Lincoln Hospital

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 43911 . Based on observation and interview, the Critical Access Hospital failed to have a certified food protection manager on staff to oversee the dietary needs of the hospital as required by the Washington State Retail Food Code (WAC 246-215) and the U.S. Food and Drug Administration Food Code (2017, 2-102.12). Failure to have the required certified food protection employee to manage the dietary services puts patients, staff, and visitors at risk of harm from food borne illnesses. Findings included: 1. On 05/29/24 at 1:00 PM, Surveyor #4 inspected the hospital’s dietary kitchen with the dietary manager (Staff #401). During the inspection, the surveyor asked Staff #401 about his Food Protection Certification. Staff #401 stated that he had not yet completed a certified Food Protection Management course. 2. On 05/31/24 at 8:30 AM, Surveyor #4 reviewed personnel files and training records with the Human Resources Manager (Staff #402). The review showed the hospital’s dietary manager has a current food handler permit but is not a certified Food Protection Manager. The surveyor discussed the requirement with Staff #402. Reference: Washington State Retail Food Code WAC 246-215-02107 Certified food protection manager (2017 FDA Food Code 2-102.12). .”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 47458 . Item #1 - Expired Emergency Supplies Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy. Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies. Findings included: 1 Document review of the hospital’s policy and procedure titled, “Code Cart and Nurse Servers Outdates - Acute Care and Emergency Room, no policy ID, last reviewed 03/24 showed the following: a. The purpose of this policy is to ensure that critical emergency response equipment and medications are current and in proper operating order. b. Code Carts will be unlocked at least monthly and complete contents will be checked for outdates, missing items, and damaged/inoperable equipment. 2. On 05/29/24 between 1:05 PM and 2:00 PM, Surveyor #2 and Surveyor #9 and the Surgery Department Manager (Staff #202) inspected the Operating Room (OR), Procedure Room, and the two Peri-Anesthesia Rooms (PAR Rooms). The inspection of the OR showed a Broselow/Hinkle Pediatric Emergency System Blue intubation module that included two laryngeal blades, one endotracheal tube (ET) , one ET stylet, one suction catheter, one nasogastric tube, one tape, one lubricating jelly, and one gauze pad with a manufacturer’s expiration date of 11/20. 3. At the time of the review, Staff #202 verified the outdated emergency supplies and indicated they would obtain a replacement. Item #2 - Outdated Emergency Resources Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy. Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies. Reference: “2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care).” 2020 Guidelines are a comprehensive revision of the AHA’s guidelines for adult, pediatric, and neonatal resuscitation education science, and system of care topics. Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Neonatal Resuscitation Provider (NRP) resources were updated in 2020. Reference: “American Academy of Pediatrics states that 2019 Broselow (Trademark) Reference Tape will be the most compliant with PALS standards.” Findings included: 1. On 05/29/24 between 9:15 AM and 10:05 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Emergency Department Code Cart located between ED beds 1 and 2. Surveyor #2 observed a Broselow Pediatric Antidote for Chemical Warfare tape, 2006 edition. 2. At the time of the observation, Staff #202 verified the outdated resource and stated they would obtain a replacement. 3. On 05/29/24 between 10:10 AM and 11:00 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Emergency Cart and the Drager infant warmer stored at the end of a hallway located in the Acute Care Unit. Surveyor #2 observed a Broselow Pediatric Emergency Reference tape, 2017 edition. 4. At the time of the observation, Staff #202 verified the outdated resource and stated they would obtain a replacement. .”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47458 . Based on observation, document review, and interview, the Critical Access Hospital failed to prevent the use of patient care supplies that exceeded the manufacturer’s recommended use or expiration date. Failure to monitor the systematic process for ensuring patient care supplies do not exceed their beyond-use or expiration date risks deteriorated, non-sterile, or potentially contaminated supplies being available for patient care. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Code Cart and Nurse Servers Outdates - Acute Care and Emergency Room,” no Policy ID, last reviewed 03/24, showed the following: a. The purpose of this policy is to ensure that critical emergency response equipment and medications are current and in proper operating order. b. “Nurse Servers” will be opened and checked monthly. c. The “Nurse Server” monthly outdate check will be documented and signed on the “Monthly Outdate Inspection” log located in each respective area. d. The House Supervisor, DNS, and/or Nurse Educator will monitor the logs for compliance. 