HospitalInspections.org

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Based on interview and document review, the hospital failed to follow manufacturer's instructions for cleaning the hydrocollator in the rehabilitation center.

Failure to maintain equipment places patients at risk of infections.

Findings included:

1. Document review of the hydrocollator manual, "Chattanooga Hydrocollator," showed on page 19 to regularly clean and drain the tank every two weeks.

2. Document review of the hospital's policy and procedures titled, " Hydrocollator Cleaning" No policy number, last revised 06/21/06, showed hydrocollator cleaning to be completed monthly. No manufacturer's instructions for use were provided.

3. On 07/30/21 at 9:00 AM, Surveyor #1 interviewed a physical therapist (Staff #117) regarding the process of cleaning and disinfecting the hydrocollator.

During the interview, Surveyor #1 observed the cleaning log which indicated to be cleaned monthly. Surveyor #1 requested to see hospital's policy and procedure regarding the frequency for cleaning the hydrocollator to ensure that the hospital was following manufacturer's instruction for use. Staff #117 provided the policy and procedure which indicated monthly. The policy did not provide any references from the manufacturers to ensure the cleaning frequency. Staff #117 did not know where the monthly cleaning frequency came from, but he indicated if it needed to be cleaned every two weeks, he would change the policy and logs to reflect that.
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Based on observation, document review and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report: Shell ZUPO21.

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Based on interview, medical record review, and review of Medical Staff Policies and Procedures, the hospital failed to ensure that they followed their approved Medical Staff Policies and Procedure for 2 of 2 Non-Credentialed Providers admitting patients for blood transfusions.

Failure to ensure the hospital had processes in place to ensure that healthcare providers are qualified risks improper care, patient harm, and death.

Findings included:

1. Document review of the medical staff policy and procedure titled, "Non-Staff Practitioners Ordering Outpatient Tests and Procedures," no policy number, revised 01/19/17, showed the following:

a. Medical Providers who are not medical staff of the hospital may only order lab tests, imaging procedures without sedation, IV hydration, physical, occupational, or speech therapy, and electrocardiograms.

b. The Medical Director of the outpatient clinic will perform a History and Physical exam on the patient prior to initiating any therapeutic interventions including the transfusion of blood or blood products and requires completion of approved blood products transfusion orders, a copy of the hemoglobin and hematocrit, and a signed blood consent.

2. On 07/29/21 at 10:23 AM, Surveyor #5 and the Acute Care Manger (Staff #503) reviewed the medical record for Patient #509 who was admitted to Outpatient Services for a blood transfusion on 06/24/21. The review showed that the provider did not have privileges at the hospital and the Medical Director had not completed the History and Physical and signed orders for the transfusion or the diuretic medication furosemide that was ordered to be given between the first and second unit of blood.

3. On 07/29/21 at 11:10 AM, Surveyor #5 and the Acute Care Manger (Staff #503) reviewed the medical record for Patient #510 who was admitted to Outpatient Services for a blood transfusion on 06/28/21. The review showed that the provider did not have privileges at the hospital and the Medical Director had not completed the History and Physical.

4. At the time of the observation, Staff #503 verified the finding, stated that the providers did not have privileges and stated that the Outpatient medical Director is supposed to write the History and Physical and verify the orders. She stated the hospital was aware and this was a process improvement initiative.

3. On 07/30/21 at 9:00 AM, the Acute Care Manager (Staff #503) verified that the Providers (Staff #509 and #510) did not have privileges to practice at the hospital.
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Item #1 Restraint Face to Face Evaluation

Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff performed a face to face assessment within 1 hour as directed by hospital policy for 3 of 4 patients placed in physical restraints reviewed (Patient #507, #508, and #509).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital policy and procedure titled, "Restraint General Guidelines," policy number 7170-94, revised 01/19, showed that a face to face comprehensive individualized patient assessment that includes a physical assessment to identify medical problems that may be causing behavior changes in the patient must be completed within 1 hour of restraint application.

2. On 07/29/21 at 2:00 PM, Surveyor #5 and a Registered Nurse (Staff #503) reviewed the discharge medical record for Patient #507. The review showed the patient was placed in restraint on 03/31/21 at 6:45 PM and removed from restraint on 04/01/21 at 1:00 AM. Surveyor #5 found no evidence a Face to Face Assessment was completed as directed by hospital policy.

3. On 07/29/21 at 2:30 PM, Surveyor #5 and a Registered Nurse (Staff #503) reviewed the discharge medical record for Patient #508. The review showed the following:

a. The patient was placed in restraint on 03/19/21 at 6:50 AM and removed from restraint at on 03/20/21 at 1:56 AM. Surveyor #5 found no evidence a Face to Face Assessment was completed as directed by hospital policy.

b. The patient was placed in restraint on 03/20/21 at 8:25 AM and removed from restraint at 12:38 PM. Surveyor #5 found no evidence a Face to Face Assessment was completed as directed by hospital policy.

