Skyline 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 11/20/24 at 9:00 AM, Surveyor #4 inspected the hospital’s dietary kitchen with the Dietary Manager (Staff #404) and the Infection Preventionist (Staff #401). During the inspection, the surveyor asked Staff #404 about her Food Protection Certification. Staff #404 stated that she had not completed a certified Food Protection Management course but thought the Registered Dietician (RD) may have completed this. 2. On 11/21/24 at 10:00 AM, Surveyor #4 reviewed personnel files and training records with the Human Resources Manager (Staff #405). The review showed the hospital’s Dietary Manager has a food handlers permit but is not a certified Food Protection Manager. The surveyor discussed the requirement with Staff #405. Staff #405 confirmed that currently no hospital staff are Certified Food Protection Management as required. Reference: Washington State Retail Food Code WAC 246-215-02107 Certified food protection manager (FDA Food Code 2-102.12). .”

“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, interview, and document review, the Critical Access Hospital failed to implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer’s expiration date. Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturer’s expiration date risks deteriorated or potentially contaminated supplies being available for patient care. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Outdates Supplies: Monitoring and Disposal,” PolicyStat ID #16990324, last approved 11/24, showed the following: a. Supplies in Acute Care and Emergency Department (ED) will be checked on a monthly basis for outdates. The monthly checks will be documented each month. It is preferable that one staff member be in charge of this duty. b. Areas that have individual monthly checklists to be completed include: crash cart in ED and Acute Care, Broselow cart in ED and the difficult airway cart in ED. c. Disposal of supplies will be according to the type of item that it is. Sharps are to be disposed of in a sharps container. Other items can be disposed of in normal garbage. 2. On 11/18/24 between 9:15 AM and 10:55 AM, Surveyor #2 and Surveyor #3 and the Chief Nursing Office inspected the Emergency Department. The inspection showed the following: a. One Glidescope B flex ultra slim 2.8 bronchoscope, with a manufacturer’s expiration date of 09/24. b. One Glidescope B flex slim 3.8 bronchoscope, with a manufacturer’s expiration date of 09/24. c. Two Glidescope B flex regular 5.0 bronchoscope, with a manufacturer’s expiration date of 09/24 and 10/24. d. Two Cook Medical pericardiocentesis set size 8.3 french with a manufacturer’s expiration date of 08/24. e. One Arrow pressure injectable arrow gard blue plus 4 lumen central venous catheter set, with a manufacturer’s expiration date of 09/24. On the Broselow cart: a. In the blue drawer, one I-gel laryngeal mask airway (LMA) size 2.5, with a manufacturer’s expiration date of 09/24. b. In the orange drawer, one I-gel LMS size 2.5, with a manufacturer’s expiration date of 09/24. 3. At the time of the review, Staff #201 verified the expired supplies and removed them from use. Staff #201 reported the supplies in the Broselow cart may be on back order. On 11/19/24 Staff #201 verified it was not the I-gel LMA’s that were on back order but a different type of airway. Staff #201 reported they are in the process of ordering additional LMA’s. 4. On 11/19/24 between 1:05 PM and 1:50PM, Surveyor #2 and Surveyor #3 and the Manager of the Surgery Department (Staff #202) inspected the Surgery Department. The inspection showed the following: On the Malignant Hyperthermia cart: a. Two purple blood tubes, with a manufacturer’s expiration date of 06/24. b. Two green blood tubes, with a manufacturer’s expiration date of 05/24. c. One blue blood tube, with a manufacturer’s expiration date of 02/24. d. One brown blood tube, with a manufacturer’s expiration date of 09/24. e. One gray blood tube, with a manufacturer’s expiration date of 09/20. f. Two ProVent arterial blood gas sampling kits, with a manufacturer’s expiration date of 09/24. 