2. On 05/29/24 between 10:10 AM and 11:00 AM, Surveyor #2 and Surveyor # 9 and the Nurse Educator (Staff # 201) inspected the Respiratory Closet and Drager Infant Warmer in the Acute Care Unit. The inspection showed the following: In the Respiratory closet a. One Glidescope GVL2 stat laryngoscope, with a manufacturer’s expiration date of 07/23. b. Two Glidescope GVL1 stat laryngoscope, with a manufacturer’s expiration date of 09/23. c. Two Glidescope GVL0 stat laryngoscope, with a manufacturer’s expiration date of 07/23. d. One intubation stylet, with a manufacturer’s expiration date of 09/21. In the Drager Infant Warmer a One Drager temperature sensor on the OB delivery cart, with a manufacturer’s expiration date of 07/22. 3. At the time of the review, Staff #201 verified the expired supplies and removed them from use. .”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 47458 . Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition. Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety. Findings included: Refer to deficiencies written on Life Safety Code Inspection Report found at shell 3YDY21. .”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): 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. This Standard is not met as evidenced by: 47458 . Based on interview and document review, the Critical Access Hospital’s Governing Body failed to ensure the medical staff periodically reviewed bylaws, rules, and regulations. Failure to periodically review bylaws, rules, and regulations risks inappropriate oversight and outdated practice. Findings included: 1. Document review of the hospital document titled, “Medical Staff Bylaws,” last approved May 2003, showed that that the medical staff shall periodically, at least every two years, review and revise its rules and regulations to comply with current practice. 2. On 05/30/24, Surveyor #9 interviewed Chief Clinical Officer (Staff #903) regarding the “Medical Staff Bylaws” and “Medical Staff Policies Rules and Regulations” which were both approved in May 2003. Staff #903 stated 2003 was the most current version of the documents. .”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 45663 . Item #1 - Emergency Department Standards of Care Based on record review and interview, the Critical Access Hospital failed to develop and implement policies and procedures to define standards of care for Emergency Services. Failure to develop and implement policies and procedures risks inappropriate and/or ineffective patient care and poor patient outcomes. Findings included: 1. On 05/29/24 at 9:00 AM, Surveyor #9 and the Director of Nursing Services (Staff #901) reviewed medical records of Emergency Department patients. Surveyor #9 requested a policy for standards of care for the Emergency Department. 2. On 05/29/24 at 4:00 PM, Surveyor #9 interviewed the Director of Nursing Services (Staff #901), Chief of Clinical Services (Staff #903) and Nurse Educator (Staff #904) regarding standards of care for the Emergency Department such as frequency of assessment and reassessment, vital sign frequency, required screenings, and discharge criteria. Staff #901 verified that they did not have a complete standard of care policy for the Emergency Department. 47458 Item #2 - Kiwi® vacuum policy Based on record review and interview, the Critical Access Hospital failed to develop and implement policies and procedures to define standards of care for the use of a Kiwi® vacuum assisted delivery system. Failure to develop and implement policies and procedures risks inappropriate use of equipment and potential serious injury or death. Reference Instructions for Use: The Clinical Innovations’ Kiwi® is a disposable vacuum assisted fetal delivery system. It is a sterile, single-patient-use device designed to provide assistance in childbirth under the following conditions: 1) Term pregnancy, 2) Ruptured amniotic membranes, 3) Engaged head, 4) Complete cervical dilation, and 5) Adequately trained or supervised operator. Adverse events for the fetus include cephalohematoma, subgaleal hemorrhage, intraventricular or parenchymal hematoma, subconjunctival, intracranial, or retinal hemorrhage, nerve injuries, subjective jaundice, elevated bilirubin, bruises, contusions, lacerations, fractures. Maternal Injuries: Vaginal, cervical, uterine, bladder, rectal. Findings included: 1. On 05/29/24 at 9:00 AM, Surveyor #2 and Surveyor #9 and the Nurse Educator (Staff #904) inspected the hospital’s acute care area. In a drawer in an obstetrical emergency cart was a Kiwi® vacuum (a device to assist childbirth). Surveyor #9 requested a policy for the use of the device. 