4. On 07/29/21 at 4:00 PM, Surveyor #5 and a Registered Nurse (Staff #503) reviewed the discharge medical record for Patient #509. The patient was placed in restraint on 05/08/21 at 12:35 PM. Surveyor #5 found no evidence a Face to Face Assessment was completed as directed by hospital policy.

5. At the time of the record reviews, Staff #503 confirmed the findings and stated that the provider should have completed a Face to Face Assessment. She stated that the hospital had just changed to a new documentation system and the providers may not have known how to document the Face to Face Assessment. Staff #503 stated that the hospital had no list of patients restrained from 03/19/21 to current 07/29/21 and that the hospital was trying to get a report from the new electronic documentation system.
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Item #2 Monitoring of Patients in Restraint

Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff monitored respiratory status and distal circulation as directed by hospital policy for 2 of 4 medical records reviewed (Patient #507 and #508).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital policy and procedure titled, "Restraint General Guidelines," policy number 7170-94, revised 01/19, showed that restraint documentation must verify that the patient was monitored every 15 minutes during the entire restraint used. Staff are to assess and document respiratory status and distal circulation every 1 hour.

2. On 07/29/21 at 2:00 PM, Surveyor #5 and a Registered Nurse (Staff #503) reviewed the discharge medical record for Patient #507. The review showed no evidence of Distal Circulation checks, Respiratory checks or Q 15 monitoring on 03/31/21 at 10:00 PM until the restraint was removed on 04/01/21 at 1:00 AM (a period of 3 hours).

3. On 07/29/21 at 2:30 PM, Surveyor #5 and a Registered Nurse (Staff #503) reviewed the discharge medical record for Patient #508. The review showed gaps in Q15 monitoring, respiratory and circulation checks including:

a. No evidence of Distal Circulation checks on 03/19/21 from 9:00 AM until 11:45 AM (a period of 2 hour and 45 minutes).

b. No evidence of Distal Circulation checks on 03/19/21 from 11:45 AM until 2:00 PM (a period of 2 hour and 15 minutes).

c. No evidence of Distal Circulation checks on 03/19/21 from 2:00 PM until 4:00 PM (a period of 2 hours).

d. No evidence of Distal Circulation checks on 03/19/21 from 4:00 PM until 6:00 PM (a period of 2 hours).

e. No evidence of Distal Circulation checks on 03/19/21 from 6:00 PM until 9:10 PM (a period of 2 hours and 10 minutes).

f. No evidence of Distal Circulation checks on 03/19/21 from 11:00 PM until 03/20/21 at 4:00 AM (a period of 5 hours).

g. No evidence of Respiratory checks on 03/19/21 from 9:00 AM until 10:45 AM (a period of 1 hour and 45 minutes).

h. No evidence of Respiratory checks on 03/19/21 from 10:45 AM until 12:30 PM (a period of 1 hour and 45 minutes).

i. No evidence of Respiratory checks on 03/19/21 from 12:30 PM until 2:00 PM (a period of 1 hour and 30 minutes).

j. No evidence of Respiratory checks on 03/19/21 from 2:00 PM until 3:37 PM (a period of 1 hour and 37 minutes).

k. No evidence of Respiratory checks on 03/19/21 from 3:37 PM until 6:00 PM (a period of 2 hours and 21 minutes).

l. No evidence of Respiratory checks on 03/19/21 from 7:11 PM until 10:49 PM (a period of 3 hours and 38 minutes).

m. No evidence of Respiratory checks on 03/19/21 from 10:49 PM until 03/20/21 at 2:55 AM (a period of 4 hours and 6 minutes).

n. No evidence of Respiratory checks on 03/20/21 from 2:55 AM until 6:31 AM (a period of 3 hours and 36 minutes).

3. At the time of the reviews, Staff #503 verified the gaps in patient restraint monitoring and stated that staff should be documenting restraint reassessments in the electronic medical record.

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Item #1 Unlabeled/ Medications

Based on observation, interview, and document review, the hospital failed to ensure that syringes containing patient medications were labeled to show the drug's name and strength, and the expiration date or beyond use date.

Failure to ensure that medications management quality processes for medication preparation and storage are implemented puts patients at risk of serious harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Labeling Medications," policy number 7071, revised 04/21, showed the following:

a. For Inpatients: All medications and biologicals shall be labeled in conformity with existing pharmacy law requirements whether the drug product is legend or non-legend. Medication containers shall contain the original label from the pharmacy. New labels will include the generic or trade name, strength of the medication, lot number and outdate. Hospital pharmacy compounded or repackaged medications should have the date of repackaging on the label.

b. For Parenteral medications: When drugs are added to an intravenous solution, a suitable label shall be affixed to the container. At a minimum, the label shall indicate the patient's initials and location, name and amount of drug added, appropriate dating, and initials of the personnel who prepared and checked the solution.