5. At the time of the review, Staff #202 verified the expired emergency supply and removed it from use. .”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 43911 . Based on observation, interview and document review, the Critical Access Hospital failed to implement policies and procedures to ensure compliance with 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 follow the Washington State Retail Food Code and the U.S. Food and Drug Administration Food Code places patients, staff, and visitors at risk of foodborne illness. Findings included: 1. Document review of the hospital’s checklist titled, “Temperature Checks,” no policy number or approval date, showed the proper range for nourishment room refrigerators is 34-41 degrees Fahrenheit (F). 2. On 11/19/24 at 9:45 AM, Surveyor #4 toured the emergency department (ED) with the Infection Preventionist (Staff #401) and the ED Manager (Staff #402). Surveyor #4 used a thin stemmed thermometer to assess the temperature of a mini refrigerator. The surveyor placed the open thermometer on refrigerator shelf and closed the door for a minute before assessing, the air reading was 45 F. The surveyor then tested the temperature of an applesauce cup stored in the refrigerator, the applesauce reading showed a temperature of 49.3 F. 3. At the time of the observation, Staff #401 confirmed the temperatures. 4. On 11/19/24 at 11:30 AM, Surveyor #4 toured the Acute Care Nourishment Room with Staff #401. The surveyor used a thin stemmed thermometer to assess the temperature of the full size refrigerator. The surveyor first tested a small butter tab, the reading showed 43.2 F. Additionally, the surveyor tested an applesauce cup, the reading was 46.6 F. Staff #401 confirmed the temperatures. Cold held TCS food must be maintained at 41 degrees Fahrenheit or below. Reference: Washington State Retail Food Code WAC 246-215-03525 Time/temperature control for safety (TCS) food, hot and cold holding .”

“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: 43911 . 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 MNLU21. .”

“PA, NP, & CLINICAL SPEC RESPONSIBILITES CFR(s): Arranges for, or refers patients to, needed services that cannot be furnished at the CAH, and assures that adequate patient health records are maintained and transferred as required when patients are referred. This Standard is not met as evidenced by: 47458 . Based on the interview, document review, and medical record review, the Critical Access Hospital (CAH) staff failed to implement policies and procedures for transferring patients from the facility to another acute care hospital for 2 of 5 patient records reviewed (Patients #302 and #303). Failure to ensure hospital staff implement guidelines for patient transfers places the patient at risk for delay in care, inappropriate level of care, and poor outcomes. Findings included: 1. Document review of the hospital’s policy and procedure titled “(EMTALA) Medical Screening Examination, Stabilization and Treatment,” PolicyStat ID 1537074, last approved on 03/24, showed “Request for Transfer/Consent for Transfer/Certification for Transfer” is required and fully completed for patients. The patient or representative’s written consent/request is on this document. 2. Document review of the hospital’s policy and procedure titled “Suicide Precautions” PolicyStat ID 16487782, last approved 08/24, showed that patient transfers required the completion of the transfer certificate. 3. On 11/19/24 between 1:50 PM and 3:15 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Officer (Staff #301), and a Health Informatics Specialist (Staff #302) reviewed the medical records of patient transfers to another acute care hospital. The review showed the following: a. Patient #302 was transferred to another acute care hospital on 11/12/24 at 11:37 PM. Review of the Consent to Transfer form showed the patient or representative’s written consent blank. b. Patient #303 was transferred to a psychiatric facility on 10/29/24 at 2:48 AM. The review showed there was no Consent to Transfer form in the electronic medical record. 4. At the time of the reviews, Staff #302 verified the blank Consent to Transfer form and the missing transfer. .”