2. On 05/29/24 at 4:30 PM, Surveyor #9 interviewed the Chief Clinical Officer (Staff #903) regarding a policy for the use of the Kiwi®. Staff #903 stated that there was not a policy for the use of that device. Item #3 - Restraint Order Based on record review, interview, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff followed policies and procedures for restraint orders for 3 of 3 patients with non-violent restraint orders reviewed (Patient #202 and #203). Failure to ensure that staff limit the use of restraints to the least restrictive intervention risks serious physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraint: Physical and Chemical Restraint,” no policy ID, last approved 03/24, showed the following: For violent or self-harm patients: a. The Provider must be notified at the time of restraint initiation. b. Provider orders will include clinical justification for the type of restraint used. For chemical restraints d. Chemical restraint orders will contain specific medication doses, frequency, and duration of use and rationale for use and re-order every 24 hours. 2. On 05/30/24 between 3:15 PM and 4:30 PM, Surveyor #2 and the Director of Nursing Services (Staff #203), reviewed the medical records of 3 restraint patients. The review showed the following: a. Patient #202 who was an 88-year-old male admitted to the Acute Care Unit (ACU) on 12/12/23 with a diagnosis of endocarditis (inflammation of the inside lining of the heart chambers and valves). On 12/23/23 at 1:00 AM, Patient #202 had a nursing note stating patient’s combative behaviors continue and alternative interventions attempted were not successful, patient continues to kick, punch, attempts to bite, and has verbal threats of harm to staff. On 12/23/23 at 1:05 AM Patient #202 had a provider order for Haldol (an antipsychotic medication) 5 milligrams to be given intramuscularly. On 12/23/23 at 1:35 AM a verbal order for restraint for non-violent behavior was placed in Patient #202’s medical record. On 12/23/23 at 1:35 AM Patient #202 had a nursing note stating patient was placed in bilateral wrist and bilateral ankle soft restraints. Surveyor #2 found no evidence of an order for physical restraints for violent or self-harm patients in the medical record. b. Patient #203 who was an 86-year-old female admitted to the ACU on 05/09/24 for failure to thrive. Patient #203 had a nursing note on 05/10/24 at 1:38 PM stating the patient was very drowsy this morning, very confused, became very agitated, making threats to staff, multiple attempts to pull IV out, unsteady on her feet, and impulsive. Patient #204 had a provider order for restraint for non-violent behvior and an order for Haldol 2 milligrams to be given intravenously. Surveyor #2 found no evidence of an order for restraint for violent or self-harm patients in the medical record. 3. At the time of the review, Staff #203 verified the missing order for violent restraints. Item #4 - Violent Restraint Face-to-Face Evaluation Based on record review, interview, and document review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff performed a face-to-face evaluation for patients with restraint orders for 2 of 3 patients reviewed (Patient #202 and #204). Failure to follow approved policies and procedures for restraint or seclusion use risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraint: Physical and Chemical Restraint,” no policy ID, last approved 03/24, showed restraints used for violent self-harm patients will have a face to face evaluation, with the provider, within one hour of the initiation of the restraint. 2. On 05/30/24 between 3:15 PM and 4:30 PM, Surveyor #2 and the Director of Nursing Services (Staff #203), reviewed the medical records of 3 restraint patients. The review showed the following: a. Patient #202 who was an 88-year-old male admitted to the Acute Care Unit on 12/12/23 with a diagnosis of endocarditis. On 12/23/23 at 1:35 AM Patient #202 had a nursing note stating patient was placed in bilateral wrist and bilateral ankle soft restraints. Surveyor #2 found no evidence of a face to face evaluation by the provider within one hour of initiation of 4-point physical restraints. b. Patient #204 who was an 86-year-old female admitted to the ACU on 05/09/24 for failure to thrive. Patient #204 had a provider order for Haldol 2 milligrams IV on 05/10/24 at 12:56 PM. Surveyor #2 found no evidence of a face to face evaluation by the provider within one hour of the medication administration. 3. At the time of the review, Staff #203 verified the missing face to face evaluation within one hour. .”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 47458 . Item #1 Pain Assessment/Reassessment Based on interview, record review, and review of policy and procedure, the Critical Access Hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 4 of 9 patients reviewed (Patient #201, #905, #906, and #907). Failure to assess and reassess a patient’s pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Pain Management”, no policy ID, last reviewed 03/24, showed all patients will be assessed for pain using a pain scale appropriate for the patient’s age and clinical condition and pain reassessments will occur within 30-60 minutes following any pain management intervention. 