HospitalInspections.org

.
Based on interview and review of patient rights information, the hospital failed to develop a process for informing patients of all of their rights in accordance with federal hospital regulations.

Failure to notify patients of healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. On 02/05/2019 at 8:45 AM, Surveyor #7 interviewed a hospital admitting clerk working at the admitting desk (Staff #701) regarding the hospital admission process. The clerk stated that on admission inpatients received a brochure titled "Patient Rights and Responsiblities".

2. Review of the patient rights brochure showed the list did not include the patient's right to have a family member or representative of his or her choice and the patient's own physician notified promptly of his or her admission to the hospital.
.

.
Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that a physician or licensed independent practitioner (LIP) wrote an order for restraints for 1 of 4 patients reviewed (Patient #701).

Failure to ensure that a physician or LIP authorizes restraint use risks loss of dignity, loss of personal freedom, and psychological and physical harm to the patient,

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint and Seclusion", no policy number, effective 11/13/18, showed that if a patient had to be restrained during their hospitalization, a physician or LIP (a physician assistant or a nurse practitioner) caring for the patient would write an order authorizing restraint use. Orders for restraints used to control violent or self-destructive behavior would be reviewed and reauthorized by the ordering healthcare provider every four hours.

2. On 02/07/19 at 3:00 PM, Surveyor #7 reviewed the medical records of four patients who were placed in seclusion during their hospitalization. This review showed the following:

Patient #701 was a 19 year-old patient treated in the hospital's emergency department on 12/01/18 for alcohol intoxication and delirium. The patient became combative and agitated and was placed in four-point restraints at 4:20 PM. The patient remained in restraints until 9:34 PM. The record included a restraint order form signed at 4:20 PM by a registered nurse. The order was not signed by a physician or a licensed independent practitioner. There was no evidence of review by a physician or LIP after four hours that authorized continued use of the restraints.

3. During an interview with Surveyor #7 at the time of the record review, the hospital's quality director (Staff #702) confirmed that hospital's restraint policy had not been followed for Patient #701.
.

.
Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that patients were released from restraints at the earliest possible time for 2 of 4 patients reviewed (Patients #701, #702).

Failure to remove patients from restraints at the earliest possible time risks loss of dignity, loss of personal freedom, and psychological and physical harm to the patient,

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint and Seclusion", no policy number, effective 11/13/18, showed that if a patient had to be restrained during their hospitalization, the restraints would be discontinued as soon as possible based on an assessment of the patient's condition. The nurse caring for the patient would document the rationale for continued use of restraints in the patient's medical records.

2. On 02/07/19 at 3:00 PM, Surveyor #7 reviewed the medical records of four patients who were placed in seclusion during their hospitalization. This review showed the following:

a. Patient #701 was a 19 year-old patient treated in the hospital's emergency department on 12/01/18 for alcohol intoxication and delirium. The patient became combative and agitated and was placed in four-point restraints at 4:20 PM. The patient's medical record showed that the patient was sleeping at 7:15 PM, was alert and cooperative at 7:30 PM, was sleeping from 8:00 PM to 9:00 PM, and was alert and cooperative at 9:15 PM. The patient was not released from restraints until 9:34 PM. The record did not include documentation that supported use of the restraints after the patient no longer exhibited violent, self-destructive behavior.

b. Patient #702 was a 55 year-old patient who was admitted on 01/26/19 for a small bowel obstruction. At 8:30 PM the patient became confused and was placed in "soft limb" restraints to protect tubes and devices used during her care. The patient was released from restraints on 01/27/19 at 10:00 AM. The patient's medical record did not include documentation of the patient's condition and behavior that supported continued use of the restraints on 01/27/19 from 2:24 AM until 8:00 AM.

3. During an interview with Surveyor #7 at the time of the record review, the hospital's quality director (Staff #702) confirmed that hospital's restraint policy had not been followed for Patients #701 and #702.
.

