Whidbeyhealth Medical Center

“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 interview and document review, the Critical Access Hospital failed to ensure staff implemented policies and procedures for medical management of health problems that included conditions requiring a medical consultation for 1 of 1 record reviewed requiring consultation (Patient #914). Failure to ensure policies are fully implemented risks delayed or inappropriate care and poor patient outcomes. Findings included: 1. Document review of the hospital’s policy and procedure titled, “WhidbeyHealth Medical Staff Policies,” no policy number, last approved 06/21, showed the following: a. The good conduct of medical practice includes proper and timely use of consultation. b. The attending physician will document the consultation request. c. The consultant will see the patient as soon as possible, preferably the same day unless other arrangements are made. 2. On 01/17/24 between 9:00 AM and 11:00 AM, Investigator #9 and Emergency Department Nursing Supervisor (Staff #901) and Director of Quality (Staff #902) reviewed the medical record of Patient #914 who was admitted to the hospital on 11/10/23 for treatment of knee pain and suicidal ideation. The review showed an order placed by a physician on 11/11/23 for a palliative care consult. Investigator #9 found no documentation that a consult had been completed, no evidence that the order had been cancelled, and no progress note by the physician regarding the consultation or a change in the plan of care from 11/11/23 to transfer to another facility on 11/21/23 (a period of approximately 10 days). 3. At the time of the review, Investigator #9 interviewed Palliative Care Manager (Staff #904) as to the process for consultation and if this patient had received a consultation as there was no note in the medical record. Staff #904 stated that when they receive a consultation, they would call to discuss with the ordering provider to see if they have bandwidth to consult. Staff #904 stated that if there is no note, the consultation probably wasn’t done. Investigator #9 asked if there was documentation as to why the consult was not done and Staff #904 stated that they would not document that. .”

“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: 42599 . Based on interview and review of the hospital’s quality plan, quality improvement program, performance data, and Governing Body documents, the Critical Access Hospital’s Governing Body failed to ensure that the hospital developed, implemented, and maintained an effective, ongoing hospital wide quality program as directed by hospital policy. Failure to ensure the hospital implemented an ongoing, data driven, hospital wide quality improvement program limited the hospital’s ability to identify quality and safety concerns and implemented effective improvements to improve outcomes and prevent harm. Findings included: 1. Document review of the hospital’s document titled, “Bylaws of Whidbey Island Public Hospital District Island County Washington,” revised 02/10/21, showed that: a. The Governing Board shall regularly evaluate the hospital’s progress and direct the Chief Executive Officer (CEO) to take necessary actions to ensure compliance with all legal, regulatory, and accreditation requirements, including voluntary compliance with Medicare regulations. b. The Quality Improvement Committee (QIC) shall consist of the CEO, the Chief Compliance Officer (CCO), 2 Commissioners, Chief of Medical Staff, Medical Director of Quality, Chief Quality Officer, and various department managers as designated by the CEO. The QIC shall be responsible for the implementation of the Quality and Patient Safety Plan. 2. On 11/02/23 at 1:44 PM, an interview with Governing Board Commissioner (Staff #9) showed that Staff #9 was appointed to the Commission on 02/01/23 and has attended the QIC meetings for the past 4 months. Staff #9 stated that quality metrics are shared at every QIC meeting, and they are updated on any regulatory or compliance issues with Medicare or the Department of Health. 3. On 11/02/23 at 2:00 PM, an interview with the CEO (Staff #10) showed that the CEO received daily quality updates from the Executive Director of Quality (Staff #1). Staff #10 stated that the quality team reviews the medical records for all patients requiring restraints each day, and Staff #1 reports the findings to the CEO. Staff #10 stated that he was responsible for reviewing statements of deficiencies from the Department of Health and for approving the hospital’s Plans of Correction for deficiencies cited as a result of investigations. Staff #10 confirmed that the facility received citations for repeat findings during a recent investigation and stated that the hospital had updated its hiring processes to ensure new staff were a good fit for the role, increased the new employee onboarding process to 4 days, and was working on staff accountability. 4. On 11/02/23 at 2:20 PM, Investigators #1 and #2, the ED Nurse Manager (Staff #4), and the Executive Director of Quality (Staff #1) reviewed hospital quality data reviewed in the monthly quality committee meeting minutes. Investigators found no evidence that information reported to the Patient Care Safety Quality Committee, Quality Improvement Committee, or Governing Body contained data, identified trends, or results from monitoring and evaluation of corrective actions implemented in the Plans of Correction. Staff #1 and Staff #4 confirmed that the hospital did not have a reliable process for completing audits identified in the Plans of Correction, for ensuring that information obtained from audits is recorded in an organized and easily retrievable manner, or for analyzing and reporting audit outcomes to the quality committees. .”