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Based on policy review, the facility failed to require a History and Physical (H&P) be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Failure to conduct an assessment on all patients undergoing procedures requiring anesthesia, puts patients at risk of an adverse outcome including death, in the event that the
patient's medical condition or co-morbidities require alteration of the treatment plan.


Findings include:

On 08/09/2012, during a review of Medical Staff Bylaws, Surveyor #1 identified that Appendix B (History & Physical Exam requirements) states:

"4. Admission H&P
a. A H&P would meet the CMS requirements that a H&P be "performed no more than 7 days prior to admission or with 48 hours after admission,". CMS State Operations Manual, Appendix A (Rev. 05-21-04)."

This requirement was revised 10/17/2008 and now states that a H&P must be performed no more than 30 days prior or 24 hours after hospital admission. The facility policy has not been updated to reflect CFR 482.22(c)(5).

Based on interview and record review, the facility did not develop care plans for their outpatients.

Failure to do so places patients at risk for inadequate care and poor outcomes.

Findings include:

1. Throughout the four days of the survey, Surveyor #2 interviewed administrative Staff #V8, #V9, and #V10 regarding the facility's procedures for collecting assessment data and formulating care plans for outpatients. The categories of patients reviewed were surgical, those undergoing gastrointestinal endoscopies and pain procedures, and those receiving chemotherapy,transfusions,and various other infusions, including antibiotics. The surveyor requested any existing pertinent facility policies and procedures. Facility staff provided only those written for medical or short stay inpatients, and rehabilitation patient admissions.

2. Surveyor #2 reviewed a cross section of ten medical records for the types of outpatients outlined above. Assisted by Staff #V8 and the Manager of Medical Records, the surveyor was unable to find a care plan in any of the records.

Based on observation, the facility failed to prepare and store medications according to accepted standards of practice and conditions of security.

Failure to do so places patients at risk for medication error or receipt of drugs which may have been tampered with.

REFERENCES:
WAC 246-873-080 Drug procurement, distribution and control.
(5) Labeling: (a) Inpatient. All drug containers in the hospital shall be labeled clearly, legibly and adequately to show the drug's name (generic and/or trade) and strength when applicable.

WAC 246-873-070 Physical requirements. The pharmacy facilities shall include: (4) Drug storage areas. Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.
Findings include:

1. During tour of the peri-operative area on 08/08/2012 Surveyor #2 observed unlabeled medication syringes in two separate operating rooms. The syringes had been used then put aside, thus risking medication errors, and not conforming to professional standard of practice.

In operating room #3 several syringes were observed atop an anesthesia cart. Staff were in the room focused on cleaning and preparing for the next case, and the medications were not being monitored.

2. On 08/08/2012 during tour of the Urology Clinic, Surveyor
#2 reviewed the medication storage. The clinic's drugs were in a locked cabinet. However the keys to the cabinet were unsecured in a drawer directly below the cabinet. Staff #V6 stated that the keys were stored there at all times, including overnight.

Based on staff observation, staff interview and policy review, the facility failed to enforce its policy on use of radiation-detection badges (dosimeters) while in controlled areas as defined in Facility policy #RAD 508.


Failure to ensure that employees comply with radiation safety policy puts staff, patients and visitors at risk of unexpected exposure to ionizing radiation.


Findings include:

On 08/07/2012 at 2:30 PM, during a tour of the computerized tomography (CT) department, Surveyor #1 observed staff #L2 with no dosimeter, assisting a patient adjacent to the CT scan device. All other personnel in the area were wearing dosimeters. This finding was confirmed by Staff #V10.

Based on observation, interview, and record review the facility failed to develop and/or implement and maintain policies and procedures for specific infection prevention practices.

Failure to do so places patients, staff, and visitors at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.

Findings include:

PART I
Reference:
Facility policy titled "Hand Hygiene ", dated 9/23/11 read in part that hand hygiene was to be performed:
· Before and after patient contact
· Before donning gloves and after removing gloves
· After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
· If moving from a contaminated body site to a clean body site during patient care

The policy did not contain an overall statement that hands should be decontaminated any time they've become potentially contaminated (such as by contact with the floor).

On 08/08/2012 Surveyor #2 observed multiple hand hygiene (HH) failures while observing preparation for, performance of, and activities following a surgical procedure. In the pre-op area Staff #V1 did not perform HH after having had contact with the patient. Also in the pre-op area Staff #V2 did not do HH prior to having contact with the patient.

