Snoqualmie Valley Hospital

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 45663 . Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff verified emergency supplies and equipment were available and ready for use as directed by hospital policy. Failure to ensure that supplies and equipment are available and ready for use risks poor patient outcomes during medical emergencies. Reference: “2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care).” 2020 Guidelines are a comprehensive revision of the AHA’s guidelines for adult, pediatric, and neonatal resuscitation education science, and system of care topics. Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Neonatal Resuscitation Provider (NRP) resources were updated in 2020. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Rapid Response Cart Stock Process,” policy number 10173, last revised 01/20, showed the following: a. The EZ IO (an emergency kit to quickly establish an intravenous line into the bone) is kept in the Emergency Department (ED) and is deployed with every Rapid Response/Code Blue. b. This supply is checked monthly by the ED technician. c. Also kept in the ED are supplies in grab and go bags to be deployed with every Rapid Response/Code Blue. c. These supplies have a separate inventory list that is also checked by the ED technician. 2. On 06/25/24 between 9:00 AM and 10:40 AM, Surveyor #9 and Emergency Department Manager (Staff #906) and Chief Medical Officer (Staff #903) inspected the Emergency Department. The inspection showed the following: In the EZ IO kit a. 1- intraosseous 15mm needle with a manufacturer’s expiration date of 10/23. In the cricothyrotomy bag b. 2- 27-gauge 1 inch needles with a manufacturer’s expiration date of 01/24. c. 1- 3.0 endotracheal tube with a manufacturer’s expiration date of 12/22. d. 2- 12 milliliter syringes with a manufacturer’s expiration date of 04/24. e. 2- 4.0 monofilament sutures with a manufacturer’s expiration date of 03/23. f. 1- 14-gauge jelco intravenous catheter with a manufacturer’s expiration date of 09/23. g. 2- 18-gauge needles with a manufacturer’s expiration date of 05/22. h. 1- laceration tray with a manufacturer’s expiration date of 05/24. In the Broselow cart h. 1- Nexiva intravenous catheter with a manufacturer’s expiration date of 04/24. i. 2- 3.5 endotracheal tubes with a manufacturer’s expiration date of 05/24. On both ED Rapid Response Code Blue carts j. 2- 2015 Advanced Cardiac Life Support algorithms. 3. At the time of the observation, Staff #906 verified the expired items and removed them from patient use. .”

“NUMBER OF BEDS CFR(s): Except as permitted for CAHs having distinct part units under §485.647, the CAH maintains no more than 25 inpatient beds. Inpatient beds may be used for either inpatient or swing-bed services. This Standard is not met as evidenced by: 45663 . Based on observation and interview, the Critical Access Hospital failed to ensure that they maintained no more than 25 inpatient beds to include inpatients, swing-bed patients, or observation patients according to Critical Access Hospital regulatory requirements. Failure to appropriately utilize Critical Access Hospital beds creates the risk that the facility will exceed its capacity for patient care, which may result in poor patient outcomes due to inadequate care or poor resource allocation. Findings included: 1. On 06/25/24 at 9:00 AM, Surveyor #9 and Chief Strategic Officer (Staff #901) and Chief Medical Officer (Staff #903) inspected the Medical unit of the CAH. The bed count showed 26 beds physically located in the rooms of the unit available for use. 2. At the time of the observation, Staff #901 verified that there were 26 beds. .”

