HospitalInspections.org

Based on interview and review of hospital policies and procedures, the hospital failed to follow its' policy and procedure for informing patient's of their rights when admitted to the hospital's Cancer Center.

Failure to inform patients of their rights limits the patient's ability to exercise those rights.

Findings:

1. Review of hospital policies related to patient rights revealed the following:

a. The hospital's policy and procedure entitled "Patient/Client Rights and Responsibilities" (Policy # 8720.0090; revised 10/2011) read as follows:

"Upon admission or registration each person will be informed of his or her rights and responsibilities as a PSMMC [Providence St. Mary Medical Center] patient or client. Each individual or responsible person will receive or have available a statement of these rights in writing."

2. Review of medical records for "Patient Rights and Responsibilities" revealed the following:

Patient #1 was a 58 year-old patient admitted to the Cancer Center for treatment of endometrial cancer. Review of Patient #1's medical record revealed that there was no evidence in the record acknowledging receipt of a patient rights pamphlet.

An interview with a Cancer Center receptionist (Staff Member #1) on 4/5/2012 at 10:35 AM revealed that the registration process for cancer center patients did not include ensuring patients received a copy of the patient rights pamphlet.

Based on record review and interview, the hospital failed to provide timely resolution of patient and family grievances.

Failure to provide timely resolution of grievances jeopardizes the patients' and families' ability to participate meaningfully in their health care processes.

Findings:

1. During review of hospital policies and procedures on 4/5/2012, it was found that the hospital policy titled "Management of Complaints/Grievances" (policy #8730.1200; Revised 2/2010) stated:

The hospital "recognizes the right of every individual to have their concerns, complaints and grievances addressed in a timely manner and through appropriate mechanisms."

"Grievances will be addressed by appropriate management personnel no greater than seven (7) days after receipt."

2. Review of patient and family complaints/grievances received by the hospital since 1/5/2012 found that of 29 complaints/grievances one (1) patient grievance had been assigned on 1/12/2012 but had not been addressed and one (1) patient grievance received on 3/16/2012 had not been assigned or addressed.

3. An interview with the Director of Quality and Risk Management (Staff Member #4) confirmed the above findings.

Based on record review, the facility failed to ensure that healthcare providers dated and timed authentication of telephone orders for 2 of 4 records reviewed (Patient #5, #6).

Failure to date and time telephone/verbal order authentication makes it difficult for the facility to ensure timely review of such orders placing patients at risk for medication/treatment errors.

Findings:

On 4/5/2012 Surveyor #1 reviewed 4 medical records (2 pediatric patients and 2 special care nursery patients) for telephone/verbal orders. Twenty-eight telephone orders were found in the 4 medical records. Of the 28 telephone orders 12 did not have a date and time of authentication.

Based on observation and staff interview, the facility failed to enforce its policy on use of radiation-detection badges (dosimeters) while in controlled areas as defined by the Radiation Safety Officer (RSO).

Failure to ensure that employees comply with radiation safety policy puts staff at risk of over exposure to ionizing radiation.

Findings include:

On 4/3/2012, during a tour of the "Linear Accelerator Room" in the Nuclear Medicine Department, surveyor #3 asked a staff member if he/she was required to wear a dosimeter badge while working in the control room. The staff member stated it was required, but that the badge was attached to his/her coat hanging on a hook in an adjacent room. A subsequent interview with the RSO on 4/5/2012 confirmed to surveyor #3 and 4, the room was considered "a controlled space" and that dosimeters were required to be worn in that area, even if the unit is not in use.

Based on observation and staff interview, the facility failed to ensure that the requirements of the State food service regulations were being followed. More specifically, Washington State Retail Food Code Working Document, Chapter 246-215 WAC, a modification of the 2001 FDA Food Code hereafter referred to as the "Working Document".

Failure on the part of the facility to implement the requirements of the food service regulations puts patients, staff and visitors of the facility at risk of food borne illness.

Findings include:

During observation of kitchen staff and activities on 4/4/2012 surveyor #3 and #4 noted the following:

a. Prep sinks containing soiled utensils, wipe-down buckets with bleach and set-up for hand sinks, being used for food prep;

b. Improper sanitizing of a cutting board that was used for vegetable prep;

c. Improper hot-holding of sliced roast beef. An internal temperature check done by a kitchen staff member indicated a hold temp of 113 degrees instead of the required 140 degrees. This was corrected at the time of survey;

d. Food tray for a patient in room #320 was stored unprotected, next to a hand sink in a clean utility on the 3rd floor, pending patient's return to his/her room. The Director of Food Service (Staff Member #13) confirmed that there is no policy for storing or discarding of food sent to patient rooms when the patient is not available.