“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: 47458 . Item #1 - Restraint orders Based on record review, interview, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure providers orders for restraint contained the appropriate type of restraints to be utilized for 1 of 3 patients placed with provider orders for restraints reviewed (Patient #207). Failure to place complete provider orders increases the risk of incorrect restraint application and 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, “Restraints,” PolicyStat ID #16990369, last approved 11/24, showed the following: a. Restraint or seclusion must be used in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient as specified under CMS 482.12 (c ) and who is authorized to order restraint or seclusion by hospital policy in accordance with State law [CMS 482.13 (e)(7)]. b. Orders for restraint for the management of non-violent, non-self-destructive behavior must be renewed every 24 hours. 2. On 11/21/24 between 11:25 AM and 12:45 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Office (Staff #201) and the Clinical Informatics Specialist (Staff #203) reviewed the medical record of Patient #207 who was admitted to the hospital on 07/08/24 with a diagnosis of diabetic ketoacidosis and started in non-violent restraints at 2:00 PM. Surveyor #2 found no evidence of a provider order for non-violent restraints in the medical record. 3. At the time of the review, Staff #201 verified the missing provider order for non-violent restraints. Item #2 - Restraint documentation Based on interview, document review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff followed policies and procedures for restraint use and documentation for 1 of 2 patients reviewed in violent restraints (Patient #208). Failure to follow hospital policies and procedures for restraint use puts patients at risk for injury or death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraints,” PolicyStat ID #16990369, last approved 11/24, showed the following: a. Face-to-face observation and documentation by the RN required at least every 15 minutes. 2. On 11/21/24 between 11:25 AM and 12:45 PM, Surveyor #2 and Surveyor #3, the Chief Nursing Office (Staff #201) and the Clinical Informatics Specialist (Staff #203) reviewed the medical record of Patient #208 who had a provider order for violent restraints for violent and aggressive behavior. Patient #208 was placed in 4-point restraints on 07/30/24 at 4:37 AM. Patient #208 had face-to-face every 15-minute observation documentation at 5:35 AM by the RN and the next documentation was at 7:15 AM (missing a period of approximately one and a half hours). 3. At the time of the review, Staff #201 verified the missing face-to-face every 15-minute documentation. .”

“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 and Reassessment Based on interview, record review, and review of policy and procedure, the Critical Access Hospital (CAH) failed to ensure staff members completed and documented pain assessments/reassessments for each pain management intervention for 3 of 3 patients reviewed with orders for pain medication (Patient #204, #205, and #305). Failure to assess/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 Assessment, Reassessment, and Management,” PolicyStat ID #16990340, last approved 11/24, showed the following: a. It is the responsibility of all clinical staff to screen all patients for the presence or absence of pain. b. If the screening assessment reveals pain is present in the patient, it is the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality (i.e., character, frequency, location and duration of pain), and response to treatment. c. Any patient care provider from any department that has implemented a pain control mechanism will reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved. d. As part of the reassessment, the multidisciplinary team should assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics. This ongoing reassessment should be done minimally every two (2) hours while active and during the night time hours when pain often becomes more intense and the patient’s ability to sleep does not mean that there is absence of pain. 2. On 11/20/24 between 1:00 PM and 2:10 PM, Surveyor #2, Surveyor #3, the Chief Nursing Officer (Staff #201), and a Clinical Informatics Specialist (Staff #203) reviewed the medical records of 3 patients seen in the ED. The review showed the following: a. Patient #204 was a 39-year-old male seen in the ED on 11/15/24 with a chief complaint of lower abdominal pain and diagnosed with diverticulitis. Patient #204 had a provider order for morphine (a narcotic medication used to treat pain) 4 milligrams intravenously that was given at 12:28 PM for a complaint of 8/10 pain. Patient #204 had nursing documentation indicating the patient was sleeping post morphine administration. Surveyor #2 found no evidence of a pain reassessment including the characteristics, intensity, or pain rating in the medical record. b. Patient #205 was a 54-year-old female seen in the ED on 10/24/24 with a chief complaint of head injury and right knee injury after an accident with a horse. Patient #205 had a provider order for oxycodone (a narcotic used to treat pain) a one-time order of 5 milligrams orally and Tylenol (a medication used to treat pain) a one-time order of 975 milligrams orally. Patient #205 received Tylenol 975 milligrams orally at 9:29 AM and oxycodone 5 milligrams orally at 9:38 AM for a pain score rating of 7/10. Surveyor #2 found no evidence of a pain score reassessment in the medical record. 