“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: 45663 . 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 T61921. .”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 45663 . Based on interview and document review, the Critical Access Hospital failed to ensure that all policies for the operation of the hospital were determined, implemented, and monitored by the Governing Body. Failure to approve policies necessary for operation of the facility and care and treatment of patients risks patient safety and quality patient care. Findings included: 1. Document review of the hospital’s document titled, “Public Hospital District Number 4 King County Bylaws,” no policy number, last amended 04/24, showed the following: a. The Board is responsible for overseeing the district’s general policies and organization with respect to the operation of the district including the delivery of quality patient care. b. The Board’s role is to adopt the necessary policies. 2. On 06/27/24, Surveyor #9 reviewed the Governing Body meeting minutes from 04/27/23, 05/25/23, 06/22/23, 07/22/23, 08/24/23, 09/28/23, 10/26/23, 11/28/23, 12/28/23, 01/25/24, 02/22/24, 03/28/24, 04/25/24, and 05/23/24. The Surveyor found no evidence of approval of hospital policies in the minutes. 3. On 06/29/24 at 10:00 AM, Surveyor #9 interviewed Director of Risk, Quality, and Compliance (Staff #902) and Chief Strategic Officer (Staff #901) regarding policy approval in the Governing Body Meeting minutes. Staff #902 verified that approvals were not in the minutes. .”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 45663 . Item #1 Pain assessment and reassessment Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff completed and documented initial pain assessments and reassessments prior to and after each pain management intervention as directed by hospital policy for 4 of 9 medical records reviewed (Patients #904, #905, #906, and #907). Failure to assess and reassess a patient’s pain risks inconsistent, inadequate, or delayed relief of pain. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Pain Management,” policy number 11073, last revised 12/23, showed the following: a. All patients will be assessed for pain in the initial assessment. b. The nurse will assess and document pain and reassess and measure pain intensity after each pain management intervention (pharmacological and non-pharmacological). c. Pain will be reassessed within 30 minutes of leaving the Emergency Department. Document review of the hospital’s policy and procedure titled, “Emergency Department Triage,” policy number 11130, last revised 06/25/24, showed that triage includes a pain scale and pain assessment completed by a Registered Nurse. 2. On 06/26/24 between 8:50 AM and 10:30 AM, Surveyor #9 and Emergency Department Nurse Manager (Staff #906) reviewed the medical records of patients who received care in the hospital’s Emergency Department. The review showed the following: a. Patient #904 was evaluated on 05/31/24 at 9:35 PM for a possible nasal fracture. The patient received Ibuprofen (a medication used for pain or fever) 400 milligrams orally and Tylenol (a medication used for pain or fever) 650 milligrams orally at 11:57 PM. The Surveyor found no evidence of a pain assessment as part of the initial assessment or prior to the pain medication intervention. b. Patient #905 was evaluated on 05/24/24 at 4:56 AM for throat pain and fever. The patient received Tylenol 469 milligrams orally, Ibuprofen 313 milligrams orally, and Zithromax (an antibiotic) 313 milligrams orally at 5:36 AM. The Surveyor found no evidence of a pain assessment as part of the initial assessment or prior to the medication intervention. 3. At the time of the review, Staff #906 verified the missing pain assessments. 4. On 06/25/24 at 2:00 PM, Surveyor #9 and Assistant Nurse Manager (Staff #907) reviewed the medical record of Patient #906 who was admitted for treatment of exacerbation of chronic pulmonary obstructive disease. The review showed the following: a. On 06/24/24 at 7:38 PM, the patient received Tylenol 650 milligrams orally for pain. The Surveyor found no evidence of a pain score prior to or after the medication intervention. b. On 06/25/24 at 1:01 AM, the patient received 650 milligrams orally for a pain score of 4 out of 10. The Surveyor found no evidence of a pain reassessment after the medication administration. 5. At the time of the review, Staff #907 verified the missing pain assessment/reassessments. 