The policy did not specifically address labeling of syringes containing medications prepared outside the pharmacy.

2. On 07/28/21 at 1:36 PM, Surveyor #5 inspected a drawer in an Anesthesia cart located in the hospital's Operating Room. Surveyor #5 observed the following:

a. 1-30 mL syringe containing clear fluid that was not labeled.

b. 1-5 mL syringe containing a clear fluid. The syringe was labeled with a preprinted label that stated, "Rocuronium" (a general anesthesia medications). There was no strength documented. The area on the preprinted label designated for date and time were blank.

c. 1-5 mL syringe containing a clear fluid. The syringe was labeled with a preprinted label that stated, "Fentanyl" (synthetic opioid analgesic that is similar to morphine). There was no strength documented. The area on the preprinted label designated for date and time were blank.

No empty vials were found in the drawer.

3. At the time of the finding, the Certified Nurse Anesthetist (Staff #505) verified the unlabeled/inappropriate labeled syringes, stated that the unlabeled syringe contained Lidocaine, and that he had drawn the medications located in the drawer for the current case coming up.


Item #2 Unusable/Expired Medications

Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability or efficacy.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Opening/Dating Sterile Vials," policy number 7071, reviewed 03/19, showed that multiple use vials when opened must be labeled with the date of expiration and are to be discarded within 28 days. No expired solutions shall be dispensed and shall be returned to the Pharmacy for destruction or return.

Document review of the hospital's policy titled, "Outdated Drug Control," policy number 7071, reviewed 03/19/21, showed that nursing stations and other locations where drugs are stored will be checked monthly for outdated items and outdated drugs will be removed by Pharmacy.

Document review of the PREMIERProRx manufacturer's instruction for use for Succinylcholine Choline Injection, USP, reviewed 06/19, showed that the medication should be stored at 36 to 46 degrees Fahrenheit and is stable for 14 days at room temperature.

1. On 07/27/21 at 10:30 AM during inspection of an empty patient room (Room #104), Surveyor #5 and a Registered Nurse (Staff #501) observed the following:

a. 1 opened bottle of Hydrogen Peroxide Solution with an expiration date of 06/03/21.

b. On opened vial of 1 % Lidocaine with Epinephrine undated.

2. At the time of the finding, Staff #501 confirmed the expired medications and removed the medications from the room.

3. On 07/27/21 at 11:41 AM, Surveyor #5 and a Pharmacist (Staff #506) inspected two rapid sequence intubation (RSI) medication boxes located in an inpatient unit medication room. Surveyor #5 observed that both kits contained Succinylcholine (a medication used for general anesthesia to provide for skeletal muscle relaxation and facilitate endotracheal intubation) that were labeled for an expiration date of 28 days. Document review of the manufacturer's instructions for use showed that the medication expired after 14 days at room temperature. Both the dated vials exceeded 14 days.

4. At the time of the finding, Staff #506 verified the dates on the vials and the manufacturer's instructions for use. She stated that the medication must be from a new vendor as their previous medication had an expiration of 28 days at room temperature.


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Based on document review and interview the hospital failed to ensure acute care admission nutritional screening and risk assessments were appropriately completed according to hospital policy for 1 of 1 patients reviewed (Patient #502).

Failure to ensure that patients receive nutritional risk assessments on admission risks improper nutrition that could lead to unanticipated patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titles, "Dietary Consultation," policy number 7170-33.1, revised 09/18, showed the following:

a. All patients will receive a dietary assessment if they fall into the high-risk category for nutritional deficiency as identified by chewing/swallowing problems, unintended weight loss in the past 3 months, new diabetic, alcohol or drug abuse history, tube feedings, impaired skin integrity.

b. On admission to the acute care unit every patient will receive an initial nutrition screening via a health history evaluation performed by the admitting nurse to trigger whether a more in-depth evaluation will be required.

c. If a patient is found to trigger any of the high risk above identified areas, a dietary consult will be ordered through Meditech for that patient.

d. The dietary manager will contact the dietician when a patient requires a more in-depth evaluation with interventions that need to be implemented to meet the patient's nutritional needs.

