HospitalInspections.org

.
0888

.
Based on observation, interview, and review of hospital policy, the hospital failed to develop and implement a quality control system to prevent the use of emergency patient care equipment and supplies that were beyond the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed their expiration dates risks deteriorated or potentially contaminated supplies being available for patient use.

Reference: "2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care)," 2020 Guidelines are a comprehensive revision of the AHA's guidelines for adult, pediatric, neonatal resuscitation education science, and systems of care topics. Previously updated in 2015 and 2018.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Central Services Sterile Supplies/Shelf Life Standards," no policy number, reviewed 10/15/20, showed that all items processed by the hospital's central sterile department are considered sterile unless the integrity of the packaging has become compromised or the item has reached its shelf life per the manufacturer's instructions for use regarding packaging material. If there are doubts regarding the integrity of the packaged item or if the item has reached its expiration date as annotated on the load sticker with "expiration" in red followed by the date the item should be considered contaminated and not used.

Document review of the hospital's policy and procedure titled, "Code Blue: Cardiac or Respiratory Arrest," no policy number, reviewed 06/08/21, showed that the hospital utilizes the American Heart Association Adult Cardiopulmonary Life Support Guidelines, the American Heart Association Pediatric Advanced Like Support Guidelines, and the American Heart Association Academy of Pediatrics Neonatal Resuscitation Program guidelines for Cardio Pulmonary Resuscitation and Basic Life Support. The policy cites as references the 2020 American Heart Association Adult Advanced Cardiac Life Support Guidelines for, the 2020 American Academy of Pediatrics Neonatal Resuscitation Textbook and the 2020 American Heart Association Pediatric Advanced Life Support Provider Manual.

2. On 06/15/21 at 10:40 AM, Surveyor #5 and the Emergency Room Director (Staff #501) inspected an emergency supply cart (code cart) located in the hospital's emergency department. Surveyor #5 observed a Central Line Triple Lumen Kit with a manufacturer's expiration of 01/31/21.

3. At the time of the observation, Staff #501 confirmed the finding and removed the kit from the emergency cart.

4. On 06/15/21 at 10:50 AM, Surveyor #5, the Emergency Room Director (Staff #501), and a Registered Nurse (Staff #502) inspected an emergency supply cart (code cart) located in the hospital's emergency department. Surveyor #5 observed the following:

a. 1 Central Line Triple Lumen Kit with a manufacturer's expiration of 01/31/21.

b. 2 Advanced Cardiac Life Support emergency treatment resource and emergency medication resources dated 2015.

5. At the time of the observation, Staff #501 and #502 confirmed the findings. Staff #501 removed the supply kit from the emergency cart.

6. On 06/15/21 at 11:05 AM, Surveyor #5, the Emergency Room Director (Staff #501), and a Registered Nurse (Staff #502) inspected a pediatric emergency supply cart (code cart) located in the hospital's emergency department. Surveyor #5 observed a medication and emergency treatment resources and emergency medication resources that included cards containing algorithms for emergency care and emergency treatment that were expired including:

a. 2 Pediatric Advanced Life Support (PALS) Crash Cart Algorithm Cards dated 2011.

b. 2 Broselow pediatric algorithm cards (Emergency System approved for the PALS care of children 3 to 36 kg. The system utilizes a color-coded system that helps provide quick and accurate medication dosing by utilizing length to categorize pediatric patients using color zones) dated 2017.

7. At the time of the finding, Staff #502 stated that the hospital had recently ordered current emergency care reference materials for the emergency carts.

8. On 06/16/21 at 9:16 AM, Surveyor #5 and the Chief Nursing Officer (Staff #503) inspected 2 emergency supply carts located in the hospital's Intensive Care Unit. Surveyor #5 observed the following:

a. 2 Thoracic Central Line catheters (sizes 32 French and 36 French) with a manufacturer's expiration date of 05/20.

b. 2 Broselow pediatric algorithm cards dated 2017.

c. 1 package of Vaseline® gauze with a manufacturer's expiration of 02/28/21.

d. 1 #10 scalpel with a manufacturer's expiration of 04/30/21.

e. 1 #11 scalpel with a manufacturer's expiration of 04/30/21
.

.
Based on record review, interview, and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for one of one record reviewed (Patient #711).

Failure to follow blood transfusion procedures, according to acceptable standards of practice, places patients at risk for transfusion reactions and complications.

Reference: Appendix W section §485.638(a)(4), showed that a properly executed informed consent form contains a date and time obtained among other items.

Findings included:

1. Document review of the hospital's policy and procedure titled, "KVH-Blood Products Transfusion", no policy number, last reviewed 04/27/21, showed that consent will be obtained prior to blood transfusion and that for an infant receiving blood, vitals will be monitored 15 min after start of blood transfusion and then every hour after that.

2. On 06/17/21 at 2:31 PM, Surveyor #7 and the Director of Medical/Surgical and the Critical Care Unit (Staff #711) reviewed the medical chart for Patient #711, a baby born on 03/23/21 at 7:20 PM. Review of the medical chart showed:

a. Patient #711 began receiving a blood transfusion at 11:22 PM on 03/23/21. Staff documented vital signs at at 11:22 PM and at 11:45 PM. Surveyor #7 found no further vitals documented. The patient transferred to a different facility at 3:10 AM on 03/24/21.

b. The signed informed consent for transfusion of blood for Patient #711 contained no time and date.

3. At the time of the record review, Staff #711 verified the consent for Patient #711 had no time noted and that no one-hour vitals were documented in the medical chart.
.

.

Based on observation, interview, and document review, the hospital failed to ensure that all facility and medical equipment is listed in an inventory which includes a record of maintenance activities.

Failure to maintain a complete inventory of equipment deemed safe to use and with record of preventative maintenance puts patients and staff at risk of injury or harm.

Findings included:

1. On 06/16/21 between 8:30 AM and 10:00 AM, Surveyors #1 and #4 inspected the Physical Therapy and Occupational Therapy Facilities with the Infection Control/Employee Health Coordinator (Staff #401). Surveyors observed an Automated External Defibrillator (AED) in the Occupational Therapy building that had no preventative maintenance (PM) sticker.

2. On 06/16/21 at 10:30 AM, Surveyors #1 and #4 inspected the Urgent Care facility in Cle Elem with Staff #401 and the Urgent Care Certified Nursing Assistant (Staff #403). During the inspection, Surveyors observed a Brechnell patient scale with no PM sticker.

3. On 6/17/21 at 11:00 AM, Surveyors interviewed the Chief of Facilities (Staff #404) about the process for PM's on equipment. Staff #404 stated these items should have a PM done by Engineering and that he would look up these items.