6. On 06/26/24 at 3:30 PM, Surveyor #9 and Nurse Manager (Staff #908) reviewed the medical chart of Patient #907 who was admitted for treatment of sepsis. The review showed the following: a. On 06/10/24 at 3:17 AM, the patient received Toradol (an anti-inflammatory medication to treat pain) 15 milligrams intravenously for a pain score of 10 out of 10. The Surveyor found no evidence of a pain reassessment after the medication intervention. b. On 06/11/24 at 11:17 AM, the patient received Baclofen (a medication used to treat pain from muscle spasms) 5 milligrams orally for a pain score of 10 out of 10. The Surveyor found no evidence of a pain reassessment after the medication intervention. c. On 06/11/24 at 1:10 PM, the patient received Toradol 15 milligrams intravenously for a pain score of 10 out of 10. The Surveyor found no evidence of a pain reassessment after the medication intervention. Item #2 Reassess prior to discharge from Emergency Department Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff followed the hospital’s policy when caring for pediatric patients discharged from the Emergency Department for 1 of 3 records reviewed (Patient #905). Failure to properly reassess prior to discharge risks inadequate, inconsistent, or substandard care. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Standard of Care Emergency Department,” policy number 10457, last reviewed 06/25/24, showed the following: a. A set of discharge vitals will be taken within an hour of discharge. b. A reassessment of the presenting problem or chief complaint will be done at least once prior to discharge. 2. On 06/26/24 between 8:50 AM and 10:30 AM, Surveyor #9 and Emergency Department Nurse Manager (Staff #906) reviewed the medical record of Patient #905 was evaluated on 05/24/24 at 4:56 AM for throat pain and fever. The initial temperature taken was 100.8 Fahrenheit (normal temperature is 97 to 100.4 Fahrenheit). The patient received Tylenol 469 milligrams orally, Ibuprofen 313 milligrams orally, and Zithromax (an antibiotic) 313 milligrams orally at 5:36 AM. The Surveyor found no evidence of a reassessment of the chief complaint including temperature reassessment prior to discharge. 3. At the time of the review, Staff #906 verified the missing reassessment of temperature prior to discharge. Item #3 Restraint orders Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure providers orders for restraint contained the appropriate type of restraint and location of the restraint to be used for 4 of 5 restraint records reviewed (Patient #908, #909, #910, and #911). Failure to place complete 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,” last reviewed 02/03/20, showed the following: a. Documentation of the order for restraints for Medical Surgical Care as well as for Violent or Self Destructive Behavior will include the following: i. Type of restraint. ii. Indication for restraint. iii. Time limit. iv. Provision for removal or discontinuation. v. Reassessment for continued need. b. A minimum of 2 restraint pieces must be used on 2 opposing extremities. c. Restraints are never written as a standing order or PRN (if needed) order. d. The initial assessment will be documented by a Registered Nurse in the electronic medical record and will include the alternative interventions tried if any, and the clinical justification that led to restraint. 2. On 06/26/24 between 2:15 PM and 3:10 PM, Surveyor #9 and Emergency Department Nurse Manager (Staff #906) reviewed the medical records of patients restrained in the Emergency Department. The review showed the following: a. Patient #908 was treated in the Emergency Department on 11/13/23 with a diagnosis of alcohol intoxication. At 9:08 PM, nursing documentation showed Locking Velcro right upper extremity, Locking Velcro left upper extremity, Locking Velcro right lower extremity and Locking Velcro left lower extremity restraints applied. The provider order for Behavioral Health Restraints at 9:06 PM showed “Siderail” and “Locked restraint-comment on location.” The Surveyor found no documentation in the order for the amount of restraint to be applied. b. Patient #909 was treated in the Emergency Department on 03/03/24 with a diagnosis of Narcotic ingestion. At 3:15 PM, nursing documentation showed Locking Velcro right upper extremity, Locking Velcro left upper extremity, Locking Velcro right lower extremity and Locking Velcro left lower extremity restraints applied. The provider order for Behavioral Health Restraints at 3:56 showed “Locked restraint-comment on location.” The Surveyor found no documentation in the order for the amount of restraint to be applied. c. Patient #910 was treated in the Emergency Department on 12/22/23 for a mental health evaluation. At 9:10 AM documentation showed Locking Velcro right upper extremity and Locking Velcro left lower extremity restraints applied. The provider order for Behavioral Health Restraints at 9:28 AM showed “soft restraint- comment on location 2 point.” 