2. On 07/27/21 at 12:00 PM, Surveyor #5 and a Registered Nurse (Staff #507) reviewed the medical record for Patient #502 who was admitted on 07/21/21 for the treatment of Pneumonia. The patient had a history of Dementia and Chronic Obstructive Pulmonary Disease. The review showed that staff assessed and documented a nutritional risk score of 4 (low risk). Review of the screening tool criteria showed that the patient should have scored a 6 (high risk) based on the patient's assessment, Impaired Nutritional Status Reference, and Severity of Disease Reference including:

a. The patient's Body Mass Index (BMI) was less than 20.5

b. The patient dietary intake was 25%

c. The patient was confined to bed related to severe illness including criteria of severe pneumonia

3. At the time of the finding, Staff #507 entered the information above into the tool, and the document showed that the patient was a high risk for nutritional deficiency. Staff #507 stated that the hospital recently changed to a new documentation system and a new screening tool and that staff may not understand how the new screening tool works. Staff #507 stated that the dietician is notified based on the results of the screening tool. Staff #507 verified that because staff failed to appropriately score the patients initial and ongoing nutritional screen and assessments this resulted in an inappropriate risk category designation, which then resulted in the failure to notify the dietary department of the patient high risk for nutritional deficiency status, and then subsequently resulted in a failure of the patient to receive a nutritional consultation by the dietician.

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Based on document review and interview, the hospital failed to maintain a list of services furnished under arrangement or agreements that described the nature and scope of the services provided.

Failure to maintain a list of services describing the nature and scope of the services provided by the contractors created a situation where the facility could not know which services were contracted and could not ensure the quality of those services.

Findings included

1. Document review of a list of hospital patient care services furnished under arrangement or agreements (contracts), no title, no date, showed a spreadsheet type document that included hospital contracted services listed in line item format.

2. On 07/29/21 at 1:00 PM, Surveyor #5 and the Executive Assistant (Staff #504) reviewed the Critical Access Hospital's (CAH) process for tracking and reviewing services furnished under arrangement. Review of the list provided to the Surveyor showed that the document failed to describe the nature and scope of the services provided and contain all the minimum requirements including:

a. The service(s) being offered;

b. Whether the services are offered on- or off-site;

c. Whether there is any limit on the volume or frequency of the services provided; and

d. When the service(s) are available.

The list appeared to contain both patient care and non-patient care services.

3. At the time of the observation, Staff #504 verified that the list did not contain all required elements and stated that the list contained all the hospital's contracted services.
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Based on interview, document review, review of the hospital's quality and performance improvement program, and Governing Body documents, the hospital failed to ensure that performance measures for all patient care services furnished under arrangement or agreements (contracted) were developed, evaluated, evaluated by a designee with experience and knowledge in the service to be reviewed, and failed to ensure that all patient care services furnished under arrangement or agreements were evaluated through the hospital's quality program and as directed by hospital policy for 2 of 4 contracts reviewed.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospital's policy titled, "Approvals and Use of Contracted Services," policy number 3208, no date, showed the following:

a. The Chief of the Medical Staff and/or the Department Director or Manager have the responsibility to review the performance of outside service providers.

b. The Chief of the Medical Staff and/or the Department Director or Manager will document findings on the "Annual Services Provider Form."

c. The Designee responsible for the evaluation must have experience and knowledge in the service to be reviewed i.e. outside MRI facility may be reviewed by a licensed MRI technician.

d. For contracted services deemed unacceptable the completed signed form will be forwarded to the Chief Executive officer and/or the Medical Staff Director and a recommendation will be forwarded to the appropriate administration leader and/or the Medical Executive Committee for final disposition/determination.

2. On 07/29/21 from 1:00 PM until 2:00 PM, Surveyor #5 and the Executive Assistant (Staff #504) reviewed the hospital's contracted service evaluations for 4 clinical contracts including the hospital's contracted dietician, "Medication Review," "Pend Oreille Paramedic Services", and "Phoenix Protective Service." The review showed the following:

a. Surveyor #5 found no evidence that services provided by "Phoenix Protective Services" and "Pend Oreille Paramedic" had been evaluated by the hospital.

b. The contractor review documents for the hospital's contracted pharmacy services, "Medication Review," contained a pre-formatted template. Surveyor #5 found no evidence that the hospital chose indicators that would measure and determine quality of care to assure that patient care services were provided in a manner that ensured compliance with the applicable requirements of the hospital's Conditions of Participation and accepted professional pharmacy practices.

The document provided to the Surveyor showed it was completed by the Pharmacy Department Manager who was a Registered Nurse. Surveyor #5 found no evidence the review was completed by a Pharmacist with experience and knowledge in the service to be reviewed.

3. On 07/29/21 at 1:45 PM, Staff #504 stated that the Chief Executive Officer (CEO) was out on leave and not available for interview. She stated the CEO was involved in evaluation of contracted services as he was a member of the Quality Committee which reviewed contracts annually in March or April. Staff #507 verified the findings and stated that the hospital would review current process and documents.