.
Based on interview and review of patient rights information, the hospital failed to develop and implement a process for informing patients of their visitation rights when admitted to the hospital in accordance with federal hospital regulations.

Failure to inform patients of the hospital's visitation policies and procedures risks violation of the patient's civil rights.

Findings included:

1. On 02/05/2019 at 8:45 AM, Surveyor #7 interviewed a hospital admitting clerk working at the admitting desk (Staff #701) regarding the hospital admission process. The clerk stated that patients admitted as inpatient received a brochure titled "Patient Rights and Responsibilities".

2. Review of the patient rights brochure showed that under a section titled "Visitations" the brochure read: "[You have a right to] To visit within Astria Health established visiting hours and guidelines. You have the right to refuse visitors." The brochure did not identify the hospital's visiting hours nor visiting guidelines.

3. Review of the hospital's policy and procedure titled, "Visitation Policy/Procedure", Policy #TCH-ADM-507 dated 02/13/18, showed that on admission or as soon as possible thereafter, hospital staff would inform each patient and/or his or her support person of his/her visitation rights, including clinical restrictions or limitations. The policy stated this information was listed in the "Patient Guide', which was given to every patient on admission to the hospital.

4. On 02/07/19 at 1:30 PM, Surveyor #7 interviewed the hospital's Chief Nursing Officer (Staff #702) and Quality Director (Staff #703) regarding the hospital's visitation policy. The staff members stated that the hospital no longer distributed a "Patient Guide" to hospital patients. The interview showed that patients were not informed of their right to receive the visitors whom he or she designated, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. Patients were not informed of the hospital's visiting hours and what restrictions, if any, would apply to that patient's visitation rights.
.

.
ITEM #1 - ANALYSIS OF ADVERSE PATIENT EVENTS

Based on interview and review of the hospital's quality improvement program and performance data, the hospital failed to ensure that aggregated data regarding patient medication errors, patient injuries, and other adverse events were aggregated and analyzed for patterns, trends, and common factors through the hospital's quality program.

Failure to systematically collect, aggregate, and analyze data regarding adverse patient events limits the hospital's ability to develop action plans to prevent medical errors and patient injuries.

Findings included:

1. Review of a document titled "Quality Assessment Performance Improvement Plan 2018", effective 01/31/18, showed that the hospital's quality program would include monitoring and analysis of adverse events that posed a significant patient safety risk, including medication errors and patient injuries.

2. On 02/07/19 at 12:00 PM, Surveyor #7 interviewed the hospital's quality director (Staff #702) and Chief Nursing Officer (Staff #701) regarding the hospital's quality improvement program. During the interview, the surveyor reviewed a log of adverse patient events data, including medication errors and patient injuries, that occurred between August 2018 and February 2019. The interview revealed that adverse patient events that occurred during this time period were analyzed individually. Data was not systematically aggregated and analyzed for patterns, trends, and common factors to determine if hospital systems changes were needed to prevent future events.


ITEM #2 - ANALYSIS OF PATIENT MORTALITY

Based on interview and review of the hospital's patient mortality data, the hospital failed to ensure that all cases of patient mortality were reviewed, analyzed, and considered for an in-depth review by the hospital's medical staff.

Failure to systematically analyze patient mortality data limits the hospital's ability to develop action plans to reduce the chance of preventable patient deaths.

Findings included:

1. Review of a document titled "Quality Assessment Performance Improvement Plan 2018", effective 01/31/18, showed that the hospital's quality program would include monitoring and analysis of adverse events that posed a significant patient safety risk, including cases of patient mortality.

2. On 02/08/19 at 9:45 AM, Surveyor #7 interviewed the hospital's quality director (Staff #702) and reviewed a log of fourteen patient deaths that occurred between 02/01/18 and 12/11/18. During the interview, the director identified two deaths that she stated she was not aware of. She stated these deaths had not been reviewed, analyzed, and considered for an in-depth review by the hospital's medical staff.
.

