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Based on record review the facility failed to conduct criminal background checks for certain individuals who are required by state law to be screened for criminal activity and/or offenses because they may have unsupervised access to children, vulnerable adults and/or developmentally disabled adults.

Failure to screen staff for criminal activity and/or offenses puts patients at risk for harm from abuse.

Reference: WAC 246-320-126 Criminal history, disclosure, and background inquiries -Hospital responsibility

Findings:

On 10/09/2014 at 2:30 PM, Surveyor #1 noted that the personnel files of three Registered Nurses (RNs) (Staff Member #3, #11 and #12) working in the Wound Healing Center (a contractual service) lacked documentation showing that criminal background checks had been performed as is required by state law for the respective RNs.

Based on interview and record review, the facility failed to obtain orders for 2 of 2 patients restrained or secluded in the Emergency Department (ED) (Patients #6, #7).

Failure to obtain orders for restraint and seclusion episodes places patients at risk of harm from not being appropriately restrained and periodically assessed for the continuing need for restraint management.

Findings:

1. On 10/9/2014 Surveyor #3 reviewed records of two patients who had been restrained and/or secluded for potential harm to themselves or others in the ED. Records were reviewed with the assistance of a Clinical Informaticist (Staff Member #6).

2. Patient #6 was brought to the ED on 7/10/2014 for suicidal gestures and intoxication with alcohol and methaphetamine. S/he was placed in restraints at 1:00 PM and released at 4:53 PM. Review of the patient's record showed no evidence that an order had been written for the restraint. This was confirmed by Staff Member #6.

3. Patient #7 was brought to the ED on 7/6/2014 with a diagnosis of schizophrenia. S/he was placed in restraints at 8:50 AM and released at 10:11 AM, at which time s/he was put in seclusion. The county Mental Health Professional evaluated her/him and determined that s/he required involuntary detention for inpatient treatment. Since no psychiatric beds were available in the community, the patient remained in the ED receiving treatment until s/he was transferred on 7/9/2014 to another facility.

The medical record documented that the patient had several episodes of seclusion while waiting for transfer. There was an initial order for the restraints; however no orders were found for the seclusion episodes. This was confirmed by Staff Member #6.

Based on review of policy and procedures and record review, the facility failed to assure adherance to procedural monitoring requirements.

Failure to do so creates risk for health complications due to procedural sedation.

Findings:

1. In review of facility policy titled, "Sedation, Procedural" (revised 11/10) page 10 outlined required monitoring elements and it included the following: "Vitals signs, including pulse, blood pressure, respirations, oxygen saturation, level of consciousness, responsiveness, pain." Then it outlined the frequency by which the indicators should be monitored and it included the following: "Baseline", "Every 5 minutes", "30 min [minutes] post-procedure or until patient meets discharge criteria."

2. Upon record review the following monitoring for procedural sedation was noted:

Patient #1 was transported from a nursing home to the hospital for a procedure to evaluate symptoms of nausea and vomiting. The patient had an endoscopic procedure to evaluate her/his esophagus on 8/25/2014 at 4:25 PM. The patient received 125 micrograms of fentanyl and 5 milligrams of midazolam during the procedure. No baseline or intraprocedure monitoring was recorded. The patient went to the recovery room at 4:45 PM. Level of consciousness was not recorded until 5:17 PM and a full set of vital signs was not recorded until 5:29 PM. No pain assessments were recorded.

Patient #2 had procedural sedation in the emergency department for a reduction of a left dislocated shoulder. The procedure started at 1:25 PM and the last dose of procedural sedation medication was administered at 1:47 PM. From 1:30-2:55 PM the patient's level of consciousness was not recorded as having been monitored per policy.

Based on interview and state pharmacy regulations, the facility failed to assure pharmacy oversight of patient medication supplies and administration.

Failure to do so creates a risk of a patient health complication from medication administration.