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Based on record review, interview, and review of policy and procedure, the critical access hospital failed to ensure staff members completed and documented pain assessment and reassessments prior to and after each pain management intervention as directed by hospital policy for 4 of 4 pain medication administrations reviewed for 2 patients (Patient #504 and #505).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain.

Findings included:

1. Document review of the critical access hospital's policy and procedure titled, "Pain Management Policy," policy number 7170-75, revised 09/18, showed the following:

a. Nursing staff will ask the patient upon initial evaluation and as part of regular patient assessments about presence, quality, and intensity of pain, and will use the patient's self-report as a primary indicator of pain.

b. All patients receiving narcotic pain medication will be assessed and reassessed according to the Ramsey sedation scale.

c. Pain assessments and reassessments will be documented in the electronic chart.

d. Pain will be evaluated on a scale of 0 to 10.

e. Nursing staff will perform pain relief interventions as indicated and evaluate their effectiveness.

2. On 07/30/21 at 9:00 AM, Surveyor #5, a Registered Nurse (Staff #501), and a Quality Registered Nurse (Staff #502) reviewed the discharge medical record for Patient #504 who was admitted to the hospital's Swing Bed program on 05/20/21 after a left hip replacement. The patient history included avascular necrosis (loss of blood supply to the bone resulting in bone tissue death and bone collapses) of both hips, rheumatoid arthritis, bilateral contractures to the right and left lower extremities and alcohol over use. Surveyor #5 and Staff #501 reviewed 3 administrations of narcotic pain medication including: Oxycodone 10mg (an opioid pain medication used to treat moderate to severe pain) administered on 05/24/21 at 5:39 AM, on 05/30/21 at 11:02 PM, and on 06/01/21 at 8:12 AM. Surveyor #5 found no evidence that staff performed a patient pain assessment prior to pain medication administration or a patient pain reassessment after pain medication administration.

3. At the time of the finding, Staff #501 and Staff #502 verified that the medical record showed no evidence that staff assessed or reassessed the patient as directed by hospital policy.

4. On 09/30/21 at 12:30 PM, Surveyor #5 and Registered Nurse (Staff #501) reviewed the discharge medical record for Patient #505 who was admitted on 05/23/21 after a pelvic fracture (a fracture located between the hip bones). Review of the provider orders showed an order for Tylenol 650 mg for pain. On 05/25/21 at 8:17 AM, the patent received Tylenol 650 mg. Surveyor #5 found no evidence nursing staff assessed the patient pain prior to pain medication administration or reassessed the patient as directed by hospital policy.

5. At the time of the observation, Staff #501 confirmed that there was no evidence that staff assessed or reassessed the patient pain.

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Based on interview and document review the critical access hospital failed to ensure the infection control professional was appointed by the governing body, and that the appointment is based on recommendation from the medical staff leadership and nursing leadership.

Failure to follow infection control program organizational policies could result in an unqualified infection control professional overseeing the program which could place patients at increased risk.

Findings included:

1. On 07/29/21 between 1:00 PM and 3:00 PM, Surveyor #1 held an infection control meeting to discuss the hospital infection control program.

2. Surveyor #1 interviewed the Infection Control Preventionist (Staff #116) about the qualifications and appointment process. Staff #116 indicated that she has an infection control background and was not aware of the current requirements of approval through the governing body.

3. On 07/29/21, a review of the Governing Body Bylaws, last reviewed 3/26/20, that showed an overview of the governing body responsibilities including to ensure governance structure and operation are appropriate and statutes are followed. No provision for infection control professional appointment was included.
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Based on interview and document review, the Critical Access Hospital (CAH) failed to implement an effective respiratory protection program that ensure staff are fit tested to use an N-95 respirator prior to working in rooms under airborne precautions for 8 of 13 staff (Staff #107, Staff #108, Staff #109, Staff #110, Staff #111, Staff #112, Staff #113, Staff #114).

Failure to provide the appropriate N-95 prior to use places patients, staff, and visitors at risk of harm from the spread of disease.

Reference: CDC Morbidity and Mortality Weekly Report (MMWR) Respiratory-Protection Program showed that
OSHA requires health-care settings in which HCWs use respiratory protection to develop, implement, and maintain a respiratory-protection program. All HCWs who use respiratory protection should be included in the program.

Reference: CDC Morbidity and Mortality Weekly Report (MMWR) showed fit testing provides a means to determine which respirator model and size fits the wearer best and to confirm that the wearer can don the respirator properly to achieve a good fit.

Findings included:

1. Document review of hospital's policy and procedure titled, "Respirator Fit Testing Procedure - General Requirements," revised 03/2017, Showed that employees with a likelihood of providing patient care will be required to have a fit testing procedure performed to be sure that respiratory masks are worn properly. The categories of employees that are required to have this testing include: Acute Care Staff, Laboratory, Environmental Services, Radiology, ED, OR/Anesthesia, all providers, Social Services and Admitting.