Surveyor #2 observed a work sequence performed by Staff #V3. S/he doffed gloves without performing HH, then entered a cart to obtain intubation supplies and prep them. Donning gloves, s/he intubated the patient, then removed the gloves without doing HH. S/he took a common roll of tape and secured the tube and positioned the patient ' s head. Without performing hand hygiene s/he removed intravenous medications from the cart and administered them, then went on to do some charting.
Staff #3 donned gloves to clean the laryngoscope handle, and removed the gloves without doing HH. S/he also picked an item up from the floor without gloves or HH afterward. For one other task s/he donned gloves but did not perform HH after their removal. After the procedure, when assisting to move the patient from the operating room table to a stretcher Staff #V2 and V3 used gloves but did not do HH after removing the gloves.

PART II
Surveyor #2 observed that the pre-op patient's shoes had been placed in the same bag as his/her clothing, there by contaminating the clothing with floor debris.

PART III
During tour of the peri-operative area Surveyor #2 observed a room turnover (removing items from the previous case and cleaning to prepare for the next one). Staff #V4's sequence of activities were observed. Using the same pair of gloves and disinfectant wipe, s/he move from dirty to clean tasks, thereby cross-contaminating items. S/he picked cords up from the floor, wiped them, then wiped part of the operating table. S/he proceeded to wipe a transfer board stored on the floor, then moved to wiping an instrument table. S/he then pulled a red biohazard bag from a floor bucket, and returned to wiping table tops. Throughout these processes s/he did not change gloves or do HH, or obtain new disinfectant wipes.

During the same tour Surveyor #2 observed that a door to an operating room had been left open during a procedure. This resulted in the potential for airborne contamination in the room.

In all the rooms observed by the surveyor a bare piece of paper had been affixed to the wall (the monthly humidity reading logs). The papers were not protected by plastic or other means, were not cleanable, and were a potential source of contamination.

PART IV
During tour of the Acute Care Unit on 08/07/2012 Surveyor #2 observed unprotected laryngoscope blades in emergency cart. Administrative staff escorting the surveyor indicated that facility policy was in keeping with recommendations from the Centers for Disease Control and Prevention, i.e. the blades were sterilized then packed to protect from contamination. However, some of the carts had not yet had their blades removed, wrapped, and sterilized.

PART V
During tour of the Acute Care Unit on 08/07/2012 Surveyor #2 observed Staff #V5 hugging a stack of clean patient linens so as to be in direct contact with his/her potentially contaminated uniform top.

PART VI
During tours of the Infusion Room and the Endoscopy area on 08/07/2012 Surveyor #2 observed two paper towel dispensers which automatically emitted long enough pieces of towel that they came in contact with the sink, thereby contaminating the towels.

Based on interview and record review, the facility failed to conduct periodic staff training for a specific potential emergency situation and to have effective procedures in place to address it.

Failure to do so risks patient care by staff unprepared to competently perform vital tasks, potentially resulting in patient debility and death.

Findings include:

Certain types of anesthetics pose a risk of causing a rare but life-threatening emergency known as malignant hyperthermia (MH). Patients who receive these drugs can develop this syndrome in the hours following exposure to the drugs. To successfully rescue a patient experiencing MH the staff's response must be immediate and ongoing until the patient is stabilized.

1. Surveyor #2 interviewed Staff #V7 on 08/08/2012 regarding the facility's ability to manage an MH crisis on the Acute Care Unit (ACU), the unit which cares for post-operative patients. S/he stated that when staff from the perioperative area were in house, they would respond. Staff in the ACU had not been trained to respond to MH. Staff #V7 confirmed that perioperative area staff were only routinely in-house Monday-Friday during the day, so that there were times when no staff with this expertise was available.

2. On 08/09/2012 Surveyor #2 reviewed Human Resources and Training files for two staff who work in ACU (Staff #V11-#V12). No evidence of MH training was found for these staff. The surveyor interviewed Staff #V8, the staff development coordinator, who stated that the need to educate ACU staff had not been recognized. Facility policy " Malignant Hyperthermia" dated 01/11/2011 had been written tailored only to the Operating Rooms and the Post Anesthesia Care Unit. An additional finding was that one reviewed perioperative staff member (Staff #V13) had training that was outdated per facility policy.