2. On 05/30/24 at 9:15 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #905 who was evaluated in the Emergency Department on 05/04/24 for a fractured clavicle. The review showed on 05/04/24 at 10:33 PM, 2 tablets of Hydrocodone (an opioid narcotic pain medication) 325 milligrams was administered orally for a pain score of 6-7 out of 10. The Surveyor found no documentation of pain reassessment after the medication administration. 3. At the time of the review, Staff #901 verified the missing reassessment documentation. 4. On 05/30/21 between 1:15 PM and 3:15 PM, Surveyor #2 and the Director of Nursing Services (Staff #203) reviewed the medical record of Patient #201 who was admitted on 05/17/24 as a swing bed patient for therapy services following a surgical repair of a left femur fracture. Patient #201 had a provider order for oxycodone (a narcotic medication used to treat pain) 5-10 milligrams orally every 4 hours as needed for pain. Patient #201 received oxycodone 10 milligrams on 05/29/24 at 4:22 AM. Surveyor #2 found no evidence of pain assessment prior to pain medication administration. 5. At the time of the review, Staff #203 verified the missing pain assessment documentation. 6. On 05/31/24 at 10:00 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #906 who was admitted on 05/29/24 for treatment of cellulitis (a skin infection). The review showed the following: a. On 05/29/24 at 3:53 PM, Hydrocodone 325 milligrams orally was administered for a pain score of 5 out of 10 at 3:31 PM. The Surveyor found no documentation of pain reassessment after the medication administration. b. On 05/30/24 at 10:15 AM, Hydrocodone 325 milligrams was administered orally. The Surveyor found no documentation of a pain assessment prior to the medication administration. c. On 05/31/24 at 8:47 AM, Hydrocodone 325 milligrams was administered orally. The Surveyor found no documentation of a pain assessment prior to the medication administration. 7. At the time of the review, Staff #901 verified the missing pain assessment/reassessment documentation. 8. On 05/31/24 at 10:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #907 who was admitted on 05/27/24 for treatment of neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves). The review showed the following: a. On 05/27/24 at 7:59 AM, Oxycodone (an opioid narcotic pain medication) 15 milligrams orally was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration. b. On 05/28/24 at 2:28 PM, Hydromorphone (an opioid narcotic pain medication) 0.8 milligrams intravenously was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration. c. On 05/28/24 at 6:14 PM, Oxycodone 15 milligrams orally was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration or a reassessment after the medication administration. d. On 05/28/24 at 10:09 PM, Hydromorphone 0.8 milligrams intravenously was administered. The Surveyor found no documentation of a pain assessment prior to the medication administration. 9. At the time of the review, Staff #901 verified the missing pain assessment/reassessment documentation. Item #2 Insulin Administration Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff implemented provider orders for sliding scale insulin administration in accordance with acceptable standards of practice as demonstrated by 1 of 2 insulin administration records reviewed (Patient #907). Failure to implement provider orders for medication administration risks patient harm from unsafe or inappropriate medication administration. Findings included: 1. Document review of the hospital policy and procedure titled, “Medication Management High Risk Medications,” no policy number, last revised 04/10/24, showed the following: a. High risk medications at Lincoln Hospital include insulin, infusion, and subcutaneous doses. b. Insulin is administered based on provider orders. c. Double checks are required for pediatric subcutaneous insulin and concentrations greater than 100 units/milliliter. 2. On 05/31/24 at 10:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical record of Patient #907 who was admitted on 05/27/24 for treatment of neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves) and diabetes. The review showed the following: a. On 05/27/24 at 11:34 AM, the patient’s blood glucose was 262 milligrams/deciliter and was to receive 6 units of insulin lispro as per the provider order. A review of the medication administration record showed that 4 units were administered. b. On 05/28/24 at 10:06 PM, the patient’s blood glucose was 162 milligrams/deciliter and was to receive no insulin as per the provider order. A review of the medication administration record showed that 2 units were administered. 