2. On 07/27/21 between the hours of 9:30 AM and 10:00 Surveyor #1 observed an Environmental Service Technician (EVS) (Staff #105) clean a standard precaution patient room. During the clean, surveyor #1 observed that staff #105 had on a N-95 respirator. Surveyor #1 asked about the fit testing process. Staff #105 indicated that he was not fit tested for the N-95 respirator (BYD) and the reason for wearing it was because he was going to clean a positive Covid-19 room after cleaning the current standard precaution room. Staff #105 indicated that he was fit tested for another type of N-95 respirator, but the hospital was only carrying this one type of N-95 respirator.

3. On 07/28/21 between the hours of 9:30 AM, and 10:00 AM Surveyor #1 interviewed a Nursing Assistant Certified (NAC) (Staff #106) regarding the process of fit testing. Staff #106 indicated that she was not fit tested for the N-95 respirator (BYD)

4. On 07/28/21 between the hours of 9:30 AM, and 10:00 AM Surveyor #1 interviewed a Registered Nurse (RN) (Staff #119) regarding the process of fit testing. Staff #106 indicated that she was not fit tested for the N-95 respirator (BYD)

5. On 7/29/21 Record review of staff personnel files showed 8 of 13 failed (BYD) N-95 respirator fit testing; (Staff #107 RN, Staff #108 RN, Staff #109 Nurse Assistant, Staff #110 Social Worker, Staff #111 Nurse Assistant, Staff #112 EVS, Staff #113 Phlebotomist, Staff #114 Paramedic). Surveyor #1 requested a report of how many staff were N-95 respirator fit tested. The report showed 34 out of 43 staff members failed the fit test for the BYD N-95 respirator,79% fail rate.

6. On 7/29/21 between the hours of 1:00 PM and 3:00 PM, Surveyor #1 interviewed the supply chain manager (Staff #115) who confirmed that the BYD is the only N-95 respirator that staff is being fit tested for.

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Based on record review and interview, the Critical Access Hospital (CAH) failed to ensure that contracted staff received annual infection control training for 2 of 10 staff files reviewed (Staff #101, and #102).

Failure to ensure that contracted staff complete annual infection control training places patients and staff at risk for infection.

Findings included:

1. Document review of hospital policy titled, "Safety Education for students, interns, contract employees, vendors, and volunteer" last revised 5/17 showed orientation is provided for contractors that included infection control and bloodborne pathogen training.

2. Document review titled, "Paramedic, Outreach and Transport Services Agreement" dated 12/28/18, showed that services provided by Pend Oreille Paramedics, LLC (POP) will provide education to its employees in methods of infection control and Bloodborne Pathogens.

3. Document review of the personnel files for a contracted security guard (Staff #101), showed no documentation for infection control training.

4. Document review of the paramedic contractor (Staff #102) showed last infection control training was completed on 4/29/2015 from the employer.

5. On 07/29/21 from 1:00 PM to 3:00 PM, Surveyor #1 reviewed personnel files with the Human Resources Manager (Staff #103). During the review, Staff #103 indicated that no other documentation was provided by the contractor's employers. He confirmed that the contractors did not go through hospital's "Safety Education" as required. Staff #103 indicated that he was unaware that staff #102 was training on site at the hospital.
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Item #1 Incomplete List of Patient Rights

Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights for 1 of 1 patient reviewed (Patient #501).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital's document titled, "Newport Hospital & Health Services Swing Bed Patient Rights," document number 3/15AcmainstationSBforms, no date, showed that the document did not include a list of all Patient Rights required by regulation established in State Operations Manual Appendix W revised 02/21/20.

2. On 07/28/21 at 10:40 AM, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the medical records for Patient #501 who was a current patient admitted to the hospital's Swing Bed program. Document review showed that the hospital failed to inform the patients of the following:

a. §483.10© Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

b. §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident's preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice.

c. § §483.15(c)(1) Transfer and discharge-(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (c)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; or (F) The facility ceases to operate.

d. §485.645(d)(3) Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

3. At the time of the observation, Staff #501 reviewed the Patient Rights document, confirmed the findings, and stated the hospital would update the document to ensure inclusion of all the patient rights.

Item #2 Patient Rights

Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to inform hospital swing bed patients of their patient rights for 2 of 2 patients reviewed (Patient #503 and #504).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital's document titled, "Newport Hospital & Health Services Swing Bed Patient Rights," document number 3/15AC mainstationSBforms, no date, showed that each patient or legally delegated representative will be informed of his/her patient rights, responsibilities, and all rules governing patient conduct on or before admission to the hospitals Swing Bed Program.

