Ocean Beach Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 38532 . Item #1 Patient Reassessment in the Emergency Department . Based on document review interview, the hospital failed to develop and implement policy and procedure to ensure that staff performed and documented appropriate ongoing assessments for patients admitted to the hospital’s Emergency Department (ED) for 3 of 3 patient’s reviewed with an ED length of stay that transitioned to the next shift reviewed (Patient #501, #504, and #505). Failure to perform ongoing assessments for patients presenting to the Emergency Department created risk that patients would not receive timely medical treatment appropriate to their care needs and could result in poor patient outcomes or death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Standards of Care,” no policy number, reviewed 12/09/24, showed that upon admission to the Emergency Department, the patient will receive a Focused Assessment on the area of concern by a Registered Nurse (RN). The policy does not address reassessment. 2. On 04/29/25 at 11:25 AM, Surveyor #5 and the Emergency Department Manager (Staff #501) reviewed the medical record for Patient #504, who was brought to the emergency department with upper quadrant abdominal pain radiating to the chest. The review showed the following: a. On 04/26/25 at 5:45 AM, the patient complained of shortness of breath and was placed on oxygen via nasal cannula. b. On 04/26/25 at 6:09 AM, night shift staff performed a brief assessment and placed the patient on a cardiac monitor. c. Between 7:42 AM and 8:12 AM, the patient complained of chest pain and received nitro glycerin sublingual and dilaudid intravenously. At 8:12 AM, staff performed a Chest Pain assessment that addressed pain level, location, and quality. Surveyor #5 found no evidence that staff performed a focused system assessment on the Day shift. d. On 04/26/25 at 6:55 PM, the patient received NitroGlycerin Sublingual for chest pain of 3/10. Surveyor #5 found no evidence that staff performed a focused system assessment on the night shift or a reassessment of the patient’s chest pain after medication administration. e. On 04/27/25 at 8:24 AM, the patient was discharged per patient request. Surveyor #5 found no evidence that staff reassessed the patient on the day shift or prior to discharge. 3. At the time of the review, Staff #501 verified that the policy did not address reassessment of patients in the Emergency Room. He stated that the staff do conduct hourly rounding, but that it is not documented and could be completed by staff who are not Registered Nurses. Staff #501 stated that for patients being discharged from the ED, staff should be completing the Discharge Condition Assessment. 4. On 04/29/25 at 1:25 PM, Surveyor #5 and the Emergency Room Manager (Staff #501) reviewed the medical record for Patient #502, who presented to the Emergency Room on 04/24/25 at 6:29 PM, for the treatment of fever, infection, and pain post-breast reduction. a. On 04/24/25 at 6:46 PM, Staff performed a focused skin assessment. b. On 04/24/25 at 10:04 PM, a transition of care occurred, and the new staff completed cardiac, respiratory, and skin-focused assessments. c. On 04/25/25 at 3:15 PM, the patient was discharged. Surveyor #5 found no evidence staff reassessed the patient on the day shift or completed an assessment prior to discharge. 5. At the time of the review, Staff #501 verified that no assessments were completed on the day shift. 6. On 04/29/25 at 2:00 PM, Surveyor #5 and the Emergency Room Manager (Staff #501) reviewed the medical record of Patient #501, who was admitted to the Emergency Department on 04/24/25 at 8:48 PM, for the treatment of stroke symptoms and weakness. The patient had a history of alcohol misuse. a. On 04/24/25 at 9:00 PM, staff performed cognitive and cardiac assessments.. b. On 04/25/25 at 1:04 AM, a note showed the patient’s oxygen saturation dropped to 77%, and the patient was placed on oxygen. Surveyor #5 found no evidence that staff completed a respiratory assessment after the change in patient status. c. On 04/25/25 at 1:40 PM, the patient was transferred to an inpatient bed. Surveyor #5 found no evidence that staff completed an assessment on the day shift. 7. At the time of the review, Staff #501 verified that focused assessments had not been completed with a change in patient status or at the transition of care from night shift to day shift. . Item #2 - Immunization Status Based on interview and document review, the hospital failed to assess the patient’s immunization status for 2 of 4 pediatric patients receiving care in the Emergency Room reviewed (Patient #502 and #503). Failure to obtain an immunization history creates a risk that immunization status may be overlooked and result in poor health outcomes, including transmission and complications of infectious disease for patients, staff, and community members. Findings included: 1. Document review of the hospital’s policy titled, “Emergency Standards of Care,” no policy number, reviewed 12/09/24, showed that the Triage Assessment by the Registered Nurse includes review of immunization status. 2. On 04/29/25 at 2:15 PM, Surveyor #5 and the Emergency Department Manager (Staff #501) reviewed the medical record for a pediatric patient who received care in the hospital’s Emergency Department (Patient #502). Surveyor #5 found no evidence that staff assessed the patient’s immunization status. 3. On 04/29/25 at 2:30 PM, Surveyor #5 and the Emergency Department Manager (Staff #501) reviewed the medical record for a pediatric patient who received care in the hospital’s Emergency Department (Patient #503). Surveyor #5 found no evidence that staff assessed the patient’s immunization status. 4. At the time of the reviews, Staff #501 verified that immunization status had not been addressed and stated that it was policy to address immunization status for all patients presenting to the Emergency Department.”

