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Based on interview and record review, the facility failed to fully implement the policy to ensure that it performed required criminal background inquiries during the privileging process for 1 of 6 practitioners whose files were reviewed.

Failure to perform background inquiries places patients, staff, and visitors at risk for interacting with a potentially unsafe practitioner.

Findings:

1. Facility policy titled "Initial Appointment Policy Medical Staff Services" reviewed and approved 12/8/2014 read in part: "*Upon receipt of a completed application... the Medical Staff Coordinator will collect the following additional information: ...7. Washington State Patrol background check."

2. On 12/9/2015 between 2:15 -2:45 PM Surveyor #3 interviewed the medical staff credentialing coordinator (Staff Member #1) and the human resources coordinator (Staff Member #2). Surveyor #3 reviewed with them 6 practitioner credentialing files. One of six files did not contain evidence of a completed disclosure form or results of a background inquiry. The practitioner was hired in 1994; the effective date of the state background inquiry law was 1989. Staff Members #1, 2 confirmed this finding.


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ITEM #1: Dietary

Based on observation, the hospital failed to fully implement the requirements of the 2013 Food and Drug Administration Food Code.

Failure to comply with food service codes puts patients, staff, and visitors of the hospital at risk from food borne illnesses.

Findings:

On 12/7/2015 at 2:30 PM, Surveyor #2 observed 4 food scoops stored in food bins with the handle touching the product. To prevent cross contamination, the handle of the scoop must be stored up and away from food product.

Reference: 2013 Food and Drug Administration Food Code 3-304.12


ITEM #2: Rehabilitation equipment

Based on observation, interview and document review, the hospital failed to develop policies and procedures designed to prevent contamination and exposure from infectious agents from patient care equipment.

Failure to develop infection control policies and procedures places patients and staff at risk for infections and/or communicable diseases.

Reference: Chattanooga Hydrocollator User Manual page 19-20 part 6, read "Regularly clean and drain the tank (every two weeks)."

Findings:

On 12/08/2015 between the hours of 10:15 AM and 11:50 AM, Surveyor #2 interviewed a physical therapy aide (Staff Member #8) at the family clinic located in Cle Elum and a rehabilitation aide (Staff Member #9) at the Ellensburg location about their process for cleaning and disinfecting the hydrocollators. Staff Member #8 and #9 explained that they cleaned the hydrocollators monthly. Review of the manufacturer's instructions for use indicated that the hydrocollator should be cleaned every two weeks.

ITEM #3: Proper Use of Ultrasound Gel

Based on observation, interview and document review, the hospital failed to prevent contamination of product before patient care.

Failure to prevent contamination of product places patients and staff at risk for infections and communicable diseases.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012), states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings:

On 12/08/2015 at 12:00 PM, Surveyor #2 observed a small squeeze bottle of "Ultrasound Gel" in the rehabilitation room. The bottle had buildup of dried gel near the tip of the spout. Surveyor #2 asked the rehabilitation aide (Staff Member #9) if they were refilling the bottle. S/he stated that they do refill the squeeze bottle from a larger container of ultrasound gel. S/he did not know when the bottles were replaced.

ITEM #4: Sterilizer Function

Based on observation, interview and document review, the hospital failed to ensure that sterile processing staff members used chemical indicators to assess function of the steam sterilizer prior to use.

Failure to implement standard practices places patients at risk for increased infection.

Reference: Titled, "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008" states on page 59, "Portable (table-top) steam sterilizers are used in outpatient, dental, and rural clinics. These sterilizers are designed for small instruments, such as hypodermic syringes and needles and dental instruments. The ability of the sterilizer to reach physical parameters necessary to achieve sterilization should be monitored by mechanical, chemical, and biological indicators. . . Typically, chemical indicators are affixed to the outside and incorporated into the pack to monitor the temperature or time and temperature."

Findings:

On 12/8/2015 at 11:00 AM, Surveyor #2 interviewed the registered nurse (Staff Member #10) who does the sterile processing of surgical instruments at the family clinic located in Cle Elum. Surveyor #2 noticed that the sterilized instruments in the peel packs did not have chemical indicators inside the pack. The surveyor also noticed that the facility had a box of chemical indicators next to the sterilizer. When asked why they weren't used, the RN stated that they weren't required anymore. On 12/9/2015 at 9:00 AM Surveyor #2 interviewed the sterile processing manager (Staff Member #11) at the hospital about the same process, s/he stated it was a requirement that every peel pack had a chemical indicator inside the pack.

ITEM #5: Pool Maintenance

Based on observation and record review hospital failed to maintain pool chemistry within the required parameters within Washington State Administrative Code (WAC 246-260)

Failure to maintain pool chemistry within the required parameters places patients at risk for increased infection.

Reference: WAC 246-260-121 Monitoring, reporting, and recordkeeping section (3)(ii) Hydrogen ion (pH) concentration frequently enough, but at least once every twenty-four hours, to determine that the level is maintained in a range of 7.2 to 8.0

Reference: CDC Centers for Disease Control and Prevention Titled "Healthy/Swimming/Recreational Water" (Last Revised April 23, 2013) States in part, "As pH goes up, the ability of chlorine to kill germs goes down. Second, a swimmer ' s body has a pH between 7.2 and 7.8, so if the pool water isn ' t kept in this range then swimmers will start to feel irritation of their eyes and skin. "

Findings:

On 12/8/2015 at 10:00AM Surveyor #2 reviewed the pool record for the week of 11/30 thru 12/4 and found that 5 out of 5 chemical tests for pH on those days were above the state parameters. The logs showed a pH of 8+ for all five days. In addition to the daily logs Surveyor #2 reviewed the last health inspection that had occurred in 3/21/2014, which stated that the facility was cited for high pH 8.0. During the survey, the surveyor observed that the test kit located in the pool storage room only had a maximum scale of 8. Since the facility is hitting the maximum pH scale of 8 (which is determined by color), the facility cannot ensure what they are measuring is a true pH value of 8 or something higher since the kit only goes to pH of 8.



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ITEM #6: Surgical Attire

Based on observation and review of hospital policy and procedures, the facility failed to ensure that staff members wore surgical attire appropriately in the operating room suite.

Failure to ensure appropriate attire in the operating room leaves patients at risk for post-operative infections.

Findings:

1. The hospital's policy and procedure titled, "Surgical asepsis: Surgical attire" (Reviewed on 4/03/2015) read in part: "Introduction: . . . all head and facial hair must be covered. . . Implementation: Put on a surgical head cover or hood and ensure that all hair and facial hair, including sideburns, are covered . . . "

2. On 12/10/2015 at 9:45 AM, Surveyor #1 observed a patient (7) in the operating room where s/he underwent an abdominal hernia repair (a surgical operation for the correction of a bulging of internal organs or tissues through the wall that contains it). Four of four staff members, including the circulating nurse (Staff Member #7), the surgical technician (Staff Member #8), the anesthetist (Staff Member #9) and the surgeon (Staff Member #10) in the surgical suite had head coverings that did not completely cover all their hair. Additionally, Staff Members #9 and #10 had facial hair that was not completely covered.

3. Surveyor #1 discussed this finding with the Manager of Surgical Services (Staff Member #11) and s/he agreed that head and facial hair should be covered when staff are in the operating room.