3. At the time of the review, Staff #201 verified the missing pain reassessment. 4. On 11/20/24 between 2:10 PM and 3:00 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302), and the Medical Surgical Manager (Staff #303) reviewed the medical surgical records of 3 patients. Staff #302 stated that the pain reassessment is completed in the medication effectiveness evaluation flow sheet. The review showed the following: a. Patient #305 was admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home. The review showed that Patient #305 reported pain at 8:12 PM a 9 /10 on the number scale (0= no pain, 10= worse pain). At 9:35 PM the medication administration follow-up showed the RN documented that the provider prescribed oxycodone (a narcotic used for pain treatment) 5 milligrams administered orally for moderate pain was effective. The pain assessment review showed that Patient #305 reported 9/10 pain at 9:35 PM. Surveyor #3 found no additional interventions for the 9/10 pain at 9:35 PM. b. Patient #305 had no pain reassessment from 9:35 PM on 10/25/24 until 8:00 AM on 10/26/24 (missing a period of approximately 10 hours). c. Patient #305 reported 10/10 on 10/25/24 at 8:00 AM and oxycodone 5 milligrams was administered. The medication administration follow-up showed the RN documented pain medication administration was “effective”. d. Patient #305 was discharged on 10/26/24 at 2:15 PM. Surveyor #3 found no pain assessments after 8:00 AM on 10/26/24 (missing a period of approximately 6 hours). 5. At the time of the review, Staff #301 verified the missing pain reassessments and missing pain assessments every two hours for patients having pain Item #2 - Initial Nursing Admission Assessment Based on interviews, document review, and review of policies and procedures, the Critical Access Hospital (CAH) staff failed to complete an initial nurse admission assessment for 3 of 3 patient records reviews (#304, #305, and #306). Failure to ensure hospital staff completes the nurse admission assessments patients at risk for inappropriate plans of care and treatment, delayed coordination of care needs, and adverse health consequences. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Adult Admission, Admission History and Daily Assessment Documentation Requirements,” PolicyStat ID #16990192, last approved 11/24, showed that: a. Factors that must be considered in the assessment include the patient and family’s perception of the illness and how the patient should be treated, the degree of illness, cognition, communication challenges, cultural and religious needs, social and economic status, education and developmental level, activities of daily living, physical, emotional and physiological status. The result of the assessment is a personalized plan of care. b. The registered nurse is responsible for assessing and completing the patient assessment within 6 hours of admission and the individualized plan of care is initiated. c. Patients are screened during the initial assessment for psychiatric or substance abuse, and discharge planning (Patients at risk include psychological diagnosis, physical barriers at home, abuse and neglect, over the age of 70, elderly frail spouse or limited/adequate support), functional status (recent falls, elderly, swallowing difficulties). d. The RN is required to complete allergy review, family history, social history, cultural/spiritual needs, discharge needs, functional assessment, vision, hearing and dental screening, and patient safety. 2. On 11/20/24 between 2:10 PM and 3:00 PM, the Surveyor #3, the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302) and the Medical Surgical Manager (Staff #303) reviewed the medical surgical patient records. The review showed the following: Patient #304 a. Patient #301 was admitted from home after suffering speech difficulties due to a transient ischemia attack (TIA) on 8/13/24 at 4:10 PM. The review showed Patient #301 had a history of subarachnoid hemorrhage. b. A review of the nurse admission assessment showed no screening or review completed for medication allergies, procedure history, psychosocial, cultural, spiritual, functional, or discharge needs. At the time of the review, Staff #302 and Staff #303 verified the missing assessment areas. Patient #305 a. Patient #305 was admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home. The review showed Patient #305 had a history of memory impairment and falls. b. A review of the nurse admission assessment showed no review completed for procedure history, family, social, psychosocial, cultural, spiritual, functional, or discharge needs. At the time of the review, Staff #302 and Staff #303 verified the missing assessment areas. #306 a. Patient #306 was admitted from home while on hospice on 11/17/24 at 3:38 AM for breathing difficulties and end-of-life care. Patient #306 had a history of chronic obstructive pulmonary disease (COPD), mental health disorders, and substance abuse. The review showed that the nurse admission assessment was incomplete during Patient #306’s hospitalization. At the time of the review, Staff #302 and Staff #303, verified the missing admission history assessment. The interview showed that nursing staff had 24 hours to complete the patient assessment. .”