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (ii) Policies and procedures for emergency medical services. This Standard is not met as evidenced by: 42599 . Based on interview, document review and review of hospital policies and procedures, the hospital failed to inform patients of the medical consequences of refusing medical care or treatment for 2 of 3 patients leaving against medical advice (AMA) (Patients #2 and #10). Failure to inform patients of the medical consequences of refusing medical care or treatment may impact the patient’s ability to make informed decisions including the risks of and alternatives to leaving and places patients at risk for injury or death. Findings included: 1. Review of the hospital document titled, “Emergency Department Standards of Care,” effective 05/08/23, showed that the nurse informs patients of their rights and responsibilities when they leave the emergency department (ED) against medical advice before an assessment is made or treatment is complete. Review of the “Patient Rights and Responsibilities,” no date, posted on the hospital website, showed that a patient has the right to refuse or change their mind about any treatment, medication, or procedure, within the restraints of the law, and to be informed of the medical consequences of such action. 2. Review of patient medical records showed the following: a. On 10/18/23, Patient #2 was seen in the ED for complaints of rectal pain and bloody stools. Patient #2 refused a rectal exam due to pain, and the provider ordered intravenous pain medication for pain control. Patient #2 refused an IV and the pain medication and told the nurse that he wanted to leave. The patient got dressed and left the hospital. The investigator found no documentation showing that the patient was informed of the medical consequences of leaving before treatment was complete. b. On 10/22/23, Patient #10 was seen in the ED for complaints of left ankle pain. The patient had a history of schizophrenia and admitted to using amphetamines. Documentation showed that the patient’s mother called stating that Patient #10 needed inpatient psychiatric treatment due to meth abuse and erratic behavior. Medical clearance labs and an x-ray were ordered, but Patient #10 demanded to leave before receiving the results and did not meet criteria for involuntary detainment. The investigator found no documentation showing that the patient was informed of the medical consequences of leaving before treatment was complete. 3. On 10/31/23 at 4:00 PM, an interview with the Executive Director of Quality (Staff #1), the Executive Director of Nursing (Staff #2), and the ED Assistant Nurse Manager (Staff #3) confirmed the investigators’ findings of the missing documentation. .”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 42599 . Based on interview, document review, and review of the hospital’s quality and performance improvement program, the Critical Access Hospital failed to ensure that performance measures for all patient care services were developed, evaluated, and reported to the respective quality committees. Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes. Findings included: 1. Review of the hospital document, “Quality Management System Manual,” no policy number, no date, showed the following: a. Quality Committees are composed of individuals representing the organization including administration, medical staff leadership, nursing leadership, quality leadership, risk management, and departmental leaders. The committees are responsible for prioritizing and supporting the efforts of all performance improvement and patient safety activities in the organization. The Quality Committees will receive periodic reports from any committee or team charged with measurement and assessment responsibilities as defined by the Quality Management System Manual, process performance and service conformance, status of corrective actions, follow-up actions from previous management reviews, and recommendations for improvement. b. Department leaders are responsible for ongoing performance improvement and patient safety activities in their departments and for acting on recommendations generated by quality assurance analysis and corrective action plans. 2. Review of hospital committee meeting minutes showed the following: a. On 06/07/23, there were 359 overdue hospital policies, including 120 overdue Laboratory Services policies. Investigators found no plan to update the overdue policies. b. On 07/05/23, there were 408 overdue hospital policies, including 140 overdue Laboratory Services policies. Documentation showed that corrective action plans were needed from 3 departments, including Laboratory Services. c. On 08/02/23, there were 377 overdue hospital policies, including 160 overdue Laboratory Services policies. Laboratory Services submitted a corrective action plan for updating overdue policies that included a new reporting structure with monthly reporting to the Patient Care Safety Quality Committee, and a goal for updating all overdue policies by 11/30/23. d. On 09/06/23, there were 389 overdue hospital policies, including 160 overdue Laboratory Services policies. Investigators found no evidence that Laboratory Services submitted a monthly report to the Patient Care Safety Quality Committee as stated in the corrective action plan. e. On 10/04/23, there were 413 overdue hospital policies, including over 160 overdue Laboratory Services policies. Investigators found no evidence that Laboratory Services submitted a monthly report to the Patient Care Safety Quality Committee as stated in the corrective action plan. 3. On 11/02/23 at 4:30 PM, an interview with the Executive Director of Quality (Staff #1) confirmed the investigators’ findings that Laboratory Services did not provide monthly reports to the Patient Care Safety Quality Committee as stated in the corrective action plan. .”