4. On 6/17/21 at 3:00 PM, the Chief Quality Officer (Staff #405) provided a policy titled, "AED Stations," no policy number, effective date 4/30/21, that showed staff will inspect each AED on a monthly basis and document on the AED inspection sheet. Staff #405 provided a blank copy of the "KVH AED Monthly Check Log" that is used for documenting monthly checks. Staff #405 stated this AED in the Occupational Therapy building had been missed in the inventory and not had its monthly checks completed.

5. Staff #405 also confirmed the patient scale at the Cle Elum Urgent Care facility had been missed and did not have its PM completed.
.

.

Based on observation and interview, the critical access hospital failed to maintain floors and walls in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Reference: AORN Guideline for Design and Maintenance, (2019) - "Recommendation XII.a. The integrity of structural surfaces (eg, doors, floors, walls, ceilings, cabinets) should be maintained, and surfaces should be repaired when damaged. ...XII.a.1. ...Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Last Update July 2019) (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee).

Findings included:

1. On 06/15/21 at 10:48 AM, during inspection of Room #2/3 located in the hospital's Emergency Department, Surveyor #5 observed a long gapping cracked areas of flooring near where the flooring met with the wall.

2. At the time of the observation, the Director of the Emergency Department (Staff #501) confirmed the finding and stated that the issue had been reported through the hospital's variance reporting system and that the hospital's aware of the issue.

3. On 06/16/21 at 12:01 PM, Surveyor #5 and the Surgery Director (Staff #517) inspected the operating room and observed a right knee arthroscopy for Patient #513. During inspection of the surgical suite, Surveyor #5 noted long gapping cracked areas near where the floor met with the wall.

4. At the time of the finding, Staff #517 confirmed the observation and stated that the hospital was aware and in discussion about floor repairs .

5. On 06/16/21 at 3:00 PM, Surveyor #1 and Surveyor #4 inspected the hospital's Emergency Department (ED) with the Director of Emergency Service (Staff #406) and the Infection Control/Employee Health Coordinator (Staff #401). During the inspection, surveyors observed several holes in the wall and cracking in the flooring along the walls in an ED patient room.

6. Staff #406 stated the flooring was being discussed for repairs/remodel.

.

.
Item #1: Air Ventilation

Based on observation, interview and document review, the hospital failed to maintain air pressure relationships consistent with industry standards for ventilation in healthcare facilities.

Failure to maintain the ventilation within industry standard tolerances places patients at risk for inadequate care or infection and staff at risk for infection or occupational exposure to hazardous chemicals.

Reference: Centers for Disease Control and Prevention (CDC): Guidelines for Environmental Infection Control in Healthcare Facilities (2003), updated July 2019. Ventilation Specifications for Health-Care Facilities Table B.2, Pg. 226. In Clean workrooms and Clean linen storage air movement relationship to the adjacent area should be out; in soiled or decontamination rooms air movement relationship to the adjacent area should be in.

Reference: TSI Healthcare Guidelines and Standards, Table 7-1 Design Parameters from ANSI/ASHRE/ASHE, Standard 170-2008. Specifies that the air flow for clean linen storage rooms need to be positive in relationship to the adjacent areas with a minimum of 2 air changes per hour.

Findings included:

1. On 06/16/21 at 10:30 AM, Surveyors #1 and #4 inspected the Urgent Care facility in Cle Elem with the Infection Control/Employee Health Coordinator (Staff #401) and the Urgent Care Certified Nursing Assistant (Staff #403). During the inspection, Surveyors could not determine the air flow relationship in the Lab/Soiled Utility room.

2. On 6/17/21 at 10:00 AM, Surveyors interviewed the Chief of Facilities (Staff #404) about the air pressure in the Lab/Soiled Utility room at the Urgent Care Facility in Cle Elem. Staff #404 was not sure if the room was under negative air pressure.

3. On 6/17/21, Surveyor #4 reviewed the 2021 (to date) checklists titled, "Weekly: Air Flow and Blanket Warmers," utilized by facilities staff to report the room air pressure pass/fail checks. The Urgent Care Facility in Cle Elem was not included in the routine air pressure checklists.

Item #2: Cold Holding

Based on observation and interview, the hospital failed to ensure that dietary staff members implemented procedures for food safety consistent with the Federal Drug Administration Food Code.

Failure to implement the food safety requirements puts patients, staff, and visitors at risk for development of food borne illness.

Reference: Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. 2009 Food and Drug Administration Food Code (FDA) (3-501.16(A)(2)), Washington State Retail Food Code, WAC 246-215-03525.

Findings included:

1. On 06/16/21 at 12:30 PM, Surveyor #1 and Surveyor #4 inspected the hospital's dietary services kitchen with the Dietary Manager (Staff #402). During the inspection, surveyors used a thin-stemmed thermometer to assess the internal temperature of Potentially Hazardous Food (PHF) in the reach-in refrigerated deli case of the cafeteria. The temperature of the PHF was above the maximum allowable 41 degrees Fahrenheit (F).

2. Surveyors interviewed Staff #402 about the process for cold holding of PHF. Staff #402 stated the items should be under 41 degrees F. Staff #402 also stated that the facility had a problem previously with the deli case being too cold on the bottom level for some items and that this tray of PHF had been incorrectly placed too far above the refrigerated bottom. Staff #402 discarded the PHF that was above 41 degrees F.

.

.
Item #1 Restraints

Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff followed its policy for restraining patients for one of two patients reviewed (Patient #715).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital policy and procedure titled, "Restraints/Net Bed," no policy number, last reviewed 03/16/21, showed that: if restraints or seclusion are used there will be an order form the physician responsible for the patient.

2. On 06/17/21 at 4:50 PM, Surveyor #7 and the Director of the Medical Surgical and CCU (Staff #711) reviewed the medical record of Patient #715 which showed: The patient was placed into restraints at 1:00 PM and has every 15 minute rounding until he was released at 2:45 PM. No documentation of an order was found for restraints in the chart.

3. At the time of the finding, the Director of Medical/Surgical and Critical Care (Staff #711) verified that there was no order for restraints in the medical chart.

Item #2 Pain Assessments and Reassessment

Based on record review, interview, and review of policy and procedure, the critical access hospital failed to ensure staff members completed and documented pain assessment and reassessments prior to and after each pain management intervention as directed by hospital policy for 11 of 13 patient records reviewed (Patient #501, #502, #503, #507, #701, #702, #704, #708, #717, #718 and #719).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain.

Findings included:

1. Document review of the critical access hospital's policy and procedure titled, Lippincott Procedures-Pain Management, KVH Pain Management," no policy number, reviewed 111/20/20, showed that staff will ask the patient to rank the pain on a scale from 0 to 10, with 0 denoting lack of pain and 10 denoting the worst pain. Upon completion of a pain assessment, symptoms should be controlled in the least invasive manner available, followed by re-assessment and evaluation. Document each step of the nursing process and describe the subjective information using the patient's own words. Note the location, quality, and the duration of the pain as well as the precipitating factors. Record the pain relief methods selected and the patient's rating of pain before and after pain management interventions.