Based on observation, the facility failed to maintain the physical environment through installation of a backflow prevention device to protect the potable water supply.

Failure to install and maintain cross-connection controls on equipment that is attached to the hospital's water supply places the patients, staff and visitors of the facility at risk for possible exposure to water-borne chemical or biological contaminates.

Findings include:

During a tour of the facility on 4/3/2012, surveyor #4 observed that the 3 West shower room hand held shower wand was missing an atmospheric vacuum breaker and had a hose of sufficient length to allow the wand to reach the floor.

Based on document review, the facility failed to ensure that emergency equipment and patient supplies were properly maintained and readily available to meet patient needs.

Failure to maintain life-saving emergency equipment and patients supplies puts patients at risk of harm.

Findings include:

4/3/2012:
a. Surveyor # 3 reviewed the inspection check list associated with Crash Cart #9 on the 4th floor. Checked inspection dates were missing for 3/9/2012 and 3/24/2012.

b. Surveyor #3 observed that the "earliest drug expiration date" on Crash Cart #5 on the 4th floor was listed as 3/31/2012.

c. Surveyor #3 observed that the electrode pads for Crash Cart #11 in the Cardiac Stress Lab expired on 02/2012. This was corrected at the time of survey.

d. Surveyor #3 observed that a "Nitrazene Buffer" test kit was expired (3/31/2012). The item was removed and discarded by the charge nurse at the time of survey.

e. Surveyor #4 observed that a package of personal hygiene wipes was stored underneath the sink in an unoccupied labor/delivery suite subjecting it to wetting and potential contamination. This finding was corrected at time of survey.

4/5/2012: During a tour of the receiving department, surveyor #4 observed that patient care items were stored on shelving units located beneath an unprotected sewer line.

This finding was confirmed by the Facilities Director (Staff Member #10).

Based on observations, the hospital failed to provide proper ventilation in certain areas of the facility.

Failure to provide ventilation that establishes proper air pressure relationships puts patients, staff and visitors in the hospital at risk from possible exposure to chemical and biological air-borne contaminants.

Findings include:

a. 4/4/2012: Surveyor #4 used a lightweight tissue paper to assess direction of airflow from soiled utility room #1 in the Emergency Department (ED). The air pressure was neutral to the corridor

b. 4/4/2012: Surveyor #4 used a lightweight tissue paper to assess direction of airflow from soiled utility room #2 in the ED. The air pressure was positive to the corridor.

c. 4/4/2012: Surveyor #4 used a lightweight tissue paper to assess direction of airflow from the " Block Room " in the Nuclear Medicine Department. The airflow was neutral to the corridor.

d. 4/5/2012: Surveyor #4 used a lightweight tissue paper to assess direction of airflow in the Laboratory Services Department. The airflow was positive to the corridor. Within the department, both the microbiology and histology suites were positive to the rest of the lab.

Based on observation, interview, and record review, the facility failed to develop and/or implement certain systems and procedures for controlling/preventing infections.

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

Part I
Reference: Policy "Hand Hygiene" dated 12/11 read in part "C. Hands are to be decontaminated in the following clinical situations ...
2. Before having direct patient contact
4. After contact with intact skin ...
5. After contact with any body fluids or excretions, mucous membranes, non-intact skin and would dressings
6. After contact with inanimate objects in the immediate vicinity of the patient
7. After removing gloves ... "

There is no reference in the policy in general referring to other ways in which hands may be contaminated and must be cleaned.

On 4/4/12 Surveyor #2 observed a patient's pre-operative activities by staff. The following were failed situations in which hand hygiene was not performed correctly:
· Staff Member #5 dried his hands on a paper towel rather than drying them by rubbing together as directed by the manufacturer instructions.
· Staff Members #5 and #6 did not do hand hygiene when entering the pre-op cubicle as required by hospital policy.
· Staff Member #5 did not perform hand hygiene after removing gloves before having patient contact.
· Staff Member #5 did not do hand hygiene after removing gloves used for placing an airway before having further patient contact.
· Staff Member #6 picked up a cable from the floor, and without cleaning it or doing hand hygiene attached it to the patient.