3. At the time of the review, Surveyor #9 interviewed Staff #906 regarding the orders. Staff #906 stated that the provider should specify in the comment on location area the amount of restraint to be applied such as 2 or 4 extremities. Surveyor #9 also asked about the soft restraint for violent behavior and Staff #906 was able to locate soft restraint as an option for ordering in the EPIC order set and stated that the provider may have chosen the wrong order. 4. On 06/27/24 at 10:20 AM, Surveyor #9 and Nurse Manager (Staff #908) reviewed the medical record of Patient #911 who was admitted on 10/09/23 with a medical diagnosis of dementia and behavioral disturbances. The review showed on 10/15/23 at 10:00 AM, a provider order showed Behavioral Health Restraints “soft wrist- comment on location”. The restraint reason was documented as “danger to others.” In the comment section was “to both hands/arm and legs if needed.” 5. At the time of the review, Staff #908 verified the order was written if needed. .”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 45663 . Based on document review and interview the Critical Access Hospital failed to ensure that policies and procedures were reviewed every two years to reflect current standards of practice. Failure to review policies and procedures every two years places patients at risk for unsafe care or injury. Findings included: 1. Document review of the hospital’s policy titled, “Policy Review,” policy number 11773, last revised 08/20, showed that all policies will be reviewed at least every 2 years by the policy owner. 2. Between 06/25/24 and 06/28/24, Surveyor #9 reviewed requested hospital policies and procedures. The following policies reviewed did not have a review date within 2 years: a. Policy Review, policy number 11173, last revised 08/20. b. Code Blue, policy number 10400, last revised 01/20. c. Infection Control Standards, policy number 11721, last reviewed 06/20. d. Rapid Response Cart Stock Process, policy number 10173, last revised 01/20. e. Contracts Policy and Procedure, policy number 11206, last reviewed 05/20. f. Mental Health in the Emergency Department, policy number 11120, last revised 07/15. g. Sexual Assault Examinations, policy number 10437, last revised 06/20. h. Infant Safe Haven, policy number 10439, last reviewed 08/19. 3. On 06/27/24 at 8:20 AM, Surveyor #9 and Director of Quality, Risk, and Compliance (Staff #902) reviewed the policies. Staff #902 verified the dates above and stated they were working on the policy process. .”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. This Standard is not met as evidenced by: 45663 . Based on document review and interview, the Critical Access Hospital failed to develop and implement policies and procedures for the medical management of health problems that included conditions requiring a medical consultation, situations and circumstances requiring consultations, and/or referral for care outside the hospital. Failure to ensure guidelines addressing consultations are developed and implemented risks delayed care, inappropriate care, and poor patient outcomes. Findings included: 1. On 06/27/24 at 8:00 AM, Surveyor #9 requested a policy to address consultations with another medical provider or outside the facility. 2. On 06/27/24 at 10:00 AM, Chief Medical Officer (Staff #903) stated that the hospital did not have a policy at present and most patients would be transferred if necessary. .”

“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: 45663 . Based on interview, document review, and review of the hospital’s quality program, the Critical Access Hospital failed to ensure that performance measures for all patient care services furnished under arrangement or agreements (contracted) were developed and evaluated, and failed to ensure that all patient care services furnished under arrangement or agreements were evaluated through the hospital’s quality program for 2 of 3 contracts reviewed. Failure to ensure that patient care services provided under contract are subject to the same hospital wide quality assessment and performance improvement evaluation as other services provided directly by the hospital risks provision of improper or inadequate care and adverse patient outcomes. Findings included: 1. Document review of the hospital’s document titled, “Public Hospital District Number 4 King County Bylaws,” no policy number, last amended 04/24, showed that Board is responsible to establish a Quality Improvement Program which will review the services rendered in the hospital. 2. On 06/25/24 at 4:30 PM, Surveyor #9 reviewed requested contracts for Remote Telemetry Services and Eagle Remote Medical Services. The Surveyor found no evidence of performance measures in the contracts or a contract review. On 06/27/24 at 10:00 AM, Surveyor #9 interviewed Chief Medical Officer (Staff #903) regarding the contract review process. Staff #903 stated that at present there is not a contract review for Remote Telemetry Services or Eagle Remote Medical Services, and they would be working on establishing that process. .”