2. On 07/28/21 at 11:48 AM, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the discharge medical record for Patient #503 who was admitted to the hospital's Swing Bed program on 04/15/21. Document review showed that the hospital failed to inform the patients of his patient rights.

3. On 07/30/21 at 9:00 AM, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the discharge medical record for Patient #504 who was admitted to the hospital's Swing Bed program on 05/20/21. Document review showed that the hospital failed to inform the patients of his patient rights.

4. At the time of the review, Staff #501 verified that the medical records for Patient #503 and #504 did not contain evidence that the patients were informed of their Patient Rights. Staff #501 stated that the hospital had transition to an electronic medical record in March and that the signed Patient Rights information document should have been scanned into the electronic medical record.
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Based on interview, the Critical Access Hospital failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 of 3 Swing Bed patients reviewed (Patients #502, #503, and #504).

Failure to provide social services risks a patient's ability to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Swing Bed Program Newport Hospital and Health Services by Definition," no policy number, reviewed 09/18, showed that the services provided to Swing Bed patients includes Social Services.

Document review of the hospital's policy and procedure titled, "Swing Bed Discharge Planning Criteria," no policy number, approved 01/06/20, showed that the Discharge Planner/Social Services will complete the Initial Discharge Assessment as well as initiate the "Potential for Discharge Care Plan" at the time of patient admission.

2. On 07/28/21 at 10:40 AM, Surveyor #5 and Registered Nurses (Staff #501 and #507) reviewed the medical records for Patient #501 who was a current patient admitted to the hospital's Swing Bed program. The medical record review showed that the patient suffered severe Dementia and that the patient's wife was unable to provide care and unable to take the patient home. Surveyor #5 found no evidence that Social Services had completed an assessment of the patient to identifying psychosocial, mental and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs.

3. On 07/27/21 at 4:00 PM, Surveyor #5 and the Social Worker (Staff #508) reviewed the Patient's medical record. Staff #508 stated that when the hospital changed to the new electronic medical record (March 2021) she was told not to complete any paper documents. She stated that the documents she used prior to the new electronic system to document her initial Social Services assessments were not built into the new system and therefore, she had not been completing them.

Staff #508 provided Surveyor #5 with 3 paper documents titled, "Swing Bed Cognitive Assessment," "Swing Bed Social History Information," "Geriatric Depression Scale Short Forms and Cornell Scale for Depression in Dementia."

4. On 07/29/21 and 07/30/21, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the medical records for Patient #503 who was admitted to the hospital's Swing Bed program on 04/15/21, and Patient #504 who was admitted to the hospital's Swing Bed program on 05/20/21. Surveyor #5 found no evidence of any Social Services assessments.

5. At the time of the review, Staff #501 verified the finding and stated that the hospital had already began following up.

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Item #1 Nutritional Assessments

Based on document review and interview the hospital failed to ensure admission nutritional screening/risk assessments and nutritional consultations were appropriately completed according to hospital policy for 2 of 3 patient's reviewed (Patient #503 and #504).

Failure to ensure that patients receive nutritional risk assessments on admission risks improper nutrition that could lead to unanticipated patient outcomes.

Findings included:

1. Document review of the hospitals policy and procedure titled, "Swing Bed Dietary/Nutritional Services," no policy number, reviewed 10/18, showed the following:

a. On admission to the Swing Bed program the Dietary Manager will be notified by the admitting staff.

b. Dietary staff will complete and document a comprehensive assessment.

c. A plan of care based on the admitting assessment will be implemented and continuously reviewed/revised throughout the patients stay.

d. Existing dietary policies will be applicable to Swing bed patients as well.

e. Weekly documentation will be entered in the dietary progress note.

Document review of the hospital's policy and procedure titles, "Dietary Consultation," policy number 7170-33.1, revised 09/18, showed the following:

a. All patients will receive a dietary assessment if they fall into the high-risk category for nutritional deficiency as identified by chewing/swallowing problems, unintended weight loss in the past 3 months, new diabetic, alcohol or drug abuse history, tube feedings, impaired skin integrity.

b. On admission to the acute care unit every patient will receive an initial nutrition screening via a health history evaluation performed by the admitting nurse to trigger whether a more in-depth evaluation will be required.

c. If a patient is found to trigger any of the high risk above identified areas, a dietary consult will be ordered through Meditech for that patient.

d. The dietary manager will contact the dietician when a patient requires a more in-depth evaluation with interventions that need to be implemented to meet the patient's nutritional needs.

