention to circulation, condition, and range of motion. The record included observations at 10:17 AM and 11:01 AM. There were no further observations of the condition of the patient that were specific to circulation, skin condition, or range of motion until the patient was released.

d. Patient #4 was a 24 year-old patient who had been admitted to the emergency department on 10/18/2011 at 5:45 PM for a mental health evaluation. According to the patient's medical record, the patient was confused and displayed psychotic behavior. The patient was placed in 4-point restraints at 5:46 PM. There was no physician's order in the medical record authorizing use of the restraints.

The record indicated that the patient was again restrained with 2-point restraints from 1:30 AM until 3:15 AM.. The record did not include a physician's order authorizing the reapplication of the restraints.

e. Patient #5 was a 38 year-old patient who had been admitted to the emergency department on 9/26/2011 at 9:43 PM for treatment of injuries that occurred during a fall related to alcohol intoxication. The patient was placed in 2-point restraints at 12:42 AM for confusion and "wandering behavior" after attempting to remove his intravenous access. The patient was in restraints until 4:29 AM. There was no physician's order in the medical record authorizing use of the restraints.

The hospital's policy and procedure entitled "Restraints" (ID #124017; Effective 5/2010, Revised 10/2011) stated that restrained patients would be observed by nursing staff at intervals of every 30 minutes with attention to circulation, skin condition, and range of motion. The record included observations at 12:45 AM, 1:45 AM, 2:45 AM, and 3:45 AM. There were no observations of the condition of the patient every 30 minutes that were specific to circulation, skin condition, or range of motion.

f. Patient #6 was a 34 year-old patient who had been admitted to the emergency department on 8/7/2011 at 12:33 PM for treatment of severe back pain. The record stated "Patient made suicide gester [sic] by taking a handful of pills and putting them in her mouth.] The patient was placed in 4-point restraints at 3:38 PM. There was no physician's order in the medical record authorizing use of the restraints.

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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure hospital staff assessed and medicated patients experiencing pain according to hospital policy and procedure for 1 of 1 patients reviewed (Patient #7)

Failure to relieve a patient's pain can result in physical and psychological harm and prolong the patient's recovery.

Findings:

1. The hospital's policy and procedure entitled "Pain Management" (ID #36231; Effective 7/2001; Revised 8/2010) read as follows: "It is the duty and responsibility of all healthcare providers to recognize pain and to provide for comfort measures as applicable within their scope of practice. The patient will experience an optimal level of pain relief and can expect this report of pain to be accepted, analyzed, and appropriate intervention to occur."

2. Patient #7 was a 24 year-old patient who had been admitted through the emergency department (ED) on 11/25/2011 at 11:42 AM. The patient presented with severe head pain in the ED and was admitted to the hospital for possible meningitis. At 2:47 PM, the ED physician ordered that he be given the pain medication hydromorphone 0.5 mg intravenously every 8-12 minutes time three doses for pain rated by the patient as above 4/10 if respirations remained greater than 12 breaths per minute.

The patient's record indicates that the patient rated his pain as 9/10 at 2:41 PM. He was given hydromorphone 0.5 mg at 2:41 PM. The patient's record did not include a reassessment of the patient's pain level until 3:12 PM. The patient rated his pain at this time as 8/10. The patient was given hydromorphone 0.5 mg at 3:12 PM. The patient's record did not include a reassessment of the patient's pain level until 4:06 PM. The patient rated his pain at this time as 7/10. The patient's record did not include a reassessment of the patient's pain level until 5:03 PM. The patient rated his pain at this time as 8/10. The patient was given hydromorphone 0.5 mg at 5:03 PM.

The patient was not assessed and medicated for pain in the ED according to the physician's order. This was verified during an interview with the Director of Patient Care Services (Staff Member #2) on 11/29/2011.

3. During an interview on 11/29/2011 in the acute care unit at 10:30 AM, Patient #7 stated that during the night he had requested that nursing staff members give him two pain pills every six hours for pain. The patient stated that nursing staff members argued with him about how many pain pills he should take at one time and gave him one pain pill every three hours. He stated this ineffectively managed his pain.

The patient's medical record included a physician's order for the pain medication hydrocodone 1-2 tablets every 6 hours as needed for pain. The patient's medication record revealed he had been given one tablet of hydrocodone on 11/28/2011 at 9:40 PM and 11:02 PM, and one tablet on 11/29/2011 at 5:34 AM and 7:18 AM.

The patient was not assessed and medicated for pain on the acute care unit according to the patient's request. This was verified during an interview with the Director of Patient Care Services (Staff Member #2) on 11/29/2011.

3. During an interview on 11/29/2011 with a registered nurse on duty (Staff Member #who was assigned to care for Patient #7, the nurse stated that it was "nursing judgement" to determine how much pain the patient was in, not the patient's judgement.