“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: 37243 . 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 KVIU21. .”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 37243 . Based on interview and record review, the hospital failed to ensure that Certified Registered Nurse Anesthetists (CRNA), allied professional members subject to requirements of the medical staff bylaws, were periodically evaluated for performance via a peer review process for 2 of 2 staff credentialing files reviewed (Staff #1702 and #1703). Failure to ensure that CRNAs are evaluated by peer review risks inadequate provider practice which could lead to negative patient outcomes. Findings included: 1. Document review of the medical staff bylaws, approved 10/25/18, did not show a process requiring or detailing periodic evaluation of allied health professional practice. 2. On 05/01/25 at 10:00 AM, Surveyor #17 interviewed the Senior Director of Risk and Quality (Staff #1704) about the peer review process for credentialed providers and reviewed records. Staff #1701 stated that peer review is conducted by an outside provider and that medical staff members are selected from the different departments of the hospital. During the review, the surveyor requested peer review documentation for 2 CRNAs (Staff #1702 and #1703). During the review, no peer review documentation was available for Staff #1702 and #1703. Staff #1704 confirmed that the CRNAs were not included in the peer review process but should be a part of the evaluation program. .”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 47461 . Based on document review, observation, and interview, hospital leadership failed to establish written procedures for staff and contracted staff regarding double checking unit-dose preparations and patient own medications. Failure to have policies and procedures for verifying and logging unit dose medications, and verifying and labeling patient own medications risks adverse drug events and poor patient outcomes. Findings included: 1. Document review of hospital policy titled, “Patient’s Own Medications”, no policy number, last reviewed on 09/24, showed that once a provider’s order has been received and before the medicine is administered to the patient, the medicine shall be properly identified by the pharmacist. POMs (patients’ own medications) will be indicated on the medication administration record within the electronic health record as “own supply” and will be stored in the patient’s locked drop down cabinet outside their room. 2. On 05/01/25 between 8:45 AM and 9:15 AM, Surveyor #5, Surveyor #10, and the Director of Pharmacy (Staff #1009) inspected the pharmacy. A Pharmacy Technician (Staff #1010) described the process for preparing unit dose medications. Staff #1009 showed the surveyors an example of a unit dose medication that was ready for dispensing. Surveyors asked to see a log or report of unit dose preparation showing verification by a pharmacist. Staff #1009 said that there was not a log. Surveyors requested the policy or procedure for unit dose preparation and documentation. Staff #1009 said that there was not a policy or procedure. 3. On 05/01/25 at 10:00 AM, Surveyor #10 and a charge nurse (Staff #1011) on the acute care unit checked the locked drop down cabinets for 4 patient rooms. The cabinet for room 5 (Patient #1008) contained 2 insulin injection pens with the hospital’s pharmacy labels, and a bottle of Entresto 24mg/26mg tablets with a patient registration label, but no pharmacy label. Surveyor #10 and Staff #1011 reviewed the patient’s medication administration record (MAR), which showed that Entresto was a POM and that it had been administered since it was ordered on 04/23/25 at 9:31 PM. Surveyor #10 asked Staff #1011 how a POM is verified if the pharmacy is closed. Staff #1011 showed Surveyor #10 a form titled, “Patient Own Medications Verification Sheet” and said that the nurse completes the form with the home medication information, including medication name, shape, color, imprint, and expiration date, and faxes it to the remote pharmacist. The on-site pharmacist picks up the faxed form upon return and creates a hospital pharmacy label for the medication bottle. At this time, Surveyor #10 asked Staff #1009 about the unlabeled POM. Staff #1009 confirmed that the medication bottle should have a hospital label and it was not clear why it did not. Surveyor #10 requested a policy or procedure for POM verification and labeling. Staff #1009 said that there was not such a policy. .”