3. At the time of the review, Staff #901 verified that the incorrect amount of insulin had been administered and documented at the times above. Item #3 Suicide screening/assessment Based on interview, record review, and review of policy and procedure, the Critical Access Hospital failed to ensure that patients receiving care in the Emergency Room received a suicide risk assessment as directed by hospital policy and procedure for 2 of 3 medical records reviewed (Patient #903 and #904). Failure to perform a suicide risk assessment, risks that patients would not receive medical treatment appropriate to their care needs. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Suicide Prevention Crisis Protocol,” no policy number, last revised 03/24, showed that all patients are screened/assessed for suicide risk upon admission to the Emergency Department or inpatient. 2. On 05/30/24 between 8:50 AM and 10:00 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical records of 3 patients who were evaluated in the Emergency Department. The review showed the following: a. Patient #903 was a 48 year old who was evaluated on 04/29/24 for a laceration. The Surveyor found no evidence of a suicide screening/assessment documented in the medical record. b. Patient #904 was a 46 year old who was evaluated on 04/28/24 for abdominal pain. The Surveyor found no evidence of a suicide screening/assessment documented in the medical record. 3. At the time of the review, Staff #901 verified there was no suicide screening documented in the medical records. Item #4 Blood administration vital signs Based on interview, record review, and document review of the hospital’s policy and procedures, the Critical Access Hospital failed to ensure staff followed its policy and procedure for blood product transfusions for 1 of 3 blood transfusion patient records reviewed (Patient #908). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Blood or Blood Derivative Administration,” no policy number, last revised 03/24, showed the following: a. For all blood components, vital signs will be taken at a minimum before starting the transfusion, 10-15 minutes from the start of the infusion, 60 minutes from the start of the transfusion, at the end of the transfusion, and 10-15 minutes following a deviation in the patient’s baseline vital signs. b. Complete documentation for all blood component administration will occur in the patient’s electronic chart. 2. On 05/30/24 between 10:30 AM and 11:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical charts of three patients who had received blood transfusions. The review showed Patient #908 received a blood transfusion which was initiated on 04/13/24 at 1:38 PM and finished on 04/13/24 at 4:10 PM. The Surveyor found no evidence of documentation of vital signs at the initiation of the blood transfusion. 3. At the time of the review, Staff #901 verified the missing vital sign documentation. Item #5 Blood administration consent Based on interview and document review, the Critical Access Hospital staff failed to obtain informed consent for blood transfusion for 1 of 3 blood transfusion patient records reviewed (Patient #909). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Blood or Blood Product Transfusions Informed Consent and Refusal,” no policy number, last reviewed 07/21, showed that informed consent is to be signed by all patients receiving a transfusion of blood products in non-emergent cases not associated with a surgical procedure. 2. On 05/30/24 between 10:30 AM and 11:45 AM, Surveyor #9 and Director of Nursing Services (Staff #901) reviewed the medical charts of three patients who had received blood transfusions. The review showed Patient #909 received a non-emergent blood transfusion for anemia which was initiated on 01/19/24 at 3:29 PM and finished on 01/19/24 at 6:20 PM. The Surveyor found no evidence of a signed consent for blood transfusion in the medical record. 3. At the time of the review, Staff #901 verified the missing signed consent and stated that during the hospital’s transition to a different electronic health record there was some confusion regarding the signing of consents which should be clarified now. .”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 43911 . Item #1 - Cleanable and sanitary surfaces Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary. Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection. Reference: AORN (Association of Perioperative Registered Nurses) Guidelines for Perioperative Practice: Design and Maintenance, (2020) - “Recommendation 12.2. Maintain the integrity of structural surfaces (e.g., doors, floors, walls, ceilings, cabinets) and have surfaces repaired with damaged.” 12.2.1 “...Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning.” Findings included: 1. Document review of the hospital’s plan titled, “Infection Prevention, Quality & Risk Management, Quality Assurance Performance Improvement (QAPI) Plan, Lincoln Hospital District #3, 2024,” approved 12/23, showed environment of care rounding will be done a minimum of 6 times per year. Document review of the hospital’s work order checklist titled, “Maintenance Sched 248,” no policy # or approval date, showed a checklist used for hospital environment of care rounding inspections. The checklist includes inspecting for damage to walls and surfaces (Item #18: “paint- tiles- door- floors- ETC”). 