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I. Based on observation and interview, the hospital failed to post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for each shift as required by RCW 70.41.420.

Failure to post the nurse staffing plan and the current nurse staffing schedule risks violation of an employee, patient or visitor's right to know that there was adequate and safe staffing levels to care for patients on each patient care unit.

Reference:

RCW 70.41.420 (7) Each hospital shall post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. The staffing plan and current staffing levels must also be made available to patients and visitors upon requests.

Findings:

1. A tour of patient care units on 8/30/2011 with the Clinical Nurse Director (Staff Member #2) revealed that nurse staffing plans and nurse staffing schedules were not posted in the Emergency Department, Acute Care Unit, and the Procedure Suite.

2. The Clinical Nurse Director (Staff Member #2) confirmed that the nurse staffing plans and nurse staffing schedules were not posted on all nursing units as required by state law.



II. Based on interview, the hospital failed to develop a nurse staffing plan as required by RCW 70.41.420.

Failure to develop a nurse staffing plan risks unmet patient needs and potential harm related to inadequate and unsafe nurse staffing levels.

Reference:

RCW 70.41.420(3) Primary responsibilities of the nurse staffing committee shall include: (b) Semiannual review of the staffing plan against patient need and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital.

Findings:

1. An interview with the Chief Nursing Officer (Staff Member #3) on 9/1//2011 revealed that the hospital had not developed a nurse staffing plan.

Based on observations and review of provided documentation, the hospital failed to ensure that code carts, more specifically defibrillators were checked on a daily basis.

Failure to ensure that emergency equipment is properly checked to ensure it is functioning places patients at risk of harm should the equipment be needed and/or it is not working properly.

Findings include:

1. On 8/30/2011 the surveyor reviewed available "ER Checklist Night" logs to determine the frequency and adequacy of daily defibrillator checks. Logs provided indicated that daily checks had been missed during the months of January 2011 (4 days), May 2011 (1 day), July 2011 (4 days) and August 2011 (6 days). Documentation was not available for the months of March and April 2011.

Based on interview and document review the facility failed to ensure that staff were provided with sufficient training to properly handle non-medical emergencies.

Failure on the part of the facility to adequately train staff to handle non-medical emergencies puts patients, staff and visitors of the facility at risk should such an emergency present itself.

Findings include:

1. On 8/31/2011 during a conversation with Staff member #1 the surveyor was informed that a disaster drill had not been performed in over one and a half years.

2. On 8/31/2011 Staff member #5 was asked by the surveyor to identify the location of the nearest fire alarm pull stations. The individual was unable to give the locations.

3. On 8/30/2011 the surveyor reviewed available fire drill documentation and found that fire drills had not been performed during the last quarter of 2010.

Based on interview the facility failed to have a system in place that would assure the safety of patients, staff and visitors of the facility during non-medical emergencies. More specifically, the facility failed to have a plan in place that would protect vital supplies of emergency fuel and water.

Findings include:

1. On 9/1/2011 during discussions with the Maintenance Supervisor (Staff member #1) the surveyor was informed that informal agreements had been made with local suppliers for emergency fuel and water but no written agreements had been entered into to assure their delivery if needed during an emergency.

Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 8/30/2011 - 9/1/2011.

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapter 19.3.2.7.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 8/30/2011 - 9/1/2011 (Tag K-0211).

Based on staff interview and review of available documentation, the hospital failed to develop a written infection control and surveillance program.

Failure on the part of the facility to implement and maintain an infection control program puts patients and staff at risk of acquiring infections and diminishes the hospital's ability to deal with infections once acquired.

Findings:

An interview with the coordinator of the infection control program (Staff Member #4) on 9/1/2011 revealed that the hospital had not developed a written infection control program. The infection control program coordinator stated that she/he was in the process of developing the infection control plan but she/he had not completed it yet.

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure requirements, of chapter 246-873 WAC, PHARMACY - HOSPITAL STANDARDS, were followed in 3 of 3 patient records reviewed (Patient #4, #5, #6).

Failure to follow pharmacy hospital standards 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.

WAC 246-873-090 (1) ...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.

Findings:

1. The hospital policy and procedure entitled "General Prescribing, Ordering and Administration Standards" (Effective 9/1/2005; Revision date 11/2010) read as follows:

"Licensed hospital personnel may accept and transcribe verbal/telephone orders related to their scope of practice and as allowed by law."

"The order shall be written on the Provider Order Sheet by the person receiving the order and noting the date and time received, the name of the practitioner issuing the order, and the receivers name and title. Person receiving the order must read back the complete order to verify accuracy and document RB [read back] and signature next to order."

Example:

"VO Dr.___________________/________________RN/LPN RB__RN"

Under the section entitled "Required Order Elements" the policy stated that the order must include date and time of order, drug name, dosage form, dose strength and units, route of administration, and frequency of administration.

