HospitalInspections.org

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Based on observation and review of hospital policies and procedures, hospital staff members failed to follow hospital procedures for patient identification prior to obtaining blood samples for point of care testing for 2 of 2 patients.
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Failure to follow the hospital's patient identification policy places patients at risk of harm due to medical error.
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Findings:
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1. The hospital policy and procedure titled "PATIENT IDENTIFIERS" (Policy #3001); (Reviewed 9/26/2011) under the section "Procedures requiring two identifiers" read: "1. Blood samples being drawn. 2. Radioactive materials and/or medications being administered. 3. Any invasive procedure."
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2. On 12/15/2015 at 11:15 AM in the medical-surgical unit, Surveyor #1 observed a registered nurse (Staff Member #1) obtain a blood sample from Patient #1 and measure the blood glucose level with a glucometer point of care device. Staff Member #1 did not identify the patient using two identifiers prior to obtaining the blood sample as required by policy.
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3. Upon exiting Patient #1's room, Staff Member #1 entered the room for Patient #2 to measure the blood glucose level for the patient. The surveyor observed that Staff Member #1 did not identify Patient #2 using two identifiers prior to obtaining his/her blood for the test.
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Based on observation, interview and review of hospital policies and procedures, the hospital failed to ensure that medical records remain secure from unauthorized access at all times, in all locations.

Failure to secure medical records puts patients at risk for loss of privacy, identity theft, as well as loss of their own record of medical care.

1. On 12/17/2015 at 2:30 PM, on the medical-surgical floor, Surveyor #3 observed that the medical record for Patient #3 was located on the wall located outside the patient room in an unsecured fold-down desk.

2. On 12/17/2015 at 2:30 PM, Surveyor #3 interviewed the director of the inpatient nursing and rehabilitative units (Staff Member #3) regarding the security of the patient's record. S/he reported that "they are secure when the desk top is up as they are painted the same color as the wall and blend in."

3. On 12/17/2015 at 2:30 PM, Surveyor #3 interviewed the manger of medical records (Staff Member #4) about safeguarding of medical records. S/he reported that the policy for all medical records (regardless if electronic or paper) was for them to be secure. Staff Member #4 indicated s/he was unaware that staff members maintained patient records unsecured on the medical-surgical floor.

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Based on observation, the hospital failed to ensure that dietary staff members implemented procedures for safe food handling consistent with the Washington State Retail Food Code (Washington Administrative Code (WAC) 246-215).

Failure to implement safe food handling practices for dietary staff members puts patients, staff, and visitors at risk for development of a food-borne illness.

Findings:

On 12/18/2015 at 9:45 AM, Surveyor #2 observed the sous chef (Staff Member #5) use a thin-stem thermometer to assess the temperature of a sausage patty that had been cooked on the grill. The staff member failed to remove the meat from the grill prior to assessing the internal temperature of the food, potentially resulting in an inaccurate reading.

Reference: Washington State Retail Food Code, WAC 246-215-02115 (6)
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Item #1 Cleaning Supplies

Based on observation, the hospital failed to secure cleaning supplies and chemicals from unauthorized access by patients and visitors.

Failure to secure cleaning supplies and chemicals puts patients and visitors at risk from exposure to toxic substances.

Findings:

On 12/15/2015 at 11:15 AM, Surveyor #1 observed two utility closets (326S and 334J) with housekeeping cleaning supplies. One closet had a locking device on the door but was unlocked and the other closet had a door handle without a locking device, allowing unauthorized persons access to housekeeping chemicals and other supplies. The Environmental Services (EVS) Supervisor (Staff Member #6) confirmed these findings. The facility engineering staff added a locking door handle to the unsecured door at the time of the survey.