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 38532 . Based on document review and interview, the hospital failed to ensure staff implemented provider patient care orders for the administration of nutritional supplements and documentation of intake for 1 of 2 patients with orders for strict intake and output measurement reviewed (Patient #501). Failure to implement provider orders accurately risks delayed or inappropriate treatment and adverse patient outcomes. Findings included: 1. Document review of the hospital’s policy titled, “Standards of Care-Acute Care,” no policy number, no date, showed that upon admission to the acute care nursing unit, the patient can expect to receive the following: Therapies and consults/specialty services, as ordered by the provider 2. On 04/30/25 at 10:00 AM, Surveyor #5 and the Manager of Quality and Safety (Staff #503), reviewed the medical record for Patient #501, who was admitted on 04/25/25 for the treatment of weakness. The patient had multiple falls at home and was no longer able to stand or walk. The patient had wounds on his legs and had a fall at home, where he lay on the ground for 16 hours until someone came by and helped him. The patient had a history of memory impairment, alcohol overuse, and weight loss. The review showed the following: a. On 04/24/25, a provider ordered “Strict I and O” (Staff are to document all intake and output). b. On 04/24/25, the provider ordered nutritional supplements twice daily at lunch and dinner. c. On 04/28/25, a nutrition evaluation by a dietitian showed a nutrition diagnosis of Severe Protein-Calorie Malnutrition. d. On 04/29/25, a provider changes the times of the supplements to breakfast and lunch. Surveyor #5 found no evidence staff documented supplement intake for 8 of 11 opportunities from 04/24/25 through 04/29/25. 3. At the time of the review, Staff #503 verified the mission documentation and stated that the supplements should have been documented. .”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. This Standard is not met as evidenced by: 38532 . 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) titled, “Ocean Beach Health List of Contract,” no date, showed only a line list of contracted services. 2. On 04/30/25 at 4:00 PM, Surveyor #5 and the Manager of Quality and Patient Safety, reviewed the hospital’s contracted services program and processes. Surveyor #5 found no evidence that the hospital maintained a list of contracted services that included a description of the nature and scope of the services provided. 3. At the time of the review, Staff #503 verified that the hospital did not keep a list of contracted services that included the nature and scope for each contracted service. .”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 38532 . Based on interview, document review, and review of the hospital’s quality and performance improvement program, the hospital failed to ensure that performance measures for patient care services furnished under arrangement or agreements were developed and evaluated through the hospital’s quality program as directed for 5 of 5 contracts reviewed. Failure to measure, analyze, and monitor the effectiveness and safety of services and quality of care of all hospital department and services (including those services furnished under contract or arrangement) limits the hospital’s ability to ensure that process improvement is developed and implemented, and improvements are sustained to ensure improved healthcare outcomes, and risks provision of improper or inadequate care and adverse patient outcomes. Findings included: 1. Document review of the hospital’s policy titled, “Contract Management,” no policy number, last reviewed 10/23/24, showed the following: a. All Ocean Beach Hospital and Medical Clinics contracts will be initially evaluated and reviewed annually for appropriateness, cost, and measurable deliverables. b. Contracts that are clinical in nature will have their yearly evaluations reviewed at the second quarter Quality Council Meeting. 2. On 04/29/25 at 4:00 PM, Surveyor #5 and the Manager of Quality and Patient Safety (Staff #503), reviewed the hospital’s contracted services program, processes, and quality reporting. Surveyor #5 reviewed 5 contracted clinical services providing patient care services. Surveyor #5 found no evidence that measurable deliverables were identified, targets for compliance established, data collected to determine quality services for 5 of 5 contracts reviewed: a. Triad Isotopes: Measurable indicators stated, “Deliver Isotopes for Nuc Medicine.” Have we measured actual deliverables compared to our contract terms stated, “yes.” b. Diagnostic Associate-Nuc Medicine Contract Evaluation: Measurable indicators stated, “Deliver Isotopes for Nuc Medicine.” Have we measured actual deliverables compared to our contract terms stated, “yes.” c. MRI Mobile Services Contract Evaluation: Measurable indicators stated, “Service Tech Support and Truck Availability.” Have we measured actual deliverables compared to our contract terms stated, “yes.” d. Inland Imaging “PACS” Nuvodia Contract Evaluation: Measurable indicators stated, “Software Licenses and Troubleshooting.” Have we measured actual deliverables compared to our contract terms stated, “yes.” e. Medication Review Contract Evaluation: Measurable indicators stated, “verification times, accuracy, errors, professionalism.” Have we measured actual deliverables compared to our contract terms stated, “yes.” Surveyor #5 found no evidence that the hospital developed measurable goals/indicators/deliverables to utilize to assess the quality of patient care services provided to its patients. 3. At the time of the review, Staff #503 verified that the quality indicators were not measurable or quantifiable. She stated that each owner of the contract determined the quality indicators, collected data, and reported the contract review. 4. At this time, the Radiology Manager (Staff #504) verified that the deliverables listed on the Radiology contracts were not written in a way that could be measured, and there were no targets for compliance established. 5. On 05/01/25 at 8:30 AM, during an interview with Surveyor #5, the Pharmacy Manager (Staff #505) verified that the quality measures were not measurable and that he did not collect specific data for the contract review. .”