Findings:

Reference: WAC 246-873-080 Drug procurement, distribution and control
(1)(b) A monthly inspection of all nursing care units or other areas of the hospital where medications are dispensed, administered or stored. Inspection reports shall be maintained for one year.

Findings:

On 10/09/2014 at 10:30 AM Surveyor #2 interviewed the Pharmacy Manager (Staff Member #1) about patient medication administration storage in the Wound Healing Center. S/he stated that the Wound Healing Center was not subject to monthly pharmacy unit inspections. This finding was confirmed by the Staff Member #1 after review of existing monthly pharmacy inspection records.

Based on record reviewand interview, the facility failed to assure that food and dietetic services policies and procedures are both current and available.

Failure to have current policies and procedures available for food and dietetic services puts patients, staff and visitors at risk from food unsafe for human consumption and/or not being available for consumption during an emergency.

Findings:

1. On 10/08/2014 between the hours of 9:30 AM and 12:00 PM, Surveyor #1 performed an inspection of the facility's Nutrition Services department. During the course of the inspection the surveyor asked for the facility's Nutrition Services policies and procedures for review and noted policy omissions, including but not limited to, emergency food supplies.


2. At the same time of the request, it was indicated by the Dietary Manager (Staff Member #13) that the department was updating policies and procedures to reflect those employed throughout the MultiCare system. And, it was further indicated that only some policies and procedures were available for staff use with the current electronic document system.

Based on observation, the facility failed to comply with both Federal and/or State food service regulations (Washington State Retail Food Code; Chapter 246-215 WAC).

Failure to comply with such regulations puts patients, staff and visitors of the facility at risk of foodborne illness.

Findings:

On 10/08/2014 at 10:25 AM, Surveyor #1 observed a self-service customer in the cafeteria reach into a bread container with his/her bare hand to retrieve a slice(s) of bread. It was noted that the facility had provided utensils (tongs) for handling bread but they were not used by the customer.

(Reference: Section 03369 Preventing contamination by consumers - - Consumer self-service operations (2009 FDA Food Code 3-306.13)

Based on observation, interview and review of hosptial policy the facility failed to adhere to protocols established to control infections.

Failure to do so creates risk for health consequences to patients, staff and visitors related to transmission of infection.

Reference: ANSI/ASHRAE/ASHE Standard 170-2008: Ventilation of Health Care Facilities.

Item #1-Protective Airflow

Findings:

1. On 10/07/2014, at 1:45 PM, Surveyor #1 used a flutter strip (light weight tissue) to determine the air balance of the clean supply room across from Room #432. Based on the movement of the flutter strip the clean supply room was determined to be negative to adjoining spaces not positive as is required.

2. On 10/07/2014, at 2:05 PM, Surveyor #1 used a flutter strip (light weight tissue) to determine the air balance of the clean supply room across from Room #338. Based on the movement of the flutter strip the clean supply room was determined to be negative to adjoining spaces not positive as is required.


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Item #2- Hand Hygiene

Findings:

1. According to facility policy titled "Hand Hygiene" (8/2014), it read, in part
to "Perform hand hygiene/decontaminate hands:...
I. After high risk contact with body fluids...
K. ...after contact with inanimate objects...in the immediate vicinity of the patient.
L. ...after removing gloves.
N. B. After any activity that could passively contaminate your hands..."

2. On 10/7/2014 between 10:40 - 11:00 AM Surveyor #3 observed a dialysis nurse (Staff Member #7) caring for a patient. The staff member moved back and forth between the patient and the dialysis machine, but did not decontaminate hands after removing gloves.

3. On 10/8/2014 while observing a perioperative process between 10:00 AM - 10:50 AM, Surveyor #3 noted the following:

a. A Registered Nurse (Staff Member #8) on four occasions lifted the potentially contaminated lid of the laundry hamper, rather than using the foot lever, pushed things into a hamper, and did not remove gloves and decontaminate hands before returning to patient care. A Surgical Technician (Staff Member #8) was observerd doing the same thing on one occasion.

b. An Anesthesiologist (Staff Member #9) brought the patient to the recovery room after performing patient care, but did not decontaminate her/his hands after removing gloves.