Document review of the hospital policy titled, "Vital Signs - Monitoring" no policy number, last revised 09/12/19, showed that vital signs will include a pain assessment with a pain scale appropriate to the patient's age and condition and reassessments shall be documented 60 minutes after pain medication administration.

2. On 06/15/21 at 11:20 AM, Surveyor #5 and an Emergency Department Registered Nurse (Staff #506) reviewed the medical record for Patient #502 who was triaged in the Emergency Department for abdominal pain on 06/15/21 at 10:49 AM. Surveyor #5 found no evidence that staff utilized a pain rating scale for the patient to rate her pain.

3. At the time of the observation, Staff #504 stated that staff generally used a numeric scale for patients to rate their pain, but that it depended on who completed the triage.

4. On 06/15/21, at 11:20 AM, Surveyor #7 and the Special Programs Coordinator (Staff #705) reviewed the medical record of a patient in the Emergency Department (ED). The review showed the following:

a. Patient #701 was a 65-year-old female that presented to the ED on 06/15/21 at 9:43 AM, with complaint of chest pain. At the time of this record review Surveyor #7 found no evidence of a pain assessment.

5. At the time of review Staff #705 verified there was no evidence of a pan assessment in the medical chart.

6. On 06/15/21 at 4:00 PM, Surveyor #5 and the Director of Family Birth Center (#504) reviewed the medical record for Patient #501 who was admitted for childbirth. The review showed the following:

a. On 06/13/21 at 11:04 PM, Patient #501 received Stadol 0.5 mg for "moderate pain." Surveyor #5 found no evidence staff completed or documented a pain assessment as directed by hospital policy. Surveyor #5 found no evidence hospital staff completed or documented a reassessment of the patient's pain after the medication intervention.

b. On 06/14/21 at 1:55 PM, the patient received Ibuprofen 600 mg for "mild pain." Surveyor #5 found no evidence staff completed or documented a pain assessment as directed by hospital policy. Surveyor #5 found no evidence hospital staff completed a reassessment of the patient's pain as directed by hospital policy including notation of pain location.

c. On 06/15/21 at 1:15 PM, the patient received Ibuprofen 600 mg for "mild pain." Surveyor #5 found no evidence staff completed or documented a pain assessment as directed by hospital policy. Surveyor #5 found no evidence hospital staff completed a reassessment of the patient's pain as directed by hospital policy including notation of pain location.

7. At the time of the document review, Staff #504 verified that the pain assessments and reassessments did not meet requirements of the hospital's policy.

8. On 06/15/21 at 3:10 PM, Surveyor #7 and a Registered Nurse (RN) (Staff #710), reviewed the medical record of Patient #702, a patient who had delivered a baby. Patient #702 received pain medication on 06/14/21 at 9:41 PM for a pain rating of 5/10. There was no reassessment noted in the chart.

9. At the time of the review Staff #710 verified there was no pain assessment found in the medical chart.

10. On 06/16/21 at 9:30 AM, Surveyor #5 and a Registered Nurse (Staff #507) reviewed the medical record for Patient #503. The review showed the following:

a. On 06/15/21 at 12:45 PM, the patient received Acetaminophen 650 mg for pain. Surveyor #5 found no evidence staff assessed and documented the patient pain prior to medication intervention or completed a reassessment after medication administration.

b. On 06/15/21 at 4:20 PM, the patient received Acetaminophen 650 mg for pain. Surveyor #5 found no evidence staff assessed and documented the patient pain prior to medication intervention or a reassessment after medication administration.

11. On 06/16/21 at 9:52 AM, Surveyor #7 and the Director of Medical, Surgical and Critical Care Unit (Staff #711), reviewed the medical record for Patient #704, an 84-year-old male who has chronic pain. On 06/12/21 at 8:07 AM Patient #704 had a complaint of 8/10 pain and received Tylenol at 8:09AM. Further review showed the patient received Oxycodone at the following times: 06/15/21 at 6:46 AM, 06/15/21 at 12:11 PM, 06/15/21 at 10:12, 06/16/21 at 3:22 AM.

Surveyor #7 found no evidence hospital staff reassessed the patients' pain to determine efficacy of the medication intervention.

12. On 06/16/21 at 9:54 AM, Surveyor #7 and the Director of Medical, Surgical and Critical Care Unit (Staff #711), reviewed the medical record for Patient #717. On 06/15/21 at 10:41 PM, Patient #717 received 10mg of Oxycodone for pain. Surveyor #7 found no evidence hospital staff reassessed the patients' pain to determine efficacy of the medication intervention.

13. On 06/16/21 at 9:59 AM, Surveyor #7 and the Director of Medical, Surgical and Critical Care Unit (Staff #711), reviewed the medical record for Patient #718. On 06/14/21 at 10:30 PM, the patient received Oxycodone, on 06/16/21 at 6:10 AM she received Tylenol and Oxycodone. Surveyor #7 found no evidence hospital staff reassessed the patients' pain to determine efficacy of the medication intervention for any of the listed times listed.

14. On 06/16/21 at 10:00 AM, Surveyor #7 and the Director of Medical, Surgical and Critical Care Unit (Staff #711), reviewed the medical record for Patient #719. On 06/15/21 at 6:50 PM, Patient #719 received 1,000 mg of Tylenol. Surveyor #7 found no evidence hospital staff reassessed the patients' pain to determine efficacy of the medication intervention.

15. On 06/17/21 at 10:20 AM, Surveyor #7, Surveyor #5 and Staff #711 reviewed the medical record for Patient #708, who was admitted to a swing bed for post hip surgery on 01/18/21. Patient #708 received pain medication at 11:42 PM on 01/22/21, at 6:18 AM and 12:03 PM on 01/23/21. Surveyor #7 found no evidence hospital staff reassessed the patients' pain to determine efficacy of the medication intervention.

16. On 6/17/21 at the conclusion of chart review, Staff #711 verified the missing reassessment findings for the patients #704, #708, #717, #718 and #719.

17. On 06/17/21 at 10:30 AM, Surveyor #5 and a Quality Improvement Registered Nurse (Staff #508) reviewed the medical record for Patient #507 who was admitted to the hospital's Swing Bed program on 01/22/21 post a hip fracture repair. The review showed that the patient was medicated for "moderate pain" on 01/22/21 at 11:42 PM and 01/23/21 at 6:48 AM.

Surveyor #5 found no evidence hospital staff assessed the patient pain per hospital policy prior to pain medication administration including location of the pain or reassessed the patient after the medication interventions

18. At the time of the finding, Staff #508 verified the incomplete assessment and lack of reassessment.

Item #3 Consent

Based on interview, record review, and review of policy and procedures, the critical access hospital failed to properly obtain informed consent as directed by the critical access hospital's policy and procedure for 9 of 9 patients consents reviewed (Patient #501, #507, #508, #509, #510, #511, #512, #713, and #714).