Part II
· Prior to a surgical procedure Staff Member #7 put the machine and tubes from the leg compressing devices on the floor before placing them on the gurney and attaching them to the patient.

Part III
· In the pre-op area Staff Member #7 brought a basket of IV (intravenous) line start supplies to the patient's bedside rather than bringing just the supplies needed. The basket was removed after starting the line, removing potentially contaminated supplies with it. Questioning management, they could not describe how the baskets were maintained and/or cleaned between patients.

Part IV

Reference:
Policy titled Mobile Computer Cleaning Guidelines stated that hand hygiene was to be done prior to contact with the computers. Sanitizing of the machine in high touch areas was also to be done after each patient use, when visibly soiled, or when likelihood for contamination had occurred.
· Throughout the survey Surveyor #2 questioned staff in each area surveyed regarding the cleaning of the laptop/computer keyboards and mice in the various care areas. A variety of responses, generally hesitant, were given, and were not consistent.
· Questions regarding cleaning of hand held telephone and paging devices which were handed off between staff at intervals revealed there was not official facility policy for doing so.

Part V

On 4/5/12 Surveyor #2 surveyed Unit 3E. Staff Member #8 identified a room as reserved for rehab patient that was not often used, but had been cleaned and prepared for patient use. Large clump of debris were observed on the floor, and dead insects on vertical surfaces.

Part VI

On 4/3/2012 Surveyor #1 was interviewing the parent of patient #2 who was in droplet and contact isolation. During the interview a respiratory therapist (Staff Member #3) walked into the room without putting on the proper personal protective equipment (gown, glove, and mask).

Part VII

On 4/5/2012 Surveyor #1 observed patient care in the Cancer Center. An RN (Staff Member #2) was observed starting intravenous fluids for Patient #3 then touching a computer keyboard to document her/his care. After the RN completed her/his documentation she/he put on a gown and gloves and entered the room of Patient #4 who was in contact isolation. The RN did not perform proper hand hygiene after caring for Patient #3 and before entering the room of Patient #4.

Based on interview and record review, the facility failed to develop and follow policies and procedures for post-anesthesia evaluation that meet the regulation and reflect professional standards of anesthesia care.

Failure to do so places patients at risk of unrecognized complications of anesthesia care and potential delays in any necessary treatment.

Findings include:

On 4/3/12 Surveyor #2 reviewed the medical record for one patient who had undergone surgery (Patient #7). Incomplete documentation of the post-anesthesia evaluation by an individual qualified to administer anesthesia was found.

"Practice Guidelines for Post-anesthetic Care", in the journal Anesthesiology, Volume 96, #3, March, 2002, and cited by CMS as best practice, provides guidelines from the American Society of Anesthesiologists (ASA) for routine post-anesthesia assessment. These include assessment of the following patient parameters:

- Respiratory function, including respiratory rate, airway patency, and oxygen saturation
- Cardiovascular function, including pulse rate and blood pressure
- Mental status
- Temperature
- Pain
- Nausea and vomiting
- Postoperative hydration

Patient #7's post anesthesia evaluation did not include blood pressure, pulse rate, temperature, and respiratory rate.

Records for Patients #8, #9, and #10 were reviewed on 4/5/12 for content of post-anesthesia evaluations. The previously-described form was used for all three patients, and all evaluations failed to address various of the parameters listed above.

Based on interview, the facility did not integrate emergency services within hospital units where they were required. The facility failed to conduct periodic staff training for a specific potential emergency situation and have procedures in place to manage it.

Failure to do so risks patient care by staff unprepared or unable to competently perform their duties, potentially resulting in patient debility and death.

Findings:

During a tour of the Emergency Department on 4/3/12 Surveyor #2 learned that a specific drug (succinylcholine) was used at times to assist with intubation. This drug poses a risk of causing a rare but life-threatening emergency known as malignant hyperthermia (MH).

The Emergency Department Director (Staff Member #9) stated that staff in the area were not trained to meet this emergency. No plan had been formulated that would address who would respond and how needed items would be obtained in rapid fashion. To successfully rescue a patient experiencing MH the response must be immediate and ongoing until the patient is stabilized.

The syndrome can occur also in areas of the facility where peri-operative patients receive care. During interviews with Staff Member #8 on 4/3/12 where post-operative patients received care, Surveyor #2 learned that no procedures were in place to manage MH should it occur on that unit.