Item #2 Patient Care Supplies

Based on observation and review of hospital policies and procedures, the hospital failed to ensure that patient care supplies did not exceed the manufacturer's designated expiration date.
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Failure to ensure patient care supplies do not exceed their expiration dates risks deteriorated and contaminated supplies being available for patient use.
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1. The hospital policy and procedure titled "Ordering Supplies and Equipment" (Policy #1665); (Revised 5/16/2011) read in part: "Expired and/or outdated supplies are to be discarded by the department and not returned to Materials Management".
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2. On 12/15/2015 at 9:15 AM during an inspection of the medical-surgical unit supply room, Surveyor #1 found the following items in a container marked "Urology Emergency Kit" :
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a. Two packages of sterile surgical gloves size 7.0 with an expiration date of 8/2015.
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b. Two packages of sterile surgical gloves size 7.5 with an expiration date of 8/2015.
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c. Two packages of sterile surgical gloves size 8.0 with an expiration date of 7/2015.
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d. Two sensor straight tip (nitinol wire with hydrophilic tip) with an expiration date of 6/2015.
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e. Two 3 cm radiofocus glidewire 150 cm length with an expiration date of 7/2014.
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f. One 7 F urethral dilation balloon catheter with open tip with an expiration date of 8/2014.
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g. One encore 26 F inflation device with an expiration date of 7/2015.
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h. Two packages of povidone-iodine swabsticks with an expiration of 10/2014.
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i. Two containers of 2% lidocaine hydrochloride jelly with an expiration date of 9/2014.
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Item #1-Linen and Laundry

Based on observation and interview, the hospital failed to ensure that the contracted laundry service had evidence of compliance with FGI (AIA) guidelines for design of healthcare laundry facilities.

Failure to ensure that the laundry contractor maintains their facility in compliance with FGI guidelines puts patients at risk from infection due to improperly cleaned hospital linens.

Findings:

1. On 12/15/2015 at 4:00 PM, Surveyor #2 reviewed the contract with Cintas, the hospital's provider of health care linens. The contract did not include any references to compliance with FGI guidelines for design of the facility.

2. On 12/18/2015 at 11:00 AM, Surveyor #2 interviewed the Materials Manager (Staff Member #7). The staff member confirmed that the required element was missing from the contract language.

Item #2- Employee Health- TB

Based on record review and interview, the hospital failed to complete Tuberculosis (TB) follow-up for employees who had a positive skin test upon hire.

Failure to ensure that all employees who have a positive TB skin test receive appropriate follow-up to prevent infection puts patients, staff and visitors at risk of exposure to airborne infection caused by TB.

Findings:

On 12/18/2015 between 11:00 AM and 12:00 PM, Surveyor #2 reviewed the hospital's system for ensuring that all employees receive appropriate screening for TB, as part of their human resource (HR) file. The hospital's employee health nurse (Staff Member #8) reported that in preparation for the review, they had identified one staff member (a registered nurse) who had a positive TB skin test but had not completed their follow-up questionnaire for symptoms, as required by hospital policy.

Item #3 - Personal Protective Equipment

Based on observation, and review of hospital policies and procedures, the hospital failed to ensure staff members correctly used personal protective equipment (PPE) when implementing barrier and transmission precautions in order to limit the risk of transmission of infectious disease.
Failure to don PPE per recommended practice puts patients and staff at risk that infections may be transmitted between patients being care for by staff.
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Reference: Guidelines for safety in the gastro intestinal endoscopy unit Copyright 2014, Volume 79, No. 3:2014 page 363. Read in part "It is recommended that staff directly engaged in GI endoscopy ... wear gloves, face and /or eye shields, and impervious gowns."
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Findings:
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1. The hospital's policy and procedure titled "Isolation Precautions" (Policy # 5200); (Reviewed 8/20/2015) read in part: "Wear a gown to protect skin and prevent soiling of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions or excretions is anticipated."
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2. The hospital policy titled "ASC Procedure Room Attire Moses Lake\Omak" (Rev. 6/18/14) read in part "All personnel in the procedure room area shall be appropriately attired." And the hospital policy titled "Isolation Precautions" (Policy #5200; Rev. 8/20/2015) read in part "Standard Precautions; Component: Mask, eye protection, face shield ...recommendations: wear mask, eye protection or face shield to protect mucous membranes of the eyes, nose and mouth during procedures ..."
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3. On 12/15/2015 at 11:15 AM in the medical-surgical unit, Surveyor #1 observed a registered nurse (Staff Member #1) enter Patient #1's room. The room was posted with a sign indicating the patient was in contact isolation. The staff member's PPE gown was not secure at the waist, which put the staff member at risk of exposure to infectious agents in the patient's environment.
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4. On 12/16/2015 at 9:15 AM in the medical-surgical unit, Surveyor #1 observed a registered nurse (Staff Member #2) enter Patient's #1 room. The room was posted with a sign indicating the patient was in contact isolation. The staff member's PPE gown was not secure at the neck. The nurse's clothing was subject to possible contamination by items in the patient ' s room.
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5. On 12/16/2015 at 10:40 AM, Surveyors #2 and Surveyor #3 interviewed the Omak Surgery Nurse Manager (Staff Member #10) regarding their policies and procedures. Staff Member #10 stated "they followed the current ASGE (American Society for Gastrointestinal Endoscopy) guidelines".