“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: 47458 . Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice. Failure to comply with policies and procedures to prevent transmission of infections places patients, staff, and visitors at risk of communicable illnesses. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Hand Hygiene,” PolicyStat ID #16100831, last approved 06/24, showed the following: Indication for handwashing and hand antisepsis include: a. Decontaminate hands before having direct contact with patients. b. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. Glove use: a. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur. 2. On 11/20/24 between 10:35 AM and 10:50 AM, Surveyor #2 and Surveyor #3 and the Surgery Department Manager (Staff #202) observed a patient undergoing cataract eye surgery (Patient #206). Surveyor #2 observed a Surgery RN (Staff #206) administer eye drops to the surgical patient in the operating room who did not perform HH or wear gloves prior to the eye drop administration and no HH post eye drop administration. 3. At the time of the observation, Surveyor #2 verified the observation with Staff # 202. .”

“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 . 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. Findings included: 1. Document review of the hospital’s policy titled, “Scheduled Maintenance and Inspections, EOC Systems,” PolicyStat ID 14781054, approved 11/23, showed that the maintenance department was responsible for environment of care inspections at the facility that included checking utilities systems and general life safety items but did not include checking walls, floors or furnishings for damages. 2. On 11/19/24 at 9:30 AM Surveyor #4 toured the emergency department (ED) with the Infection Preventionist (Staff #401) and the ED Manager (Staff #402). During the tour, the surveyor observed several areas where the walls had been patched but not painted. 3. During the observation, Surveyor #4 discussed the damage to the walls as being a non-cleanable surface with Staff #401. Staff #401 confirmed the damage. 4. On 11/19/24 at 10:30 AM Surveyor #4 observed a discharge cleaning of Acute Care Room 9. During the observation the surveyor noted a small wood dresser next to the patient bed. The wood sealer on the dresser was worn and missing along the top corners. Staff #401 confirmed the wood dresser was losing its varnish/seal and no longer a cleanable surface in those areas. 5. On 11/20/24 at 4:00 PM, Surveyor #4 observed a colonoscope reprocessing with Staff #401 and a surgical technician (Staff #403). During the observation, the surveyor saw 3 areas of exposed drywall on the wall directly above the reprocessing sink. Staff #401 confirmed the wall was missing paint in those areas and was not a cleanable surface. .”

“DISCHARGE PLANNING PROCESS CFR(s): The CAH’s discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 46745 . Based on interviews, document review, and review of policies and procedures, the Critical Access Hospital (CAH)failed to identify or screen for discharge planning needs in 3 of 3 patient records (Patients #304, #305, and #306). Failure to ensure hospital staff screens all at-risk patients for post-discharge needs during the nurse admission assessment places patients at risk for delayed coordination of care needs and adverse health consequences. Findings included: 1. Document review of the CAH’s policy and procedure titled “Discharge Planning,” PolicyStat ID #17014727, last approved 11/24, showed: a. Initial identification/screening for discharge planning needs shall be conducted during the nursing admission assessment. b. An automatic referral to the discharge planner is made for all high-risk patients (homeless, long-term intravenous infusions, suspected abuse, unable to perform activities of daily living by themselves, terminal diagnosis). 2. Document review of the hospital policy and procedure titled “Admissions,” PolicyStat ID #17014605, last approved 11/24, showed that: a. The registered nurse (RN) is responsible for assessing and completing the patient assessment within 6 hours of admission and the individualized plan of care is initiated. b. Patients are screened during the initial assessment for psychiatric or substance abuse, and discharge planning (Patients at risk include psychological diagnosis, physical barriers at home, abuse and neglect, over the age of 70, elderly frail spouse or limited/adequate support), functional status (recent falls, elderly, swallowing difficulties). 3. On 11/20/24 between 2:10 PM and 3:00 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301), the Clinical Informatics Specialist (Staff #302), the Medical Surgical Manager (Staff #303) reviewed the medical surgical patient records. The review showed the following: a. Patient 304 was an 88-year-old patient admitted from home after suffering speech difficulties due to a transient ischemia attack (TIA) on 8/13/24 at 4:10 PM. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs. b. Patient #305 was a 75-year-old patient admitted on 10/25/24 at 7:36 PM for treatment of a urinary tract infection and fall at home, and Patient #305 had a history of memory impairment and falls. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs. c. Patient #306 was a 55-year-old patient admitted from home while on hospice on 11/17/24 at 3:38 AM for breathing difficulties and end-of-life care and had a history of chronic obstructive pulmonary disease (COPD), mental health disorders, and substance abuse. Surveyor #3 found no evidence of a nurse admission assessment that showed screening or review of discharge needs. 4. At the time of the review, Staff #302 and Staff #303, verified missing the nurse admission screening for discharge needs and incomplete nurse admission assessment. .”