.
Based on interview and record review, the hospital failed to ensure nursing staff members performed blood transfusion procedures according to facility policy and procedure for 2 of 3 patients reviewed (Patients #703, #704).

Failure to perform blood transfusion procedures according to acceptable standards of practice risks transfusion reactions and complications.

Findings included:

1. On 02/08/19 at 10:30 AM, Surveyor #7 reviewed the records of three patients who received blood transfusions during their hospital stay. This review showed the following:

a. The records for Patient #703 showed that two nursing staff members did not verify the identify of the patient and the blood unit prior to initiating the transfusion for 1 of 3 units transfused on 01/17/19.

b. The records for Patient #704 showed that the patient's vital signs, including the patient's temperature, were not reassessed within 15 minutes after the start of the blood transfusion for 2 of 3 units transfused on 01/23/19 and 01/24/19.

2. During an interview with Surveyor #7 at the time of the record review, and hospital's quality director (Staff #102) stated that the hospital's transfusion policy and procedure had not been followed for Patients #703 and #704.
.

.
Based on interview and review of hospital policies and procedures, the hospital failed to develop and implement a process for investigation of possible security breeches of its electronic medical records (EMR) system.

Failure to investigate EMR security breeches risks unauthorized access to protected healthcare information and violation of the patient's right for confidentiality.

Findings included:

1. On 02/05/19 at 3:05 PM during an interview with Surveyor #7, the obstetrical department nurse manager (Staff #708) demonstrated how nurses accessed and maintained the electronic medical records of obstetrical patients hospitalized at Astria Toppenish Hospital. The interview and demonstration showed that through the Cerner EMR system the nurse could also access the medical records of patients located at Astria Sunnyside Hospital.

2. On 02/07/19 at 1:00 PM, Surveyor #7 conducted a telephone interview with the director of the health information management (HIM) department (Staff #709), the assistant director of the HIM department (Staff #710), and the information technology/information systems director (Staff #711). During the interview, the surveyor asked how the hospital ensured that electronic medical records in the Cerner EMR system were not accessed, altered, and disclosed by unauthorized individuals. The staff members stated that when complaints or concerns regarding medical records security were reported, the records were audited to determine who and how the records had been accessed. The staff members also stated that random audits were performed quarterly. The staff members stated that the policy and procedure that identified how staff members were to perform these audits was outdated and had not been revised since the Cerner EMR system was installed in August 2018.
.

.

.
Based on interview and review of hospital policies and procedures, the hospital failed to develop policies and procedures for safe preparation of intravenous (IV) medications and fluids.

Failure to comply with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.

References:

RCW 18.64.270. Responsibility for drug purity-Compounding-Adulteration-Penalty.
(2) Any medicinal products that are compounded for patient administration or distribution to a licensed practitioner for patient use or administration shall, at a minimum, meet the standards of the official United States pharmacopoeia as it applies to nonsterile products and sterile administered products.

United States Pharmacopoeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016).

Nursing Care Quality Assurance Commission Advisory Opinion - "Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Practice Registered Nurse Practitioners" (Effective 11/17/17)

Findings included:

On 02/06/19 at 2:10 PM, Surveyor #7 interviewed the hospital's pharmacy director (Staff #704) regarding pharmacy services at the hospital. During the interview, the pharmacist stated that a pharmacist was not on site at all times, and that IV fluids with medication additives not available in a pre-mixed form were prepared by nursing staff members. The pharmacist stated that the hospital did not have a policy and procedure to direct nursing staff how to safely prepare compounded intravenous medications. The pharmacist showed the surveyor a draft policy and procedure dated 04/28/17 for preparing such medications according to USP 797 and stated it had not been finalized.
.

.
Based on document review and interview, the hospital failed to develop and implement a preventative maintenance program for the hospital's steam sterilizer.

Failure to perform preventative maintenance of such equipment places patients at risk of infection due to improperly sterilized reusable medical instruments and devices.