Failure to properly obtain informed consent risks patients not being fully informed of potential risks.

Findings included:

1. Document review of the hospital policy titled, "Informed Consent", no number, last reviewed 02/06/17, showed that a consent is only valid if it is signed and dated prior to treatment and the treating physician should obtain a properly filled out consent."

2. On 06/15/21 at 4:00 PM, Surveyor #5 and the Director of Family Birth Center (#504) reviewed the medical record for Patient #501 who was admitted for childbirth. The review showed that the provider failed to date and time the anesthesia consent. The provider failed to ensure that the patient completed all sections of the consent including the section for considerations to be observed, and the section discussing other providers participating in anesthesia care that directs the patient to give consent by circling yes, no, or not applicable.

3. At the time of the finding, Staff #504 verified the lack of date and time by the provider and the blank sections of the document.

4. On 06/17/21 from 9:15 AM until 11:30 AM, Surveyor #5, a Quality Improvement Registered Nurse (Staff #508), the Director of Medical/Surgical and Critical Care (Staff #510), and the Chief Nursing Officer (Staff #503) reviewed the medical records for 3 patients admitted to the hospital's Swing Bed program (Patient #507, #508 and #509). The review showed that the Swing Bed Contract Consent forms were dated but not timed by the hospital representative for all 3 patients. The document did not provide a space for staff to document the time of the signature verifying the patient's consent.

5. At the time of the finding, Staff #508 verified the absence of timing of the hospital representatives signature verifying the patient's consent.

6. On 06/17/21 at 3:00 PM, Surveyor #5 and a Quality Improvement Registered Nurse (RN) (Staff #508) reviewed the medical records for 3 patients receiving blood transfusions (Patient #510, #511, and #512). The review showed the following:

a. Patient #510 received 2 unit of blood on 02/04/21. The hospital's witness to the blood consent failed to date and time the document.

b. Patient #511 received 2 units of blood on 02/19/21. The hospital's witness to the blood consent failed to time the document.

c. Patient #512 received 1 unit of blood on 03/02/21. The hospital's witness to the blood consent failed to time the document.

7. At the time of the observation, Staff #508 confirmed the incomplete documentation and noted that the document did not provide an area for staff to "time" the document.

8. On 06/17/21 at 3:55 PM, Surveyor #7 and the Director of Medical, Surgical and Critical Care Unit (Staff #711), reviewed the medical record for Patient #714, who was being treated for a malignant neoplasm of the colon. Patient #714 has no time noted on her anesthesia consent.

9. On 06/18/21 at 8:40 AM, Surveyor #7 and Staff #711 reviewed the medical record for Patient #713, a 61-year-old female who was admitted for abdominal pain. On 01/02/21 at 1:58 PM, Patient #713 had a surgical procedure and no documentation of an anesthesia consent was found in the chart.

10. On 06/18/21 at 9:50 AM, Staff #711 verified the missing time on the consent for Patient #714 and the missing consent form for Patient #713.

Item #4 Immunization Status for Pediatric Patients

Based on interview and document review the hospital failed to ensure staff assessed and documented pediatric patients' immunization status for 2 of 3 pediatric patients presenting to hospital's Emergency Department for care and treatment (Patient #504 and #505).

Failure to assess patients for immunization status limits the hospitals ability to assess and determine priorities of treatments and can lead to patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Lippincott Procedures-Triage, emergency department: KVH Triage, Emergency Department," no policy number, revised 05/15/20, showed that staff must assess the pediatric patient immunization status during the triage assessment.

2. On 06/17/21 at 3:30 PM, Surveyor #5 and a Quality Improvement Registered Nurse (RN) (Staff #508) reviewed the medical records for Patient #504, a pediatric patient seen in the hospital's Emergency Department. Surveyor #5 found no evidence that staff assessed or documented the patient's immunization status.

3. On 06/17/21 at 3:45 PM, Surveyor #5 and a Quality Improvement Registered Nurse (RN) (Staff #508) reviewed the medical records for Patient #505, a pediatric patient seen in the hospital's Emergency Department. Surveyor #5 found no evidence that staff assessed or documented the patient's immunization status.

4. At the time of the observation, Staff #508 verified that the medical record did not contain evidence that staff assessed or documented the patient's immunization status.

Item #5 Newborn Screenings

Based on interview and document review the hospital failed to ensure staff completed and documented newborn phenylketonuria (PKU) screening test (a blood test given to newborns 24-72 hours after birth to identify a rare disorder that prevents the body from properly breaking down a substance called phenylalanine) and hearing testing for 1 of 4 newborn patients reviewed (Patient #506).

Failure to ensure newborn screening are completed risks failure to identify and treat conditions that can cause serious health problems.

Reference:

WAC 246-650-020: Performance of screening tests: (1) Hospitals and other providers of birth and delivery services or neonatal care to infants shall: (b) Obtain a blood specimen for laboratory testing as specified by the department from each newborn no later than forty-eight hours following birth (c) Use department-approved newborn screening specimen/information forms and directions for obtaining specimens (d) Enter all identifying and related information required on the newborn screening specimen/information form following directions of the department (e) In the event a parent or guardian refuses to allow newborn screening, obtain signatures from parents or guardians on the newborn screening specimen/information form (f) Forward the newborn screening specimen/information form with dried blood spots or signed refusal to the Washington state public health laboratory so that it will be received no later than seventy-two hours following collection of the specimen, excluding any day that the state laboratory is closed.

"Washington State Department of Health Protocol for Newborn Hearing Screening Overview," no date, The Washington State Early Hearing Detection, Diagnosis and Intervention (EHDDI) program recommends screening all infants for hearing loss before one month of age. This protocol includes guidance from the Joint Committee on Infant Hearing (JCIH) 2007 position statement. For the initial screening, use one of the following: Evoked Otoacoustic Emissions (EOAE, OAE, TEOAE, DPOAE), Auditory Brainstem Response (ABR, AABR, BAER, ABAER), or a combination of both measures. The birth hospital typically performs the initial screen while the baby is still an inpatient. Perform the screen as close to discharge as possible, preferably 12 hours or more after birth. Record screening results in the infant's medical record. Report screening results to the Department of Health (DOH) on the newborn hearing screening cards. Send results to DOH every week.

Finding included:

1. On 06/15/21 at 3:10 PM, Surveyor #5 and a Registered Nurse (Staff #509) reviewed the medical record of a newborn infant who was being discharge home. Surveyor #5 found no evidence in the medical record that the PKU and hearing screening had been completed and the patient was being readied for discharge home with its parent. Surveyor #5 requested the hospital's policy related to newborn/infant assessment and screening.