“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: 38532 . Item #1 Medication Administration for CIWA Assessments Based on document review and interview, the hospital failed to ensure staff implemented provider patient care orders for medication management of alcohol withdrawal for 1 of 1 patients with orders for alcohol withdrawal management reviewed (Patient #501). Failure to implement provider orders accurately risks delayed or inappropriate treatment and adverse patient outcomes. Reference: RCW 18.79.040 (1) “Registered Nursing Practice means the performance of acts requiring substantial specialized knowledge, judgement, and skill based on the principles of the biological, physiological, behavioral, and sociological sciences in (e) the executing of medical regimen as prescribed ....” Findings included: 1. Document review of the hospital’s policy titled, “Standards of Care-Acute Care,” no policy number, no date, showed that upon admission to the acute care nursing unit, the patient can expect to receive the following: Medication administration as ordered by the provider. 2. On 04/30/25 at 10:00 AM, Surveyor #5 and the Manager of Quality and Safety (Staff #503), reviewed the medical record for Patient #501, who was admitted on 04/25/25 for the treatment of weakness. The patient had multiple falls at home and was no longer able to stand or walk. The patient had wounds on his legs and had a fall at home, where he lay on the ground for 16 hours until someone came by and helped him. The patient had a history of memory impairment, alcohol overuse, and weight loss. The review showed the following: a. On 04/26/25, a provider ordered assessment and medication management for a patient experiencing alcohol withdrawal. The order stated: i. Complete a CIWA assessment (The Clinical Institute Withdrawal Assessment for Alcohol) every 4 hours. ii. For a CIWA score of less than 9, reassess the patient in 4 hours. iii. For a CIWA of 9-14, administer Ativan (a benzodiazepine used for the management of anxiety disorders, insomnia, panic attacks, and alcohol withdrawal) 1 mg intravenous (IV) and reassess in 2 hours. iv. For a CIWA of 15-20, administer Ativan 2 mg IV and reassess in 1 hour. v. For a CIWA of 21-25, administer Ativan 3 mgIV and reassess in 30 minutes. vi. For a CIWA greater than 25, administer Ativan 4 mg IV and reassess in 30 minutes. b. On 04/26/25 at 10:30 PM, the patient’s CIWA score was 10. Surveyor #5 found no evidence that the patient was medicated per provider orders. c. On 04/27/25 at 3:30 AM, the patient’s CIWA score was 9. Surveyor #5 found no evidence that the patient was medicated per provider orders. d. On 04/29/25 at 2:44 AM, the patient’s CIWA score was 14. The record review showed that staff administered 2 mg of Ativan IV. The provider’s order showed the patient should have received Ativan 1 mg and then reassessed in 2 hours. e. On 04/29/25 at 5:16 AM, the patient’s CIWA score was 10. Surveyor #5 found no evidence that the patient was medicated per provider orders. 3. At the time of the review, Staff #503 verified that the documentation showed missing medication administration and that there was one occurrence of overmedication per the provider order. Item #2 Reassessment after CIWA medication administration Based on document review and interview, the hospital failed to ensure staff reassessed a patient after medication management for alcohol withdrawal for 1 of 1 patients with orders for alcohol withdrawal management reviewed (Patient #501). Failure to implement provider orders accurately risks delayed or inappropriate treatment and adverse patient outcomes. Reference: RCW 18.79.040 (1) “Registered Nursing Practice means the performance of acts requiring substantial specialized knowledge, judgement, and skill based on the principles of the biological, physiological, behavioral, and sociological sciences in (e) the executing of medical regimen as prescribed ....” Findings included: 1. Document review of the hospital’s policy titled, “Standards of Care-Acute Care,” no policy number, no date, showed that upon admission to the acute care nursing unit the patient can expect to receive the following: Medication administration as ordered by the provider and reassessments as needed for change in patient condition. 