2. On 05/29/24 at 9:30 AM Surveyor #4 observed a terminal cleaning of the hospital’s operating room (OR). During the observation, the surveyor noticed the wall of storage cabinets had unsealed wood trim around all the glass panes. Additionally, the door into the OR had areas where the varnish or seal had worn off and was exposing the wood as well as the door into the sub-sterile storage room just outside the OR (where anesthesia supplies are kept). 3. During the observation, Surveyor #4 discussed the unsealed wood as being a non-cleanable surface with the OR Supervisor (Staff #403). 4. On 05/29/24 at 11:30 AM, Surveyor #4 observed a room cleaning (Room 18) in the Transitional Care Unit (TCU). During the observation, the surveyor noted that the wood handrails outside of Room 18 and all down the TCU main hall had several areas where the sealer or varnish had completely worn off (especially in the areas underneath the wall mounted alcohol-based hand rub dispensers). The surveyor later discussed the non-cleanable surfaces on the handrails with the hospital’s Chief Financial Officer (Staff #404). Staff #404 stated he was aware of the handrails and the facility was considering removing unnecessary older rails in some areas of the hospital and would address fixing the needed ones. Item #2 - Outdated cleaning supplies Based on observation and interview, the Critical Access Hospital failed to prevent the use of cleaning supplies that exceeded the manufacturer’s recommended expiration date. Failure to maintain cleanng supplies that do not exceed their beyond-use or expiration date in patient care areas puts patients at increased risk of infection. Findings included: 4. On 05/29/24 between 1:05 PM and 2:00 PM, Surveyor #2 and Surveyor #9 and the Surgery Department Manager (Staff #202) inspected the Operating Room (OR), Procedure Room, Pain Procedure room and the two Peri-Anesthesia Rooms (PAR Rooms). The inspection of the Pain Procedure Room showed the following: a. One container of Clorox healthcare bleach germicidal wipes, with a manufacturer’s expiration date of 03/24. b. One container of Clorox healthcare hydrogen peroxide wipes, with a manufacturer’s expiration date of 12/21. 5. At the time of the review, Staff #202 verified the expired supplies and removed them from use. .”

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) 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. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §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. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 47458 . 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 2 of 5 patients reviewed (Patient #204 and #205). 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 policy and procedure titled, “Informed Consent for Delivery of Care,” no policy ID number, last revised 10/23 showed the goal of informed consent is to give the patient autonomy and self-determination. All patients have the right to make an informed, un-coerced decision about their medical care. To that end the patient should be provided with sufficient information to be able to give meaningful consent concerning their medical care. 2. Document review of the hospital policy and procedure titled, “Patient Registration and Admitting,” no policy ID number, last revised 02/23, showed the following: a. The functions of Admitting Personnel are vital to the overall operational success of the hospital. b. Admitting Personnel are responsible for obtaining signatures on the Patient Rights and Responsibilities form. 3. Document review of the hospital document titled, “Lincoln Hospital Swing Bed Resident Rights,” not dated, listed all the Swing Bed Resident Rights, and page 3 included the Notice of Swing Bed Resident Rights Acknowledgement that indicates by your signature below, you acknowledge receipt of Lincoln Hospital Swing Bed Resident Rights. 4. On 05/30/24 between 1:15 PM and 3:15 PM, Surveyor #2 and Surveyor #9 and the Director of Nursing Services (Staff #203) reviewed the records of 3 Swing Bed patients. The review showed the following: a. Patient #204 had an order to admit to Swing Bed in the transitional care unit on 05/10/24 as a non-skilled extended care Swing Bed. Surveyor #2 found no evidence of a Swing Bed Residents Rights form signed from this admission in the medical record. b. Patient #205 had an order to admit to Swing Bed in the transitional care unit on 06/09/23 as a non-skilled extended care Swing Bed (date of transition to new EMR). Surveyor #2 found no evidence of a Swing Bed Resident Rights form signed from this admission in the medical record. 5. At the time of the review, Staff #203 verified the missing signed Swing Bed Resident Rights. .”