2. At the time of the observation, Staff #509 verified that there was no documentation of the screenings being performed but stated that she mailed them to the state that morning. She had no documentation or paperwork to verify that the screening had been completed or had been mailed. She stated she would call the nurse who would have completed the screenings to verify completion prior to the patients discharge home. Staff #509 stated that PKU and hearing screening were required at 24 hours after birth, but that parents could refuse.

3. On 06/16/21, the hospital provided Surveyor #5 with policies related to admission assessments, discharge planning, and required documentation. The policies did not address newborn assessments or screenings. The hospital did not provide a specific policy related to newborn assessment or screenings.

Item #6 Patient Care Equipment

Based on observation, interview, and document review, the hospital failed to develop policies and procedures based on nationally recognized organizations for the use of patient care equipment.

Failure to follow best practices based on nationally recognized organizations for blanket warmer cabinets places patient at risk of burns.

Reference: Evidence-based guidelines and recommendations by organizations such as but not limited to Association of peri-Operative Registered Nurses (AORN) and Emergency Care Research Institute (ECRI) to determine optimal and safe temperatures for blankets warmers. Both AORN and ECRI recommend not to exceed maximum temperature setting of 130 degrees Fahrenheit (54 degrees Celsius) for blanket warming cabinets.

Findings included:

1. On 06/16/21 at 3:10 PM, Surveyor #1 and #4 observed a blanket warmer cabinet in the emergency department with an adult set temperature of 140 degrees Fahrenheit (F).

2. On 6/17/21 at 10:00 AM, Surveyors interviewed the Chief of Facilities (Staff #404) about the adult set points being at 140 F for the blanket warmers. Staff #404 stated that all the blanket warmers had an adult set point for 140 F and that the maintenance checklist specified checking and documenting they were at or above 140 F weekly. Staff #404 was unaware why 140 F was used as the set point and believed this was established by his predecessor.

3. On 6/17/21, Surveyor #4 reviewed the 2021 (to date) checklists titled, "Weekly: Air Flow and Blanket Warmers," utilized by facilities staff to document weekly blanket warmer temperature checks. The checklists include 4 blanket warmers throughout the facility (PAR, Radiology, ED Upper, M/S) to be checked for temperature ">140F."

4. On 6/18/21 at 8:00 AM, Surveyors discussed the national recommendations for blanket warmers with the Chief Quality Officer (Staff #405). Staff #405 stated the temperature setting would be changed and implemented to reflect ECRI and AORN recommendations.
.

.
Item #1 Expired medication

Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability or efficacy.

Findings included:

1.Document review of the hospitals policy titled, "Medication Storage," no number, last reviewed 05/01/14, showed that medications should be discarded according to the manufacturers expiration date.

2. On 06/15/21 at 1:35 PM, Surveyor #7 with the Director of the Family Birth Center (Staff #707) and an Anesthesiologist (Staff #709) found an anesthesiologist cart with several expired medications which are listed as follows:

a. Forty vials of 1% Lidocaine 10mg/ml that expired between 05/20 and 05/21.

b. One Saline flush that expired in 02/21.

c. Twenty-five vials of 1.5% Lidocaine, with epinephrine, which expired between 11/17 and 06/21.

3. On 06/16/21 at 3:30 PM, Surveyor #7 and a Registered Nurse (Staff#719) toured the Cle Elum Clinic and found unsecured medications which are listed as follows:

a. A nitro tablets vial that expired in 02/21.

b. Heparin 5000 units that expired in 09/21.

c. Racemic Epinephrine, 2.25% that expired in 07/20.

d. Four 10-ml saline flushes that expired on 12/31/20.

4. At the time of the findings, Staff #719 verified the counts and that the medications were expired.

Item #2 Unsecured medications

Based on observation, interview, and review of hospital policy and procedures, the hospital failed to ensure that medications were kept secure from potential unauthorized access.

Failure to secure medications risks potential diversion, medication errors, and patient safety.

Findings included:

1.Document review of the hospitals policy titled, "Medication Storage", no number, last reviewed 05/01/14, showed that medication storage cupboards will be locked.

2. On 06/16/21 at 3:30 PM, Surveyor #7 and a Registered Nurse (Staff #719) toured the Cle Elum Clinic. The surveyor found medications in an open, unlocked drawer in room 4. The meditations are listed as follows:

a. A full vial of nitroglycerin tablets.

b. Heparin, 1 bottle containing 5000 units.

c. Racemic Epinephrine 2.25%.

d. Four 10-ml saline flushes.

3. At the time of the finding Staff #719 verified the medications were not in a secured room or drawer.
.

.
Based on interview and document review the critical access hospital failed to ensure the infection control professional was appointed by the governing body, and that the appointment is based on recommendation from the medical staff leadership and nursing leadership.

Failure to follow infection control program organizational policies could result in an unqualified infection control professional overseeing the program which could place patients at increased risk.

Findings included:

1. On 06/17/21 between 3:15 PM and 4:30 PM, Surveyor #1 and Surveyor #4 held an infection control meeting to discuss the hospital infection control program.

2. Surveyors interviewed the Chief Quality Officer (Staff #405) about the qualifications and appointment process of the recently hired Infection Control/Employee Health Coordinator (Staff #401). Staff #405 stated Staff #401 was not appointed through the governing body and that she was not aware this was a requirement. Staff #405 stated she had previously discussed the qualifications and hiring with leadership.

3. On 6/17/21, a policy was provided titled, "Responsibilities of Board," no policy number, last reviewed 4/22/21, that showed an overview of the governing body responsibilities including to ensure governance structure and operation are appropriate and statutes are followed. No provision for infection control professional appointment was included.
.

43911

.
Item #1: Water Management Plan

Based on observation, interview and document review, the Critical Access Hospital failed to fully develop and implement their water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

b. Implement a water management program that considers the ASHRAE industry standard and/or the CDC toolkit, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and/or environmental testing for pathogens.

c. Specify testing protocols and acceptable ranges for control measures and document the results of testing and provide corrective actions taken when control limits are outside of acceptable ranges.

Findings included:

1. On 06/16/21 at 10:30 AM, Surveyors #1 and #4 inspected the Urgent Care facility in Cle Elem with the Infection Control/Employee Health Coordinator (Staff #401) and the Urgent Care Certified Nursing Assistant (Staff #403). During the inspection, Surveyors observed a support room at the Urgent Care facility identified as Lab/Soiled Utility with a humidifier running. Staff #403 stated the humidifier was needed to increase the humidity of the room and if it was too low, it could interfere with the lab testing done in the room.

2. Surveyors observed a digital thermometer with humidity reading 38%.

3. On 06/16/21 at 12:30 PM, Surveyor #1 and Surveyor #4 inspected the hospital's dietary services kitchen with the Dietary Manager (Staff #402). During the inspection, surveyors observed the kitchen ice machine with algae build up on the exterior of the ice machine drain line above the air gap.