2. On 04/30/25 at 10:00 AM, Surveyor #5 and the Manager of Quality and Safety (Staff #503), reviewed the medical record for Patient #501, who was admitted on 04/25/25 for the treatment of weakness. The patient had multiple falls at home and was no longer able to stand or walk. The patient had wounds on his legs and had a fall at home, where he lay on the ground for 16 hours until someone came by and helped him. The patient had a history of memory impairment, alcohol overuse, and weight loss. The review showed the following: a. On 04/26/25, a provider ordered assessment and medication management for a patient experiencing alcohol withdrawal. The order stated: i. Complete a CIWA assessment (The Clinical Institute Withdrawal Assessment for Alcohol) every 4 hours. ii. For a CIWA score of less than 9, reassess the patient in 4 hours. iii. For a CIWA of 9-14, administer Ativan (a benzodiazepine used for the management of anxiety disorders, insomnia, panic attacks, and alcohol withdrawal) 1 mg intravenous (IV) and reassess in 2 hours. iv. For a CIWA of 15-20, administer Ativan 2 mg IV and reassess in 1 hour. v. For a CIWA of 21-25, administer Ativan 3 mg IV and reassess in 30 minutes. vi. For a CIWA greater than 25, administer Ativan 4 mg IV and reassess in 30 minutes. b. On 04/27/25 at 1:04 PM, the patient received Ativan 1 mg for a CIWA score of 9. Surveyor #5 found no evidence that staff reassessed the patient in 2 hours per provider’s orders. c. On 04/27/25 at 10:06 PM, the patient received Ativan 1 mg for a CIWA score of 10. Surveyor #5 found no evidence that staff reassessed the patient in 2 hours per provider’s orders. d. On 04/28/25 at 4:13 PM, the patient received Ativan 1 mg for a CIWA score of 10. Surveyor #5 found no evidence that staff reassessed the patient in 2 hours per provider’s orders. 3. At the time of the review, Staff #503 verified the missing reassessments and stated that the patient should have been reassessed. .”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 38532 . Based on document review and interview, the hospital failed to develop and implement an individualized nursing care plan for the acute problems in 1 of 2 patient care plans reviewed (Patient #501). Failure to develop and implement an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of a patient’s needs and may lead to patient harm and lack of appropriate treatment for a medical condition. Findings included: 1. Document review of the hospital’s policy titled, Standards of Care-Acute Care, no policy number, no date, showed that upon admission to the acute care nursing unit the patient can expect to receive the following: Individualized care plan and review of the individualized care plan each shift and as needed. 2. On 04/30/25 at 10:00 AM, Surveyor #5 and the Manager of Quality and Safety (Staff #503), reviewed the medical record for Patient #501, who was admitted on 04/25/25 for the treatment of weakness. The patient had multiple falls at home and was no longer able to stand or walk. The patient had wounds on his legs and had a fall at home, where he lay on the ground for 16 hours until someone came by and helped him. The patient had a history of memory impairment, alcohol overuse, and weight loss. The patient was placed on oxygen at the hospital during the night for oxygen saturations in the 70’s. Surveyor #5 found no evidence that the patient’s care plan addressed problems or interventions related to the patient’s respiratory, mobility, or skin alterations, or discharge. 3. At the time of the review, Staff #503 verified that the care plan did not address all the major problems. 4. On 05/01/25 at 1:00 PM, the Chief Nursing Officer (Staff #506) stated that the hospital did not have a specific Care Plan Policy. .”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 38532 . Based on observation, interview, and document review, the hospital failed to ensure it had an effective process in place to manage and maintain its Controlled Air Purifying Respirators (CAPR). Failure to manage and maintain CAPR’s puts staff and patients at risk of contracting infectious disease. References: MAX Air CAPR Filter Media Frequently Asked Questions, no date, stated the following: a. How often does the filter need to be changed? It depends upon the application, the environment where used, the frequency and duration of use, and the organization’s protocol for the prevention of cross contamination. Regardless, MAXAIR CAPR’s Yellow LED provides a self-monitoring function that effectively takes these concerns into consideration. The yellow LED will illuminate when airflow intake begins to be compromised near the threshold of 6 cfm (170 lpm). This visual warning provides the user with ample time to exit the working environment and change out a heavily loaded filter. Otherwise, filter change-out a minimum of every six-to-twelve month is recommended. b. Can the filter be reused? There are no procedures for cleaning MAXAIR Filters for reuse. Once the filter is loaded to the point that the Helmet Yellow LED is lighted, or after 6-12 months use, whichever occurs first, the MAXAIR Filter should be discarded per institutional and local regulatory agency recommendations. Findings included: 1. Document review of the hospital’s policy titled, “Respiratory Protection Program,” no policy number, undated, showed the following: a. CAPR’s and respirators will be stored in clean locations and in designated carts. b. CAPR’s and respirators will be inspected before and after every use to ensure proper functioning. c. If a CAPR, or respirator is not working properly, the equipment will be removed from service immediately, and a WorkXHub ticket will be completed indicating the need for repair. d. Staff will leave the area where respirators are required to replace filters, cartridges, and batteries. 