“DENTAL SERVICES CFR(s): Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). “ §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge a Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This Standard is not met as evidenced by: 45663 . Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy regarding dental care and dentures for Long Term Care Services “Swing Bed” patients. Failure to develop and implement a policy regarding dental care risks poor oral care, infection, and nutritional deficiencies. Findings included: 1. On 05/30/24, Surveyor #9 reviewed the policies and procedures provided by the Critical Access Hospital. The Surveyor was unable to locate policies that addressed the dental care of the long term care services “swing bed” patient. 2. On 05/30/24 at 4:00 PM, Surveyor #9 interviewed Chief Clinical Officer (Staff #903) regarding the dental policy. Staff #903 stated that they were unable to locate a policy regarding dental care and dentures for long term care services “swing bed” patients however they do have a dentist who provides dental care for their patients. .”

“This report is the result of an unannounced fire and life safety state licensure survey conducted at Lincoln County Public Hospital District No. 3 in Davenport, Washington on May 29 and 30, 2024 by a representative of the Washington State Patrol, Fire Protection Bureau (WSP/FPB). The survey was conducted in concert with the Washington State Department of Social and Health Services health survey team. The facility’s maintenance director accompanied the WSP/FPB surveyor during portions of the physical tour of the facility. The facility is licensed for 25 beds and at the time of this survey the census was 17. The existing section of the 2012 Life Safety Code was used in accordance with 42 CFR 482.41. The facility is a one story structure with a partial basement of Type II (1-1-1) hour construction with exits to grade and is protected by a Type 13 sprinkler system and an automatic / manual fire alarm system with corridor smoke detection. The Peak Fitness Physical Therapy is located at 506 Morgan St, Davenport, WA. The facility is located in a one story Type II (1-1-1) hour construction with exits to grade, single station smoke detection, carbon monoxide detectors and fire extinguishers. The facility is not in compliance with the 2012 Life Safety Code as adopted by the Centers for Medicare & Medicaid Services.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 21754 Based upon observations and staff interviews on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors. The findings include: The TCU electrical room wall has penetrations. The above was discussed and acknowledged by the facility staff.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire. The findings include: 1. The facility was unable to provide the most recent smoke detector sensitivity testing report. 2. The fire alarm pull station outside the OR is blocked by a fold down desk area with chairs. The above was discussed and acknowledged by the facility staff.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility. The findings include: 1. The Fire Department Connection on the building does not have a sign. 2. The storage closet by the OR has a fire sprinkler escutcheon missing. 3. The storage room across from the soda machines has storage too close to fire sprinklers. The above was discussed and acknowledged by the facility staff.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility. The findings include: The fire extinguisher in the laboratory is installed too high and is inaccessible. The fire extinguisher outside the OR is obstructed by storage. The above was discussed and acknowledged by the facility staff.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment. The following doors have penetrations: 1. Acute care West and East side doors have penetrations. 2. The TCU toilet shower combo room door has penetrations. 3. The TCU medical prep door frame has penetrations. The above was discussed and acknowledged by the facility staff.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger residents/patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. The findings include: The ER electrical panel is obstructed by storage. The above was discussed and acknowledged by the facility staff.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, residents, staff and/or visitors. The findings include: Facility failed to complete an evening shift fire drill the 4th quarter of 2023. At the PEAK Fitness Physical Therapy there have been no fire drills completed in the prior year. The above was discussed and acknowledged by the facility staff.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 21754 Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility. The findings include: Weekly inspections are not completed on the emergency generator. The above was discussed and acknowledged by the facility staff.”