4. Staff #402 confirmed there was a small amount of growth on the drain line.

5. On 6/17/21 at 10:30 AM Surveyors interviewed the Chief of Facilities (Staff #404) about the water management plan titled, "Kittitas Valley Healthcare Hospital Water Management Program," no policy number or date.

6. During the interview, surveyors determined that the plan was missing the following elements:

a) The facility has not conducted a complete risk assessment to identify risks in the hospital, such as medical equipment located at outpatient sites.

Staff #404 was not aware there was a humidifier located in the Cle Elem Urgent Care Facility.

b) The hospital had identified some risks on a flow chart but had not provided control measures such as temperature management, flushing system of areas of stagnation and/or disinfection level controls.

The water management plan included a "standard work" procedure for disinfection of the ice machines that did not address cleaning the drain line.

c) The hospital did not fully specify protocols and acceptable ranges for control measures and action levels when control levels are outside of the acceptable ranges.

7. At the time of the review, Staff #404 confirmed the missing elements of the plan.

Item #2: Discharge Cleaning

Based on observation, interview, and document review, the hospital failed to ensure staff cleaned patient rooms according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable diseases.

Findings included:

1. Document review of the hospital's policy titled, "Cleaning and Maintenance Standards," no policy number, last reviewed 07/31/18, and procedure titled, "Standard Work, Cleaning Patient Room After Discharge/Transfer," showed that Environmental Services (EVS) staff are to first clean the patient bed, then continue cleaning clockwise around the room.

2. On 6/15/21 at 2:15 PM, Surveyors #1 and #4 and the Infection Control/Employee Health Coordinator (Staff #401) observed a discharge room cleaning by EVS (Staff #407). Staff #407 removed the garbage from the room and stripped the patient bedding then proceeded to clean the toilet and bathroom before returning to clean the bed and the rest of the patient room.

3. During the observation the surveyors interviewed Staff #401 about the procedure for discharge cleaning. Staff #401 stated the room had not been cleaned according to hospital policy.

4. On 6/16/21 at 8:30 AM, Staff #401 reported that Staff #407 was being retrained on hospital cleaning policy and procedures.

Item #3: Sterile Processing PPE

Based on observation and review of hospital policy and procedure, the critical access hospital failed to ensure staff members followed the hospital policy for surgical attire when in a semi-restricted area.

Failure to properly secure masks and maintain coverage of facial hair poses a risk to contamination of the sterile processing area.

Findings included:

1. Document review of the hospital's policy titled, "Surgical Attire," no policy number, last reviewed 5/3/21, showed that clean surgical attire will be worn in semi-restricted areas (including central sterile processing) and that those with beards will wear a hood hair cover or beard cover.

2. On 6/15/21 at 10:00 AM, Surveyors #1 and #4 inspected the central sterile processing (CS) area of the hospital. During the inspection, the CS manager (Staff #408) wore a procedural mask without beard coverage while inside the semi-restricted rooms (short beard was visible).

3. On 6/16/21, surveyors requested confirmation on the personal protective equipment (PPE) policy requirements during sterile processing. The Chief Quality Officer (Staff #405) confirmed the surgical attire policy was used in CS and provided additional Lippencott educational materials for Standard Precautions (web page print out titled: Standard precautions, revised May 15, 2020) that would also apply.

Item #4: Instrument Storage, Prep and Transport

Based on observation, interview and document review, the hospital failed to develop and maintain effective infection control and sanitization practices for reprocessing reusable patient medical equipment/instruments, when storing clean re-usable instruments, and when transporting used medical equipment from clinics to the central sterile processing room (CS).

Failure to implement infection control practices places staff and patients at risk of infection.

References: Guideline for Disinfection and Sterilization in Healthcare Facilities, 2009, updated 05/19. Recommendations: C. 2. Cleaning of Patient-Care Devices b. Meticulously clean patient-care items with water and detergent, or with water and enzymatic cleaners before high-level disinfection or sterilization procedures.

Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. Recommendations of the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) Part II. Recommendations of HICPAC III. Prevention of Transmission of Microorganisms. A. Sterilization or Disinfection and Maintenance of Equipment and Devices 1. General measures a. Thoroughly clean all equipment and devices to be sterilized or disinfected.

Medline Dual Enzymatic Detergent and Presoak Manufacturer's Instructions for use stated to remove gross soil prior to soaking or cleaning. Use 0.5 to 1.0 ounces of concentrated solution to one gallon of water. For optimal enzyme action, mix the solution immediately prior to use. Change the cleaning solution after every batch of soiled instruments. Thoroughly rinse instruments with water to remove all traces of enzymatic detergent.

Findings included:

1. Document review of policy titled, "Central Services Sterile Supplies/Shelf Life Standards," no policy number, last reviewed 10/15/21, showed that items sterilized by CS should be stored to maintain package integrity and the end user is responsible for thoroughly inspecting the packages for integrity (seal, moisture, expiration) prior to use.

Document review of policy titled, "Clinic Instrument Preparation and Transportation," no policy number, no approval/review date, showed that offsite clinics are to properly prepare (drain, secure and pack) instrument bins for transport. The policy does not include any instructions for pre-cleaning or disinfection requirements.

2. On 06/15/21 at 12:01 PM, Surveyor #7 and a Medical Assistant Certified (MA-C) (Staff #723) inspected the supply cabinet for the procedure room in the GI clinic. Surveyor #7 observed the following:

a. Two Skylar 80-1972 Banding instruments unpackaged comingled in a basket on the shelf.

b. Three Welch Allyn anoscopes GTIN0073209407975 unpackaged comingled in a basket on the shelf

3. At the time of the finding, Staff #723 verified that the hospital reprocessed Skylar banding instruments and Welch Allyn GTIN0073209479975 anoscopes and that the items had not been stored in a way to prevent recontamination, or left in the packaging, due to the area of the body they are used in not being a sterile one and for ease of accessibility when needed.

4. On 06/16/21 at 10:30 AM, Surveyors #1 and #4 inspected the Urgent Care facility in Cle Elem with the Infection Control/Employee Health Coordinator (Staff #401) and the Urgent Care Certified Nursing Assistant (Staff #403). During the inspection, Surveyors observed sterilized reusable instruments in a pouch with a broken seal located in a patient room drawer.

5. Staff #403 confirmed the pouch integrity was compromised; she removed the instrument from the patient room for reprocessing.

6. During the Urgent Care inspection, surveyors interviewed Staff #403 about the process for returning reusable instruments to CS. Staff #403 stated the instruments were placed directly (no enzymatic pre cleaning or disinfection) into a sealed, clear box with biohazard label for pickup twice a day during the week. Staff #403 showed surveyors the box which was stored in the soiled utility/lab room.