“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: 45663 . Based on interview, record review, and review of the hospital’s policy and procedure, the Critical Access Hospital failed to ensure staff followed its policy and procedure for blood product transfusions for 4 of 4 blood transfusions reviewed (Patients #901, #902, and #903). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Blood Component Administration,” policy number 11529, last revised 02/24, showed the following: a. Ensure a pretransfusion set of vital signs has been obtained within 30 minutes of the start of the transfusion. b. Obtain vital signs 15 minutes after the start of the transfusion, then 30 minutes after the start of the transfusion, then hourly. c. Conclude with a set of vital signs at the completion of the transfusion. d. Document all vital signs in EPIC. 2. On 06/26/24 between 9:50 AM and 2:15 PM, Surveyor #9 and Emergency Department Manager (Staff #906) reviewed the medical records of patients who had received a blood transfusion. The review showed the following: a. Patient #901 received a unit of packed red blood cells that was initiated on 05/03/24 at 1:10 PM. At 1:30 PM (a period of approximately 25 minutes later), no temperature or respiratory rate was documented. At 1:45 PM, no temperature or respiratory rate was documented. At 2:00 PM, no temperature or respiratory rate was documented. At 2:30 PM, no temperature or respiratory rate was documented. At 3:00 PM, no temperature or respiratory rate was documented. The transfusion ended at 3:02 PM. b. Patient #901 received a second unit of packed red blood cells that was initiated on 05/03/24 at 3:34 PM, there was no respiratory rate documented. At 4:00 PM (a period of approximately 25 minutes later), there was no temperature, or respirations documented. At 4:15 PM, there was no temperature or respiratory rate documented. At 4:30 PM, there was no temperature or respiratory rate documented. The transfusion ended at 5:51 PM. At 6:02 PM, there was no temperature documented. c. Patient #902 received a unit of packed red blood cells that was initiated on 07/10/23 at 2:08 PM. At 2:29 PM (a period of approximately 21 minutes after initiation) vital signs were documented. At 2:56 PM (a period of approximately 48 minutes after initiation) vital signs were documented. d. Patient #903 received a unit of packed red blood cells that was initiated on 07/23/24 at 7:05 PM. The transfusion ended at 9:59 PM. The Surveyor found no evidence of vital signs documented from the end of the transfusion until 07/24/24 at 7:31 AM (a period of approximately 9.5 hours). 3. At the time of the review, Staff #906 verified the times and missing vital sign documentation. .”

“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: 37242 . Item #1 Laryngoscope blades Based on document review, observation, and interview, the Critical Access Hospital failed to prevent cross contamination of reprocessed laryngoscope blades during storage. Failure to prevent cross contamination of clean patient care supplies places patients and staff at increased risk of exposure to infection. References: Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, Recommendations of CDC (Centers for Disease Control and Prevention) and the Healthcare Infection Control Practices Advisory Committee (HICPAC): Items that directly or indirectly contact mucous membranes of the respiratory track should be sterilized or subjected to high-level disinfection (HLD) before reuse; after sterilization or HLD, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process. CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008 (updated 06/24): Semicritical items contact mucous membranes or nonintact skin. This category includes laryngoscope blades. Findings included: 1. Document review of the manufacturer instructions for use (MIFU) for WelchAllyn laryngoscope blade assemblies showed that after reprocessing, laryngoscope blades should be packaged and stored to remain clean, dry, and ready for service. 2. On 06/25/24 between 9:00 AM and 10:00 AM, Surveyor #9 and Nurse Manager (Staff #906), ED Nursing Director (Staff #905) and Chief Medical Officer (Staff #903) inspected the Emergency Department (ED). The observation showed in the Broselow cart there were 12 unpackaged laryngoscope blades stored in a drawer with other unpackaged, non-sterile/non disinfected equipment. 