The nurses statement was not consistent with the hospital's pain management policy. This was verified during an interview with the Director of Patient Care Services (Staff Member #2) on 11/29/2011.
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Based on record review and review of facility policies, the Critical Access Hospital failed to ensure that healthcare providers authenticated orders for care and treatment of patients according to the hospital's medical staff rules and regulations and Washington State Board of Pharmacy regulations for 16 of 16 healthcare providers reviewed (Physicians #1, #2, #3, #4, #5, #6, #7. #8, #9, #10, #11, #12, #13, #14; CRNA #1; Medical Student #1)

Failure to write and authenticate orders for medications and treatment risks provision of incorrect and/or inadequate patient care.

Reference: WAC 246-873-090 Administration of drugs. (1) General. Drugs shall be administered only upon the order of a practitioner who has been granted clinical privileges to write such orders. Verbal orders for drugs shall only be issued in emergency or unusual circumstances and shall be accepted only by a licensed nurse, pharmacist, or physician, and shall be immediately recorded and signed by the person receiving the order. Such orders shall be authenticated by the prescribing practitioner within 48 hours

Findings:

1. The hospital's medical staff rules and regulations (Reviewed March 9, 2010) read in part as follows" "All verbal orders will be signed with the name of the practitioner per their own name [sic]. The responsible practitioner will authenticate such orders at the next visit."

2. On 11/29/2011 at 1:35 PM, at the request of Surveyor #13692, the hospital's electronic medical record support nurse (Staff Member #4) ran a report of orders that had been entered into the hospital's electronic medical record system but had not been electronically signed by the ordering healthcare provider.

The report revealed that a total of 189 orders dated from 7/22/2011 to 11/25/2011 that had been written by 14 physicians, 1 CRNA, and 1 medical student had not been electronically signed by the ordering provider. 84 of these orders were for medications.

An interview with Staff Member #4 at the time of the observation confirmed that the orders had not been authenticated according to the hospital's medical staff rules and regulations and the Washington State Board of Pharmacy.

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Based on staff interviews and review of the hospital's quality assurance program and quality assurance documentation, it was determined that the facility failed to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program impairs the facility's ability to provide quality care in a safe environment.

Findings:

Failure to respond in a timely manner to deficiencies discovered following a fire that occurred on 10/24/2011 created a risk of serious injury or death for patients, staff and visitors in the hospital.

Refer to Tag C0342(1)

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1. Based on interview and review of quality improvement documentation, the Critical Access Hospital failed to take appropriate remedial action to address deficiencies found during review of a fire that occurred on 10/24/2011.

Failure to respond in a timely manner to deficiencies discovered following a fire that occurred on 10/24/2011 created a risk of serious injury or death for patients, staff and visitors in the hospital.

Findings:

a. During an interview on 11/29/2011, the hospital facilities manager (Staff Member #5) stated that a fire event occurred in the hospital basement boiler room. Smoke from this event was carried into the first floor of the hospital where patient care takes place, leading to the evacuation of patients from the acute care unit.

b. On 11/29/2011. review of a document entitled "Mid-Valley Hospital After Action Response Improvement Plan" (Not dated) revealed that the following problems had been identified related to the fire:

1) Staff failed to activate the fire alarm upon noticing smoke in the patient care area
2) Lack of smoke detection in the hospital basement permitted smoke to penetrate the patient care areas without activation of the fire alarm
3) The hospital's HVAC system failed to prevent smoke from spreading between smoke compartments in the patient care area
4) Fire fighters did not have access to a master key and were unable to access the hospital
5) Staff failed activate the Hospital Incident Command System (HICS)
6) Firefighting equipment blocked egress routes for patient evacuation and ambulance
7) Not all relevant staff were notified of the emergency
8) The on-call administrator did not respond to calls

c. Interviews with the hospital facilities manager, the acting hospital administrator, and the director of patient care services on 11/29/2011 revealed that action had not been taken to correct these problems.


2. Based on interview and review of the hospitals quality improvement plan and quality program documents, the Critical Access Hospital failed develop a process to track the progress of actions taken to improve hospital performance.

Failure to systematically identify problems and formulate action plans reduced the hospital's ability to provide quality clinical care and improve patient outcomes.

Findings:

a. On 12/1/2011 at 9:15 AM, Surveyor #13692 and #14866 interviewed the hospital's Director of Patient Care Services, Director of Human Resources, Chief Financial Officer, and Quality Improvement Coordinator about the hospital's quality improvement program. Review of quality improvement documents and meeting minutes during this interview revealed that the minutes included information from hospital departments on actions that had been taken in the past to improve performance but did not include plans to improve future performance. There was no method to track action plans developed during quality improvement meetings related to the data submitted by individual hospital departments.

b. The hospital's quality plan entitled "Performance Improvement (Improving Organizational Performance)" (Version ID#55159; Effective Date 06/2001, Revised 11/2010) did not identify how the hospital would develop and track action plans to improve hospital performance.

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