7. On 06/17/21 at 11:57 AM, Surveyor #5, the General/Vascular Surgery Clinic Manager (Staff #511) and the Chief Nursing Officer (Staff #503) inspected a utility room located in the hospital's General/Vascular Surgery Clinic. Surveyor #5 observed a rectangular clear plastic container in the sink that was used to presoak/preclean reusable medical instruments prior to transport to the hospital for sterile reprocessing. The container was not marked in any way to determine volume measurement.

8. During interview with Surveyor #5, a Medical Assistant (Staff #515) stated that they used 30 milliliters of detergent, but she did not know how much water was added and could not verify the appropriate concentration of enzymatic detergent to water.

9. On 06/16/21 at 12:20 PM, Surveyor #5, the Clinic Manager (Staff #511), a Medical Assistant (Staff #514), and the Chief Nursing Officer (Staff #503) inspected the hospital's Orthopedic Surgery Clinic. Surveyor #5 observed that there was no dirty utility room and that a plastic container used to store used instruments was located on top of a bookshelf near the nurse's station.

10. At the time of the observation, Staff #514 stated that the plastic container was used to store reusable suture sets prior to transport to the hospital. He stated that the instruments were not sprayed or wiped prior to transport.

Item #5 Laryngeal Blade Storage

Based on observation, interview and document review, the hospital failed to store semi-critical equipment according to acceptable standards of practice and/or manufacturer instructions for use for laryngoscope blades.

Failure to properly store semi-critical devices risks contamination with microorganisms and places patients at risk for infection.

Reference: "Guidelines for Preventing Health-Care--Associated Pneumonia, 2003" (Centers for Disease Control and HICPAC), Semi-Critical equipment including laryngeal scope blades must be cleaned using sterilization or high-level disinfection and then packaged and stored in a manner to prevent recontamination.
Findings included:

1. Document review of the hospital's policy and procedure titled, "Central Services Sterile Supplies/Shelf Life Standards," no policy number, reviewed 10/15/20, showed that all items processed by the hospital's central sterile department are considered sterile unless the integrity of the packaging has become compromised, or in the item has reached its shelf life per the manufacturer's instructions for use regarding packaging material. If there are doubts regarding the integrity of the packaged item or if the item has reached is expiration date as annotated on the load sticker with "expiration" in red followed by a date the item should be considered contaminated and not used.

2. On 06/15/21 at 2:50 PM, Surveyor #5 and the Director of Family Birth Center (Staff #504) inspected an Anesthesia cart located in the Family Birth Center Operating Room. During the inspection, Surveyor #5 observed the following:

a. 2 laryngeal blades (1 Mac and 1 Miller) unpackaged and comingled in the anesthesia cart drawer.

b. 1 laryngeal blade unpackaged and attached to a handle sitting on top of the Anesthesia work cart.

3. At the time of the finding, Staff #504 verified that the hospital reprocessed the laryngeal blades and the blades had not been stored in a way to prevent recontamination.

Item #6 Expired Supplies

Based on observation, interview, and review of hospital policy, the hospital failed to develop and implement a quality control system to prevent the use of emergency patient care equipment and supplies that were beyond the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed their expiration dates risks deteriorated or potentially contaminated supplies being available for patient use.

1. On 06/15/21 at 10:18 AM, Surveyor #7 and the Special Programs Coordinator (Staff #705) inspected the Emergency Department (ED). Surveyor #7 observed the following expired supplies:

a. Yellow top culture bottle that expired on 03/19/21.

b. Purple top culture bottle that expired on 03/19/21.

2. At the time of the observation Staff #705 verified the expired supplies and removed them from the room.

3. On 06/15/21 at 1:35 PM, Surveyor #7 with the Director of the Family Birth Center (Staff #707) and an Anesthesiologist (Staff #709) found an anesthesiologist cart with several expired supplies which are listed as follows:

a. Intubating Stylet that expired in 08/17.

b. 25-gauge needle that expired in 06/16.

c. Steri strips that expired in 09/19, four 25-gauge needles that expired in 04/19 and two 30ml syringes that expired in 02/20.

4. At the time of the finding, Staff #707 verified the expired supplies and removed them from the cart.

5. On 06/16/21 at 8:51 AM, Surveyor #7 and the Director of the Medical Surgical and Critical Care Unit (Staff #711) inspected the Med/Surg unit. During the tour several expired supplies were found which are listed as follows:

a. Room #120: Two 22-gauge needles that expired in 03/26/21 and two 20-gauge needles with expiration dates of 03/26/21 and 04/28/21.

b. Med room: Two pair of Sensicare gloves size 8.5 that expired in 01/21, one 18-gauge needle that expired 12/31/20, Super Sani cloth wipes that expired in 09/15, and a Sani cloth bleach wipes that expired in 01/19.

6. On 06/16/21 at 12:00 PM, Surveyor #7 and a Registered Nurse (Staff #714) inspected the Post Anesthesia Care Unit (PACU). During the tour, expired supplies were found and are listed as follows:

a. Ten suction toothbrushes that expired on 05/13/21.

7. At the time of the observation, Staff #714 verified the expired supplies and removed them from the unit.

8. On 06/16/21 at 3:30 PM, Surveyor #7 inspected the Cle Elum Clinic and found expired supplies which are listed as follows:

a. An Artificial Manual Breathing Unit (AMBU) bag that expired on 09/05/19.

b. An EMT tooth saver in the dental box that expired in 11/20.

9. At the time of the finding, the Licensed Practical Nurse (Staff #516) verified the expired supplies and removed them.

10. On 06/17/21 at 12:18 PM, Surveyor #7 and the Clinic Manager (Staff #721), inspected the Ortho Clinic and found expired supplies in the cabinet and room #6 which are listed as follows:

a. Casting tape (room #6)

b. Three, 4-inch ScotchCast Plus casting tapes that expired in 04/20 (x2) and in 12/20 (cabinet).

c. Nine, 3-inch purple casting tapes that expired between 02/21 and 03/21 (cabinet).

d. Four, 1-inch casting tapes that expired in 03/21 (cabinet).

e. One, 3-inch pink casting tape that expired in 05/20 (cabinet).

f. One, 3-inch green casting tape that expired in 02/18 (cabinet).

g. Eleven, 2-inch casting tapes that expired between 02/18 and 03/21 (cabinet).

h. One, 2-inch orange casting tape that expired in 12/20 (cabinet).

11. At the time of the observation, Staff #721 confirmed the expired supplies and removed them from the room.

12. On 06/17/21 at 12:46 PM, Surveyor #7, a Licensed Practical Nurse (LPN) (Staff #724), and The Director of Surgery and Wound Care (Staff #725) inspected the Wound Care Clinic and found expired supplies in a wound care cart which are listed as follows:

a. Two 6.0 Biopsy punches that expired on 05/07/21.

b. Two 8.0 Biopsy punches that expired on 10/17/20.

c. Two Skintegrity that expired in 04/21.

d. Lipogel that expired on 04/11/21.