4. On 10/08/2014 at 12:15 PM, Suveyor #2 observed a nurse (Staff Member #3) provide care to Patient #3 in the Wound Healing Center. During the course of care, the nurse removed her/his protective gloves and failed to perform hand hygiene before obtaining dressing supplies from the cabinet in treatment room.


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Item #3- Surveillance Program for Adherance to Hand Hygiene Practices

Findings:

1. Upon review of the facility's policy titled, "Infection Prevention Program Risk Assessment and Plan 2014" page 30 provided information about hand hygiene surveillance activity. In the section titled, "Patient Population" it stated, "All units" and further specified the target goal and method of analysis, among other items.

2. On 10/09/2014 at 1:00 PM Surveyor #2 interviewed the Infection Prevention Program Director (Staff Member #2) about hand hygiene surveillance. S/he acknowledged that hand hygiene surveillance had not been reported for the first 8 months of 2014 for the following areas where invasive procedures were performed: operating room, day surgery and the Wound Healing Center.

Item #4-Cross-Contamination

Findings:

1. On 10/08/2014 at 12:15 PM a nurse (Staff Member #3) provided care to Patient #3 in the Wound Healing Center subsequent to a debridement performed by another health care provider. The patient required a new dressing to the wound and during the course of care the nurse removed and discarded a pair of protective gloves onto the Mayo stand (procedure tray) where clean dressing supplies for use were located. When discarded, the gloves came in contact with a tube of gel medication (Iodosorb), paper tape and bandage scissors. The paper tape was to be left in the room for subsequent use and the medication was to be wiped with a Sani-wipe for placement in a centrally located medication cabinet for subsequent use.

2. During the same procedure, the nurse removed a pair of unpackaged bandage scissors from a cabinet drawer to cut dressing material (Alginate) for placement to the interior of the wound. The scissors had been used to remove the old dressing and then were cleaned prior to placement in the drawer. However, the scissors were in direct contact with the interior of the drawer prior to removal for use.

Item #5-Storage of Patient's Own and Over-the-Counter Medications

Findings:

1. In review of facility policy titled, "Multiple Dose Container Medication Management" (revised 11/12) under section VII. about cleaning patient specific bins it stated, "The patient specific bin will be cleaned with a Sanicloth after removal of the multiple dose container(s) at discharge." The procedure did not state who was responsible for cleaning the bins.

2. On 10/09/2014 at 10:30 AM, the Pharmacy Manager (Staff Member #1) was asked about whose responsibility it was to clean the bins between patient use. S/he stated was the responsibility of the nursing staff.

Later that day at 11:30 AM a nurse (Staff Member #4) was asked about the system for cleaning the patient specific bins between use for different patients. S/he stated that she did not know who was responsible for that activity but that it was not a nursing staff responsibility.

3. On 10/09/2014 at 11:30 PM the following medications were located in patient specific bins on the medical surgical unit.
Patient #4: triamcinolone cream and earwax removal ear drops
Patient #5: advair and albuterol inhalers and mupricin ointment

It was not known if the bins had been cleaned prior to patient medications being placed in them by staff or if they would be cleaned prior to use for the next patient.

Item #6- Equipment Cleaning

Findings:

1. Upon review of facility policy titled, "Glucose (POC) Testing Using Nova Stat Strip Device" [glucometer] (revised 4/16/2014) on page 5, under item V.5. it stated, "Between each patient ...."2. Wipe the entire device with a Sani-wipe that has been squeezed to remove excess moisture...3. Allow to dry for 2 minutes. 4. Wipe with a dry soft cloth or lint-free tissue..."

2. On 10/08/2014 at 10:40 AM Surveyor #2 interviewed a nurse (Staff Member #5) on the Geropsych Unit about cleaning glucometers. S/he stated that she cleaned glucometers with an alcohol swab after use with each patient.