2. On 04/29/25 at 9:50 AM, Surveyor #5 and the Emergency Department Clinical Manager (Staff #501) inspected the CAPR storage cart located in the Emergency Department. Surveyor #5 inspected 6 CAPR Helmets (#OB068, #OB071, #OB075, #OB076, OB085, #OB143). Surveyor #5 was unable to determine when the filters had been changed and requested the hospital’s policy and documentation for each helmet. 3. On 01/26/25 at 4:00 PM, Staff #501 stated that they did not have a CAPR policy but provided Surveyor #5 with the Hospital’s Respiratory Protection Program policy. At this time, Staff #501 verified that the policy did not address filter changes, and that the hospital did not have documentation of filter changes. .”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 47461 . Based on document review and interview, the hospital failed to develop and implement a comprehensive person-centered care plan measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs for 2 of 3 swing bed patients reviewed (Patient #1008 and #1009). Failure to include required disciplines, address assessed needs, and determine timelines for goal achievement may result in the inappropriate, inconsistent, or delayed treatment and patient harm. Findings included: 1. Document review of hospital policy titled, “Swing Bed Program: Provider Rounding”, no policy number, last reviewed 10/24, showed that CMS requires a comprehensive person-centered care plan which is developed by an interdisciplinary team that includes the provider. The care plan will have measurable objectives and timeframes to meet the patient’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. As part of the interdisciplinary team, the rounding provider will contribute to the comprehensive patient-centered care plan. Document review of hospital policy titled, “Swing Bed Program: Social Services”, no policy number, last reviewed 06/24, showed the following: a. Based on an initial assessment, the Social Worker (SW) will develop a plan to meet the individual needs of each patient; b. The plan will be reviewed at least weekly at the multidisciplinary team care conference and updated as needed; c. The SW will participate in ongoing assessment of each patient’s status and needs, and communicate this to the care team; d. The SW will lead and oversee the discharge planning process. 2. On 04/30/25 between 2:00 PM and 3:45 PM, Surveyor #10, a Compliance Officer (Staff #1007), the Quality and Patient Safety Manager (Staff #1006), and a Social Worker (Staff #1008) reviewed the medical records of Swing Bed patients. The review showed the following: a. Patient #1008 was admitted on 04/11/25 following surgery at an outside hospital, and discharged on 4/16/25. The provider’s history and physical showed that medical problems of hypertension, and insulin-dependent diabetes would be followed with medications and treatments as needed. Provider orders included daily wound care. Surveyor #10 found that the patient’s care plan did not include any problems related to the patient-specific conditions of hypertension, diabetes, or wounds, and that 11 of 15 goals did not have any timeline for completion. b. Patient #1009 was admitted on 01/06/25 and discharged on 01/16/25. A care conference was held on day 7, 01/13/25. Documentation of the conference was done by a social worker, and showed that the patient, nursing and physical therapy participated in the conference. Surveyor #10 found no evidence that the attending physician, a nurse aide, or a dietician were involved in the preparation of the comprehensive care plan, and no social work or discharge planning needs were addressed. Surveyor #10 interviewed Staff #1008 about the care plan process. Staff #1008 explained that by day 7 of a swing bed admission, the treatment team gathers in the patient’s room to discuss assessments, progress and plans. Typically this includes a social worker, nurse, doctor, and dietician; a physical or occupational therapist may also join. The social worker takes notes of the meeting and creates the care conference note in the medical record. Staff #1008 said that social work does not document in the care plan section of the medical record, and they were not certain if doctors had access to the care plan section. 3. At the time of the review, Staff #1006 confirmed the findings of comprehensive care plans missing medical problems, timelines, and involvement by required disciplines.”