3. At the time of the observation, Surveyor #9 interviewed Staff #905 regarding the laryngoscope blades being stored together in an open drawer. Staff #905 stated that the blades were clean and not sterile, so it is alright to store them this way. 4. On 06/25/24 at 3:15 PM, Surveyor #6 interviewed an Emergency Technician (Staff #601) about reprocessing laryngoscope blades. Staff #601 stated that after manual cleaning, laryngoscope blades are sterilized in an open pouch. On 06/25/24 at 4:30 PM, Surveyor #6 interviewed the ED/Med-Surg Nursing Director (Staff #602) about reprocessing laryngoscope blades. Staff #602 and the Surveyor reviewed the MIFU. Staff #602 confirmed the MIFU included packaged storage to allow the blade to remain clean, dry, and ready for service. Item #2 Blood pressure cuffs Based on observation, interview, and document review, the hospital failed to prevent the use of disposable single patient use blood pressure cuffs from being utilized on multiple patients. Failure to prevent cross contamination by using single patient use items between patient’s places patients and staff at increased risk of infection. Reference: Medline MDS9913HP Disposable Blood Pressure Cuff 1 Tube with HP Connector is a single patient use cuff made of soft comfortable woven polyester fabric. Findings included: 1. On 06/25/24 between 3:00 PM and 4:00 PM, Surveyor #9 and Nurse Manager (Staff #905) and Chief Medical Officer (Staff #903) inspected the endoscopy procedure area. Surveyor #9 observed multiple disposable blood pressure cuffs of various sizes that had no outer wrap covering. 2. At the time of the observation, Surveyor #9 interviewed Registered Nurse (Staff #906) regarding the blood pressure cuffs. Staff #906 stated that the blood pressure cuffs were wiped down between each patient and reused. Item #3 Hand hygiene Based on document review, observation, and interview, the Critical Access Hospital failed to ensure that staff performed hand hygiene (HH) according to hospital procedure and accepted standards of practice. Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable diseases. Findings included: 1. Document review of the hospital’s policy titled, “Infection Control Standards,” DocID: 11721, revised 06/12/20, showed that “Hand hygiene is the most important first step to take in the procces [sic] of preventing transmission,” and that hand hygiene must be performed immediately after removing gloves. Document review of the hospital’s policy titled, “Guidance For the Selection and Use of Personal Protective Equipment,” DocID: 10698, revised 05/26/20, showed that gloves are included in the elements of PPE (Personal Protective Equipment), and that staff should perform hand hygiene before and immediately after removing PPE. Document review of the hospital’s policy titled, “Hand Hygiene,” DocID: 11269, revised 03/18/24, showed that “Hand hygiene is the single most important way to reduce and prevent the spread of infectious microbes,” and that staff should perform hand hygiene after removing PPE. 2. On 06/26/24 between 10:00 AM and 11:15 AM, Surveyor #6 observed an Endoscope Technician (Staff #603) reprocess an endoscope. The observation showed that Staff #603 changed gloves at least 3 times, twice without first performing hand hygiene, and once without immediately performing hand hygiene after removing the gloves. 3. On 06/26/24 between 12:20 PM and 1:00 PM, Surveyor #6 observed the between case cleaning of the endoscopy procedure room by an endoscopy nurse (Staff #604). The observation showed that Staff #604 changed gloves 3 times, once without first performing hand hygiene and twice without immediately performing hand hygiene after removing gloves. 4. At the time of the observation, Surveyor #6 interviewed Staff #604 about the hospital’s policy for hand hygiene and glove use. Staff #604 stated that she should have completed hand hygiene before and after putting on gloves. .”

“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: 37242 . Based on observation and interview, the Critical Access Hospital failed to ensure that surfaces of patient care equipment are cleanable and sanitary. Failure to maintain cleanable surfaces puts patients and staff at increased risk of exposure to harmful microorganisms. Findings included: 1. On 06/26/24 at 1:30 PM, Surveyor #6 toured the Rehabilitation Unit with the Rehabilitation Unit Manager (Staff #605). The observation the following patient care equipment with non-cleanable surfaces: a. a bare wood 27-inch-long piece of lumber with a variety of screws & nails used for occupational therapy. Bare wood is absorbent and not cleanable. b. porous foam blocks used to assemble range of motion tools. Porous foam is not smooth or cleanable. c. the vinyl safety cover for rebounder (trampoline) springs was peeling and torn. Peeling vinyl is absorbent and not cleanable. 2. At the time of the observations, Surveyor #6 interviewed Staff #605 about cleaning patient care items between uses. Staff #605 stated that staff would review the unit’s patient care devices and remove those that are not cleanable. .”