“This report is the result of an unannounced Fire and Life Safety re-certification survey conducted at Skyline Hospital on 11/21/2024 by a representative of the Washington State Patrol, Fire Protection Bureau. The survey was conducted in concert with the Washington State Department of Health. 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. 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.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering. The findings include: Emergency exit in operating room hallway blocked by equipment 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 11/21/2024 between approximately 0930 to 1530 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: Facility failed to provide strain protection on kitchen cooking devices that are on casters and gas fueled. Facility failed to privde to new employees on hiring and to all employees annually on the use of portable fire extinguishers and the manual actuation of the fire-extinguishing system. Facility failed to provide signage on the exhaust hood or system cabinet, indicating the type and arrangement of cooking appliances protected by the automatic fire-extinguishing system. Signage shall indicate appliances from left to right, be durable, and the size, color, and lettering shall be approved. 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 11/21/2024 between approximately 0930 to 1530 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: OR hallway pull station found blocked by table. Facility shall provide semi annual fire alarm testing. 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 11/21/2024 between approximately 0930 to 1530 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: Facility failed to provide 5 year internal inspection and 5 year FDC hydrostatic inspection report. Pressure switch needs replaced per fire sprinkler report. Fire sprinkler name plate are faded and illegible, unknown system demand. The above was discussed and acknowledged by the facility staff.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility. The findings include: OR cross corridor fire door found to have excessive gap. 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: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. The findings include: Electrical junction box in operating room found to be open. The above was discussed and acknowledged by the facility staff.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors. The findings include: Fire dampers were found to be inspected/repairs/replaced and have not had a 1 year inspection conducted after. 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: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 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, staff and/or visitors. The findings include: The facility failed to provide documentation of a fire drill during the third quarter of 2024 on night shift. The above was discussed and acknowledged by the facility staff.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain a maintenance program for their medical gas equipment. This could lead to the equipment malfunctioning endangering patients, staff, and visitors. The findings include: The facility failed to have a medical gas, vacuum, WAGD, or support gas systems having a documented maintenance program. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. The above was discussed and acknowledged by the facility staff.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire. The findings include: The facility failed to inspect and test gas and vacuum systems as part of a maintenance program and include the required elements. 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 11/21/2024 between approximately 0930 to 1530 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: Shutoff valves failed to identify room or area served. Shut off valves in operating hallway found blocked. 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 11/21/2024 between approximately 0930 to 1530 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 records for every 36 months testing for 4 continuous hour exercise on each generator. 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 99 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer ’ s recommendations. NFPA 8.4.7.1 Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years. NFPA 99 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer ‘s recommendations. Facility failed to conduct conduce testing and specific gravity testing on generator batteries The above was discussed and acknowledged by the facility staff.”

“Features of Fire Protection - Fire Loss Preve CFR(s): NFPA 101 Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99) This Standard is not met as evidenced by: 35231 Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain a written policy or regulation for fire loss in operating rooms. This could result in the ignition of gases; endanger the staff and patients within the room. The findings include: Facility failed to provide education and training to OR surgeons for chemical spills, and extinguishment of drapery, clothing and equipment fires. Facility failed to remove solution-soaked materials have been removed from the OR prior to draping and use of surgical devices. The above was discussed and acknowledged by the facility staff.”