Findings included:

1. On 02/06/19 at 9:30 AM, Surveyor #1 requested to see the preventive maintenance records for the steam sterilizer located in the central sterile processing room. The Quality Director (Staff #102) provided documentation of the last preventative maintenance, which occurred in November 2017.

2. On 02/07/19 at 2:45 PM, Surveyor #1 interviewed the facility plant manager (Staff #101) and the Quality Director (Staff #102) regarding the frequency of preventive maintenance for the steam sterilizer. The Quality Director provided a contract from the vendor "Getinge Group", which showed that the contractor would perform preventive maintenance of the steam sterilizer annually and inspect the sterilizer quarterly.

3. The Quality Director was unable to provide documentation for the annual preventive maintenance and four quarterly preventive maintenance inspections of the steam sterilizer during 2018.
.

.
Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that supplies stored in emergency treatment carts did not exceed their manufacturer's expiration date and were not available for patient treatment.

Failure to ensure emergency supplies storage areas do not contain outdated or otherwise unusable items risks patient injury during emergency treatment.

Findings included:

1. The hospital's policy and procedure titled "Maintenance and Replacement of Code Carts", no policy number, dated 11/18, showed that each month pharmacy staff members would inventory and restock medications stored in emergency medication and supplies carts ("code carts") located throughout the hospital. Nursing staff members and respiratory therapists were to restock their own supplies after use.

2. On 02/06/19, Surveyor #7 inspected five emergency medications and supply carts. This inspection showed the following:

a. At 9:05 AM, the code cart located in the post anesthesia recovery unit contained nine outdated 10 cc saline flushes. One was marked with an expiration date of 01/01/19, one with an expiration date of 08/18, and seven with an expiration date of 03/01/18. These observations were confirmed by the surgery department director (Staff #706) at the time of the observation.

b. At 11:15 AM, the code cart located in trauma room #1 in the emergency department (ED) contained one 1000 ml bag of 0.9% normal saline with an expiration date of 01/31/19. The code cart located in ED examination room #2B in the emergency department contained two 10 ml saline flushes marked with an expiration date of 01/01/19, one 100 ml bag of 5% dextrose with an expiration date of 11/18, and nine blood sample collection tubes with expiration dates ranging from 06/30/17 to 01/01/19. These observations were confirmed by the ED director (Staff #707) at the time of the observation

c. At 11:35 AM, the code cart located between the Family Maternity Center and the Medical Withdrawal Management unit contained two 10 ml saline flushes marked with expiration dates of 09/01/18 and 02/01/18, one 20 ml vial of saline diluent with an expiration date of 02/01/18, and eight blood sample collection tubes with expiration dates ranging from 01/31/18 to 11/30/18. These observations were confirmed by the Chief Nursing Officer (Staff #701) at the time of the observation

3. On 02/06/19 at 11:35 AM during an interview with Surveyor #7, the Chief Nursing Officer (Staff #701) confirmed that the current code cart inventory process addressed how medication expiration dates were monitored but did not address routine inspection of the code carts for outdated supplies.
.

ITEM #1 - MULTI-DOSE MEDICATIONS IN PATIENT CARE AREAS

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that multi-dose vials of medication prepared in patient care areas were discarded after use and were not available for administration to other patients, as recommended by the Centers for Disease Control and Prevention (CDC).

Reference:
"Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007"; Part III: Precautions to Prevent Transmission of Infectious Agents; III.A.1.b. Safe Injection Practices

Findings included:

1. On 02/06/19 at 12:15 PM, Surveyor #7 observed an open 20 ml multi-dose vial of rocuronium and an open 20 ml multi-dose vial of succinylcholine (muscle relaxants used during anesthesia) in the top drawer of the anesthesia cart in operating room (OR) #1.

2. At the time of the observation, Surveyor #7 interviewed a certified registered nurse anesthetist on duty (Staff #703). During the interview, the anesthetist stated that multi-dose vials of medications accessed in the OR were used for multiple patients if dated when opened and discarded within 28 days.