“DENTAL SERVICES CFR(s): Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). “ §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge a Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility’s responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This Standard is not met as evidenced by: 45663 . Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy regarding dental care and dentures for Long Term Care Services “Swing Bed” patients. Failure to develop and implement a policy regarding dental care risks poor oral care, infection, and nutritional deficiencies. Findings included: 1. On 06/27/24, Surveyor #9 reviewed the policies and procedures provided by the Critical Access Hospital. The Surveyor found no evidence of policies that addressed the dental care and dentures of the long term care services “swing bed” patient. 2. On 06/27/24 at 4:00 PM, Surveyor #9 interviewed Chief Strategic Officer (Staff #901) regarding the dental policy. Staff #901 stated that they were unable to locate a policy regarding dental care and dentures specifically for long term care services “swing bed” patients. .”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 37242 . Based on document review and interview, the Critical Access Hospital failed to evaluate and update its emergency preparedness plan at least every 2 years as required by CMS (Centers for Medicare and Medicaid Services) Appendix Z of the State Operations Manual (SOM). Failure to evaluate and update the emergency preparedness plan at least every 2 years risks an emergency response the does not meet the needs of patients, staff, and visitors. Findings included: 1. Document review of the hospital’s plan titled, “Emergency Operations Plan,” DocID: 10939, approved 10/30/20, showed that the plan has not been updated for more than 3 years. 2. On 06/27/24 between 10:00 AM and 11:00 AM, during a Management of Environment for Care meeting, Surveyor #6 interviewed the Director of Quality, Risk and Compliance (Staff #606), the Director of Facilities (Staff #607), the hospital’s Environment of Care Specialist (Staff #608), and the Infection Preventionist (Staff #609). Staff #607 confirmed that the Emergency Operations Plan has not been updated since 2020 and stated that the plan is currently under review. .”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 37242 . Based on document review and interview, the Critical Access Hospital failed to develop policies and procedures for the hospital’s emergency preparedness plan to include provisions for food, water, medical and pharmaceutical supplies for staff and patients whether they evacuate or shelter in place. Failure to provide provisions for subsistence needs places staff and patients at risk of harm during an emergency event. Findings included: 1. Document review of the hospital’s plan titled, “Emergency Operations Plan,” DocID: 10939, approved 10/30/20 showed that the plan did not include provisions for food, water, medical, or pharmaceutical supplies. 2. On 06/27/24 between 10:00 AM and 11:00 AM, during a Management of Environment for Care meeting, Surveyor #6 interviewed the Director of Quality, Risk and Compliance (Staff #606), the Director of Facilities (Staff #607), the hospital’s Environment of Care Specialist (Staff #608), and the Infection Preventionist (Staff #609). Staff #607 confirmed that the hospital does not have written plans that include an emergency supply of food, water, medical supplies, or pharmaceuticals, but that the supplies on hand should last at least 96-hours. .”

“This report is the result of an unannounced Fire and Life Safety state survey conducted at the Snoqualmie Valley Hospital on June 25, 2024 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 Services (DOH) survey teams. The facility has a total of 25 beds and at the time of this survey the census was 25. 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.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 49526 Based upon observations and staff interviews on June 25, 2024 between approximately 1030 to 1230 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion. The findings include: The cross-corridor fire doors near central supply failed to close and latch when the doors were released from their hold open devices. 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: 49526 Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 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: The facility could not provide documentation indicating the forward flow inspection had been completed in the last year. 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 Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 49526 Based on observation and staff interview on June 25, 2024 between approximately 1030 to 1230 hours the facility has failed to properly maintain fire/smoke barriers 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: There was an unsealed penetration found in the basement IT room. 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: 49526 Based upon observations and staff interviews on June 25, 2024 between approximately 0900 to 1030 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: The facility could not provide documentation indicating the Won door has had its annual testing. The above was discussed and acknowledged by the facility staff.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 49526 Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place patients, staff, and visitors of electrical shock or harm. The findings include: The facility could not provide documentation indicating that periodic testing on hospital grade receptacles had been completed or provide annual testing. 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: 49526 Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 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 patient, staff, and/or visitors within the facility. The findings include: The facility could not provide documentation indicating weekly inspections are being performed on the generator. The above was discussed and acknowledged by the facility staff.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 49526 Based on observation and staff interview on June 25, 2024 between approximately 1030 to 1230 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk. The findings include: The facility is using a power-strip in place of permanent wiring found 1st floor room 1135 housekeeping room. The above was discussed and acknowledged by the facility staff.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 49526 Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions. The findings include: The facility could not provide documentation indicating guidelines, documentation of training for usage of medical gas equipment. The above was discussed and acknowledged by the facility staff.”