“This report is the result of an unannounced Fire and Life Safety state survey conducted at the Ocean Beach Hospital on 04/29/2025 by a team of representatives of the Washington State Patrol, Fire Protection Bureau. The survey was conducted in concert with the Washington State Department of Health (DOH) survey team. The facility has a total of 25 beds and at the time of this survey the census was 7. The existing section of the 2012 Life Safety Code was used in accordance with 42 CFR 482.41. The facility is a type 2 construction with exits to grade. The facility is protected by a Type 13 fire sprinkler system throughout and an automatic fire alarm system with corridor smoke detection. All exits are to grade with paved exit discharges to the public way. The facility is not in substantial compliance with the 2012 Life Safety Code as adopted by the Centers for Medicare & Medicaid Services. Any citation that requires inspection, testing, or maintenance (ITM) is required to have the testing completed, paper results delivered, and any deficiencies found during the ITM corrected before the citation is cleared.”

“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: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 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: Boiler/ fire sprinkler riser room found to have hole in fire wall for PA speaker. The above was discussed and acknowledged by the facility staff.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility. The findings include: A hood suppression system has been added above the kitchen cooking appliance in kitchen, however, the following items were found to be out of compliance for the new installation on cooking equipment. 1. Facility failed to provide strain protection of cooking appliance that was on castor and supplied by gas. 2. Facility failed to provide all employees annual training on the use of portable fire extinguishers and the manual actuation of the fire-extinguishing system. Records of compliance shall be maintained and shall be available to the authority having jurisdiction. 3. Facility failed to provide fusible links in accordance with heat survey that has been conducted 4. Construction review services system shows that the hood system project has not been completed. 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: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 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: Facility failed to provide a semi-annual fire alarm inspection report. The above was discussed and acknowledged by the facility staff.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger patients, staff and/or visitors. The findings include: Facility failed to provide fire sprinkler protection in operating rooms. 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: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 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: Two standard response fire sprinkler heads found in basement supply room mixed with quick response sprinkler heads. Archives room found have IT cables hanging on fire sprinkler piping. The above was discussed and acknowledged by the facility staff.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building. The findings include: Facility provided an annual fire door inspection that identified fire door failure that have not been corrected at time of inspection. The above was discussed and acknowledged by the facility staff.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 hours the facility has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place patients, staff, and/or visitors in danger. The findings include: Portable space heaters found in patient care room in clinic and in lobby of clinic. The above was discussed and acknowledged by the facility staff.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 hours the facility has failed to provide signage where oxygen or other medical gases are in use or stored. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the patients, staff, and/or visitors within the facility. The findings include: Piped in medical gas system found to have incorrect signage in emergency room. 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: 35231 Based upon observations and staff interviews on 04/29/2025 between approximately 0830 to 1500 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 patients, staff, and/or visitors within the facility. The findings include: Facility failed to provide main and feeder circuit breakers annual inspection, and a provide records of program for periodically exercising the components that is established according to manufacturer’s recommendations. Feeder is defined as 3.3.53 All circuit conductors between the service equipment, the source of a separately derived system, or other power supply source and the final branch-circuit overcurrent device. (ELS) Facility failed to provide a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. NFPA 110 8.4.7% EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the “off” position. NFPA 110 8.4.8 The routine maintenance and operational testing program shall be overseen by a properly instructed individual. The above was discussed and acknowledged by the facility staff.”