6. On 12/16/2015 at 9:30 AM, Surveyor #3 observed a colonoscopy procedure (Patient #4) staffed with two registered nurses and one surgeon. None of the operating room staff members wore protective eye shields which cover the mucous membranes of the nose and mouth or wore masks during the procedure potentially exposing them to aerolized bodily fluids.



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Item #4 - Surgical Attire

Based on observation, interview and review of hospital policies and procedures, the hospital failed to ensure that staff members followed policy for surgical attire to reduce the risk of microbial contamination within the surgical environment.

Failure to wear surgical attire properly places patients at increased risk for infection.

Findings:

1. The hospital policy titled "Operating Room Attire, Personnel" (Rev. 4/30/15) read in part: "Procedures 2. Head Coverings: A. Hair shall be completely covered and contained."

2. On 12/15/2015 at 9:20 AM, Surveyor #3 observed two registered nurse circulating staff wearing bouffant caps with hair outside the band of their caps.

3. Immediately following the observation, Surveyor #3 interviewed the operating room nurse manager (Staff Member #9) who confirmed the observed practice was not acceptable.
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Based on observation, interview and review of hospital policies and procedures, the hospital failed to provide documentation in the medical record for 7 of 8 records reviewed to indicate patients received a pre-operative medical history and physical within 30 days of surgery (Patient #5, #6, #7, #8, #9, #10, #11,#12).

Failure to complete a history and physical exam prior to surgery places patients at risk for poor outcomes due to changes in unknown or known co-morbid conditions.

Reference: "A focused history and physical examination, including the patient's current medications and ASA classification, should be completed before the start of the procedure." ASGE Standards of Practice Committee. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008;68(5):815-26.

Findings:

1. The hospital's policy and procedure titled "Physician Requirements for Hospital Medical Records" (Policy #8050); (Revised 1/2009) read in part: "C. Outpatient Surgery: A H & P would meet the CMS requirement . . . if: 1. H&P was performed within 30 days prior to the outpatient surgery; AND a. An appropriate assessment [i.e. immediately prior to surgery] performed by the MD/DO, which should include a physical examination of the patient to update any components of the patients current medical status that may have changed since the prior H&P. . . 2. An H & P performed more than 30 days prior to hospital admission/outpatient surgery does not comply with the currency requirements and a new H & P must be performed."

2. On 12/16/2015 at 2:30 PM, at the Moses Lake Clinic and Ambulatory Surgery Center, Surveyor #3 reviewed 8 surgical charts. Seven of the charts had documentation of history and physical (H & P) examinations that occured more than 30 days prior to the patient's procedure (range: 5 to 90 days).

3. On 12/16/2015 at 2:30 PM, Surveyor #3 interviewed the nurse manager of the Moses Lake Surgery Center (Staff Member (#11) about the requirements for a current history and physical. Staff Member #11 confirmed the history and physical examinations and updates for the seven medical records did not meet the timeframes required by hospital policy.