2. On 07/29/21 and 07/30/21, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the medical record for Patient #504 who was admitted to the hospital's Swing Bed Program on 05/20/21 following a left hip fracture with repair. The patient history included avascular necrosis (loss of blood supply to the bone resulting in bone tissue death and bone collapses) of both hips, rheumatoid arthritis, bilateral contractures to the right and left upper and lower extremities and alcohol over use. The medical record review showed that staff assessed and documented a nutritional risk score of 1 (low risk). Review of the screening tool criteria showed that the patient should have scored a 5 (high risk) based on the patient's assessment, Impaired Nutritional Status Reference and Severity of Disease Reference including:

a. The patient's Body Mass Index (BMI) was less than 20.5

b. The patient was confined to bed related to severe illness.

c. Staff failed to document the percentage of food intake.

Surveyor #5 found no evidence that a dietary consultation was completed.

3. On 07/30/21 at 9:00 AM, Staff #501 verified the finding and stated that the admitting nurse completed the nutritional screening. She stated that the electronic documentation system had been recently implemented and the hospital recognized that the dietician was not automatically notified of a consultation. She stated that the charge nurse notified the dietician when consultations were needed. Staff #501 stated that the hospital's policies had not been updated to match the new documentation system and processes.

4. On 07/30/21 at 12:14 PM, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the medical record for Patient #503 who was admitted to the hospital on 04/15/21 and then to the Swing Bed program on 04/19/21 for a closed hip fracture and left rib fracture. The patient had a history of dementia, iron deficiency anemia, mild-protein-calorie malnutrition, atherosclerosis, peripheral vascular disease and pain with long term opiate analgesic use. The record review showed the following:

a. Staff assessed and documented a nutritional risk score of 0 (low risk). Review of the screening tool criteria showed that the patient should have scored a 5 (high risk) based on the patient's assessment, Impaired Nutritional Status Reference and Severity of Disease Reference.

b. On 04/30/21 the patient scored a 6 on the nutritional screen. Surveyor #5 found no evidence a nutritional consultation was ordered or completed.

c. On 05/05/21 the patient scored a 6 on the nutritional screen. Surveyor #5 found no evidence a nutritional consultation was ordered or completed.

5. At the time of the medical record review, Staff #501 confirmed the findings and stated that staff would need to be educated on the new risk screening tool and that the hospital would need to update the policies to match the current system.

Item #2 Swing Bed Patient Dietary/Nutrition Consults

Based on document review and interview the hospital failed to ensure all patients admitted to the Swing Bed program received an initial Dietary Consultation as directed by hospital policy for 2 of 3 patient's reviewed (Patient #503 and #504).

Failure to ensure that patients receive nutritional risk assessments on admission risks improper nutrition that could lead to unanticipated patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Swing Bed Dietary/Nutritional Services," no policy number, reviewed 10/18, showed the following:

a. On admission to the Swing Bed program the Dietary Manager will be notified by the admitting staff.

b. Dietary staff will complete and document a comprehensive assessment.

c. A plan of care based on the admitting assessment will be implemented and continuously reviewed/revised throughout the patients stay.

d. Existing dietary policies will be applicable to Swing bed patients as well.

e. Weekly documentation will be entered in the dietary progress note.

2. On 07/29/21 and 07/30/21, Surveyor #5 and a Registered Nurse (Staff #501) reviewed the medical records for Patient #503 and #504 who were admitted the hospital's Swing Bed Program. The review showed that neither patient received an admitting Dietary Consultation as directed by hospital policy.

3. On 07/30/21 at 12:14 PM, Staff #501 confirmed that the charge nurse should notify the dietician, that the electronic documentation and screening tools had recently changed, and the that the hospital would need to update the policies to match the current system.

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Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure policies and procedures were developed using an all-hazards approach based on the hospital's risk assessments and communication plan.

Failure to base policies and procedures on the hospital's risk assessment prevents the facility from preparing a coordinated and meaningful response to emergencies, hazards, and disasters most likely to occur, thus placing patients and staff at risk for serious harm.

Findings included:

1. Document review of the hospital's Hazard Vulnerability Assessment (HVA), effective date 2020, showed top 10 risks were identified in the risk assessment. Two of the 10 policies and procedures were not aligned with the identified hazard within the facility's risk assessment.

2. On 07/28/21 between the hours of 1:00 PM and 3:00 PM, Surveyor #1 interviewed the emergency preparedness coordinator (Staff #104), about their emergency preparedness program. Surveyor #1 was provided documentation for the top 10 risks that were identified in the risk assessment. In review of the documentation 2 of the 10, "Wildfire/Smoke" and "Acts of Intent" did not have policy and procedures specific to the risk. Staff #104 indicated that the evacuation plan would be enacted for Wildfire/Smoke. The evacuation plan did not provide procedures for wildfire/smoke or elements of the communication plan specific to the risk. For the "Acts of Intent", The hospital only provided a poster/handout for "Acts of Intent" no policy and procedure for this emergency event was provided.
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