13. At the time of the finding, Staff #725 confirmed the expired supplies and removed them from the cart.

14. On 06/17/21, Surveyor #7 requested the hospitals policy for expired supply management. The hospital provided a policy titled, "Medication Storage and Access," no policy number, reviewed 05/01/14. The policy described the hospital's process for management of expired medication but did not discuss the hospital's process for outdated or expired supply and equipment management.


.

.

Based on observation and interview, the facility failed to provide a handwashing station in the soiled utility room used for high-level disinfection (HLD) of shared patient care equipment prior to transport to the Hospital's Central Sterile Department for sterilization.

Failure to provide hand-washing stations places staff at increased risk of exposure to infectious microorganisms during reprocessing of contaminated patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.8.1 Soiled workrooms shall contain (1) A clinical sink (or equivalent flushing-rim fixture) and a hand-washing station. Both fixtures shall have a hot and cold mixing faucet.

Findings included:

1. On 06/17/21 at 11:57 AM, Surveyor #5, the General/Vascular Surgery Clinic Manager (Staff #511) and the Chief Nursing Officer (Staff #503) inspected a utility room located in the hospital's General/Vascular Surgery Clinic. Surveyor #5 observed that the room contained one sink. A plastic container used to presoak/preclean reusable medical instruments prior to transport to the hospital for sterile reprocessing was located in the sink. Surveyor #5 checked the airflow and noted the airflow to be neutral to the hallway.

2. At the time of the observation, Staff #511 stated that there was not a separate clean utility room but that this room was utilized as both the clean and dirty utility room. Staff #511 verified there was no hand washing sink in the room and stated that as far as she knew it had always been used as a clean/dirty utility room and to disinfect used medical instruments prior to transport to the hospital. Staff #511 and #503 verified the airflow was neutral to the hallway.

3. On 06/16/21 at 12:20 PM, Surveyor #5, the Clinic Manager (Staff #511), a Medical Assistant (Staff #514), and the Chief Nursing Officer (Staff #503) inspected the hospital's Orthopedic Surgery Clinic. Surveyor #5 observed that there was no dirty utility room and that a plastic container used to store used instruments was located on top of a bookshelf near the nurse's station.

4. At the time of the observation, Staff #514 stated that the plastic container was used to store reusable suture sets prior to transport to the hospital. He stated that the instruments were not sprayed or wiped prior to transport. Staff #511 verified that there was no dirty utility room.

5. On 06/16/21 at 12:44 PM, Surveyor #5, the Director of Surgery and Wound Care (Staff #512), and a Licensed Practical Nurse (Staff #513) inspected the hospital's Wound Care Clinic. Surveyor #5 inspected a clean/dirty utility room that stored both medications and supplies and used instruments that were being collected for recycling. Surveyor #5 observed a piece of tape taped to the counter separating the clean area from the dirty area. The room contained just one sink on the dirty side.

6. Staff #513 stated that the room was used as a combined clean/dirty room and there was only one sink.

.
Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights for 3 of 3 patients reviewed (Patient #507, #508, and #509).

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

Findings included:

1. Document review of the hospital's policy titled, "Patient Rights and Responsibilities," no policy number, reviewed 08/27/20, showed that the policy did not include a list of all Patient Rights required by regulation established in State Operations Manual Appendix W revised 02/21/20.

2. On 06/17/21 from 9:15 AM until11:30 AM, Surveyor #5, a Quality Improvement Registered Nurse (Staff #508), the Director of Medical/Surgical and Critical Care (Staff #510), and the Chief Nursing Officer (Staff #503) reviewed the medical records for 3 patients admitted to the hospital's Swing Bed program (Patient #507, #508 and #509). The review showed that the hospital failed to inform the patients of the following:

a. §483.10(c)(2)(iii): The right to be informed, in advance, of changes to the plan of care.

b. §483.10(e)(4): The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

c. §483.10(g)(18): The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.

d. §483.12(a)(1): The right to be free from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

3. At the time of the observation, Staff #503 reviewed the Patient Rights document and Swing Bed Contract signed by the patient's, confirmed the findings, and stated the hospital would update the documents to ensure inclusion of all the patient rights.
.

.

Based on interview, record review, and review of policies and procedures, the hospital failed to develop and keep current an individualized plan of care for 3 of 3 patients admitted to the hospital's Swing Bed Program for 3 of 3 patients reviewed (Patient #507, #508, and #509).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient's needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. Document review of the hospital's Standard of Work document titled, "Standard Work Swing Bed-RN (Registered Nurse) duties," no date, showed that the admission process for a new admit is for the RN Initiate Swing Bed plan of care and to initiate diagnosis specific plan of care.

2. On 06/17/21 from 9:15 AM until 11:30 AM, Surveyor #5, a Quality Improvement Registered Nurse (Staff #508), the Director of Medical/Surgical and Critical Care (Staff #510), and the Chief Nursing Officer (Staff #503) reviewed the medical records for 3 patients admitted to the hospital's Swing Bed program (Patient #507, #508 and #509). The review showed the following:

a. Patient #508 was admitted to the hospital's Swing Bed Program on 03/20/21, after hospitalization for Covid-19 Pneumonia. The medical record showed the patient was experiencing shortness of breath, weakness, and decreased appetite. The patient's Care Plan contained one electronic pre-formatted treatment plan problem titled, "Swing Bed." Surveyor #5 found no evidence that patient problems including shortness of breath, weakness, and decreased appetite were addressed in the patient's plan of care.

b. Patient #507 was admitted to the hospital's Swing Bed Program on 01/22/21, after a right hip fracture repair for additional rehabilitation. The patient was diagnosed with Diabetes Type II, weakness, a Right Hip wound, pain, required strengthening prior to return home. The patient's Care Plan contained one electronic pre-formatted treatment plan problem titled, "Swing Bed." Surveyor #5 found no evidence that patient problems including Diabetes, weakness, a Right Hip wound, or pain were addressed as part of the patients plan of care.

c. Patient #509 was admitted to the hospital's Swing Bed Program on 07/09/20 after hospitalization for a left hip replacement. The medical record showed the patient was experiencing confusion, pain, weight loss, unsteady ambulation, weakness, and had a left hip wound. The patient's Care Plan contained one electronic pre-formatted treatment plan problem titled, "Swing Bed." Surveyor #5 found no evidence that patient problems including altered mentation, pain, weight loss, unsteady ambulation, weakness, or a wound were addressed as part of the patient's plan' of care.

3. At the time of the review, Staff #503, #508, and #510 confirmed the findings and stated that staff should have added additional problems to the plan of care (IPOC's).
.