3. Review of the hospital's policy titled "Single and Multi-dose Vials", Policy #PH-020-1580 effective 12/15, showed that the policy did not state that multi-dose vials of medications accessed in patient care areas should be used for a single patient and not retained for use for other patients.

4. On 02/06/19 at 2:00 PM, Surveyor #7 interviewed the hospital's pharmacy director (Staff #704). During the interview, the pharmacist stated he was unaware of the CDC's recommendation.


ITEM #2 - ICE MACHINE DRAIN LINES

Based on observation, interview, and document review, the hospital failed to install ice machine drain lines according to the Food and Drug Act (FDA food Code).

Failure to comply with food service regulations puts patients, staff, and visitors at risk of food borne illness.

Findings included:

1. On 02/05/19 between the hours of 9:30 AM and 11:45 AM, Surveyor #1 observed that the ice machines in the following areas did not have an air gap (a minimum of one inch air space between the ice machine drain line and the floor drain) to prevent contamination of the ice:

a. Main kitchen ice machine
b. Obstetrical department ice machine
c. Emergency department ice machine

2. On 02/06/19 between the hours of 1:00 PM and 2:00 PM, Surveyor #1 interviewed the facility plant director (Staff #101) and showed the director the ice machine drain line in the main kitchen. During the interview, the surveyor informed the director that the ice machines located in the obstetrical and emergency departments had similar connections. The facility plant manager confirmed that the ice machine drain lines did not have a one-inch air gap.

Reference: Design, construction and installation-Backflow prevention, air gap (2009 FDA Food Code 5-202.13) and Washington State Retail Food Code, WAC 246-215-05215.

Reference: Retention, drainage, and delivery design, construction, and installation-Backflow prevention (2009 FDA Food Code 5-402.11) and Washington State Retail Food Code, WAC 246-215-05410 (1)


ITEM #3 - FOOD PREPARATION SINKS

Based on observation, interview, and document review, the hospital failed to install and use food preparation sinks according to the Food and Drug Act (FDA food Code).

Failure to comply with food service regulations puts patients, staff, and visitors at risk of food borne illness.

Findings included:

1. On 02/05/19 at 9:00 AM, Surveyor #1 observed meat defrosting in the kitchen's three compartment warewashing sink.

2. During the observation, Surveyor #1 interviewed the dietary manager (Staff #103) and informed the manager that food preparation must be done in a dedicated food preparation sink. The dietary manager stated that the kitchen had a food preparation sink but that it was too small to use.

Reference:Washington State Retail Food Code; WAC 246-215-04325 Equipment-Designated food preparation sinks.

"Food establishments must have designated food preparation sinks that are:
(1) Sufficient in number and size to wash, soak, rinse, drain, cool, thaw, or otherwise process any food that requires placement in a sink;
(2) Appropriate for the menu, method of food preparation, and volume of food prepared; and
(3) Not used for handwashing, Utensil washing, or other activities that could contaminate food."
.

.
Based on interview and review of hospital policies and procedures, the hospital failed to maintain written policies and procedures that (1) clearly outlined the discharge planning process; and (2) included a process for addressing changes in patient condition that called for development of a discharge plan in patients not previously identified as in need of one.

Failure to develop policies and procedures to guide staff in the discharge planning process risks inability to identify patients who require a discharge plan; and risks patient harm due to inadequate discharge planning.

Findings included:

1. On 02/06/19 at 3:00 PM, Surveyor #7 interviewed the hospital's case manager (Staff #705) regarding the hospital's discharge planning process. The case manager stated she reviewed all patients for discharge planning needs each day Monday through Friday. She stated that when she was not on duty, registered nurses caring for the patient developed the patient's discharge plan.

2. During the interview, Surveyor #7 reviewed the hospital's discharge planning policies and procedures. The case manager stated they were not available to all staff and did not reflect the hospital's current discharge planning process.
.