2. Review of the medical records of 3 patients admitted to the hospital for diagnostic procedures revealed the following:

a. Patient #4 was a 69 year-old patient who was admitted on 4/15/2011 for a screening colonoscopy. During Patient #4's procedure a registered nurse (RN) administered procedural sedation (medications to make the patient drowsy and relaxed). The patient received a total of 162.5 mcg of Fentanyl and 6 mg of Versed during the procedure.

Review of Patient #4's medical record revealed that the physician signed the back page of the form but there were no physician's orders for the medications administered during the procedure documented in the medical record.

b. Similar findings were found in the medical record of Patient #5 and Patient #6.

3. An interview with Staff Member #4 on 8/31/2011 revealed that during endoscopy procedures the physician gives verbal orders to the RN for sedation medications. The RN documents the medications administered to the patient on a form entitled "Conscious Sedation Record". Following the procedure the physician signs the back page of the conscious sedation record acknowledging the care provided by the nurse during the procedure.

The process for documenting verbal orders during endoscopy procedures does not comply with the hospital's verbal order policy.

4. Staff Member #4 confirmed the above findings.

Based on interview and record review, the facility failed to develop an individualized plan for care for 3 of 3 Outpatient Infusion records reviewed (Patient #4, #5, #6).

Failure to develop an individualized plan for care may result in the inappropriate, inconsistent, or delayed treatment of patient's needs.

Findings:

1. Patient #4 was an 87 year-old patient who was admitted on 4/12/2011 in order to receive a monthly subcutaneous injection of erythropoietin (a medication that encourages red blood cell production). Review of Patient #4's medical record revealed that the patient did not have a plan of care that included specific care of the patient.

2. Similar findings were found in the medical record of Patient #5 and Patient #6.

3. Staff Member #2 confirmed the above findings. The facility did not have a policy that addressed development of a plan of care for patients receiving treatments as outpatients.

Based on record review, interview, and review of policy and procedure, the facility failed to ensure that outpatient records contained adequate, pertinent information that promoted continuity of care in 3 of 3 records reviewed (Patients #4, #5, #6).

Failure to ensure adequate information is present in the patient record risks inadequate and/or inappropriate care and treatment during emergencies and on subsequent hospital admissions.

Findings:

1. The facility did not have a policy specifically related to the content of the medical record in an outpatient setting.

2. Patient #4 was an 87 year-old patient who was admitted on 4/12/2011 in order to receive a monthly subcutaneous injection of erythropoietin (a medication that encourages red blood cell production). The patient's record did not include the patient's history and physical from the physician.

Similar findings were found in the outpatient records of Patient #5 and #6.

3. Staff Member #2 confirmed the above findings.

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:

1. Review of patient records on 8/30/2011 to 9/1/2011, both acute care and swing bed (long term care patients), revealed that swing bed patients were given the same patient rights handout entitled "Patient Rights and Responsibilities" as acute care patients. The handout did not include all items listed under ?483.10(a-m) that are specific to swing bed patients.

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

? Exercise rights as a citizen of the United States
? Access his/her records and photocopies thereof within the defined time frames
? Be fully informed in a language that he/she can understand
? Choose a personal attending MD/DO
? Refuse to perform services for the facility
? 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
? Privacy in written communications; send and receive mail; access to stationery, postage, and writing implements at residents expense
? Access and visitation rights
? Retain and use personal possessions
? Share a room with his or her spouse when married residents live in the same facility

2. The Chief Nursing Officer (Staff Member #3) and the Clinical Nurse Director (Staff Member #2) confirmed the above finding.

Based on interview, review of policy and procedure, and record review, the hospital failed to provide for an ongoing program of activities, and failed to have a qualified person directing an activities program.

Failure to develop and implement an activities program risks diminished quality of life, and deterioration of the patients' physical, mental, and psychosocial well-being.

Findings:

1. Review of the medical record of 3 "swing bed" (long-term care) patients revealed the following:

Patient #1 was a 90 year old patient admitted on 8/20/2011 for treatment of pain following surgery on her/his back. Review of Patient #1's medical record revealed that nursing had performed an activities assessment but there was no activities plan in the patient's record.

The same was found in the medical record of Patient #2 and Patient #3.

2. The hospital's policy entitled "Swing Bed Activity Program" (Effective date 7/05; Revision date 11/07) stated that "upon admission to the Swing Bed Program, the RN [Registered Nurse] shall do an assessment of activity needs and develop the activities plan within 24 hours of admission."

3. An interview with the Clinical Nurse Director (Staff member #2) on 8/30/2011 confirmed that staff had not followed the hospital's policy for development of an activities plan for Swing Bed patients. In addition, the Clinical Nurse Director stated that the hospital had not designated a person to direct the activities program.