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820 NORTH CHELAN AVENUE

WENATCHEE, WA 98801

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

1. Based on interview and review of hospital policies and procedures, the hospital failed to develop a process for informing patient's of their rights when admitted to the hospital according to 42 CFR 482.13(a)-(d).

Findings:

On 7/13/2010 at 2:45 PM, an interview with the Director of Hospital Operations (Staff Member #2) and the admitting desk receptionist (Staff Member #3) revealed that patients were given a brochure entitled "Patient Rights and Responsibilities" (Publication #24493; Revised 12/2009) when admitted to the hospital.

This handout did not include all of the patient's rights identified in current hospital regulations, including the right to be informed of whom to contact to file a grievance [42 CFR 482.13(a)(2)]; the right to participate in the development and implementation of his or her plan of care [42 CFR 482.13(b)]; the right to formulate and advanced directive and to have hospital staff and practitioners who provide care in the hospital comply with these directions [42 CFR 482.13(b)(3)]; and the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital [42 CFR 482.13(b)(4)].


2. Based on interview and review of hospital policies and procedures, the hospital failed to develop a process for informing patient's of their rights when admitted to the emergency department according to 42 CFR 482.13(a)-(d).

Findings:

On 7/14/2010 at 1:00 PM, an interview with the Emergency Department manager (Staff Member #1) revealed that the hospital's brochure entitled "Patient Rights and Responsibilities" (Publication #24493; Revised 12/2009) was not given to patients when they were admitted to the emergency department. There was no process for informing these patients of their rights.

This was corrected during the hospital survey on 7/15/2010.


3. Based on record review and interview, the hospital failed to ensure that patients who were hospitalized longer than four days were notified of their right to appeal their discharge to a designated Quality Improvement Organization according to designated timelines for 4 of 4 patients reviewed (Patients #1, #2, #3, #4).

Reference: 42 CFR 405.1205(b) - Hospitals must provide each Medicare beneficiary who is an inpatient a standardized notice, the Important Message from Medicare, within two days of their admission and again within two calendar days before discharge.

Findings:

1. Review of the medical records of four Medicare patients who were hospitalized longer than four days revealed that 4 of 4 patients had not been notified of their discharge appeal rights and the appeal process within 2 days of discharge (Patients #1, #2, #3, #4).

Patients #3 and #4 received a second notice of their discharge appeal rights four days prior to discharge. There was no documentation in their medical record that Patients #1 and #2 received a second notice of their discharge appeal rights.

2. On 7/13/2010 at 2:45 PM, an interview with the Director of Hospital Operations (Staff Member #2) and the admitting desk receptionist (Staff Member #3) revealed that information entitled "An Important Message from Medicare About Your "Rights" was given to Medicare patients on admission. Hospital staff members were instructed to give a second copy of this information to these patients on their second inpatient day. This did not meet the timelines mandated by Medicare for patients who stayed longer than four days.

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DIRECTOR OF DIETARY SERVICES

Tag No.: A0620

Based on observation and interview, the hospital Director of Food and Dietetic Services failed to develop and implement food safety policies and procedures in accordance with recognized dietary practices for highly susceptible populations [U.S. Public health Service, Food and Drug Administration (FDA) & Center for Disease Control and Prevention (CDC) 2001 Food Code].

The hospital failed to:
ITEM 1) Substitute pasteurized shell eggs, pasteurized liquid, frozen or dry egg products for the preparation of items in which more than one egg is broken, except when raw eggs are combined immediately before cooking for one consumer's serving at a single meal and cooked to 145 degrees F for 15 seconds. [Chapter 3-801.11 (B) (2), (E) (1)].

ITEM 2) Prevent employee bare hand contact with ready to eat food, except when washing fruits and vegetables [Chapter 3-301.11 (B)].

ITEM 3) Train employees to wash their hands before donning gloves for working with food.[Chapter 2-301.14 (H)].

ITEM 4) Ensure the Person in Charge (PIC) is able to demonstrate knowledge of foodborne disease prevention, application of HACCP principles and the requirements of the Washington Food Code [Chapter 2-101.(A)]

Failure to develop and implement policies in accordance with the WAC 246-215 and FDA/CDC model Food Code risks forborne disease in patients which are by definition highly susceptible populations more likely than the general population to experience food borne illness.

FINDINGS:

1. During tour of the kitchen on 7/14/10, a large (approximately 1.5 feet x 1 foot x 6 inches) container was found at 1:30 PM stored under a tray of thawing hamburger in the walk in. When the kitchen manager (Staff Member #B) was asked what the yellow slurry in the container, s/he answer that it was unpasturized eggs broken from the shell prepared for the next day breakfast. S/he explained that the container of unpasturized eggs is set on ice next to the grill for cooking. S/he explained staff are taught they can handle raw meat with bare hands and to wash hands after handling meat. No temperature check or other HACCP plan for the preparation of the unpasturized eggs were found. The kitchen manager was not able to explain the HACCP controls or probable bacteria contamination for raw eggs.


2. During a tour of the kitchen on 7/14/10, Staff Member #D was observed at 1:10 PM cooking hamburgers on the grill and assembling the buns and lettuce for service. S/he touched the buns and the lettuce and tomatoes with no gloves. At 1:20 PM S/he was observed cooking a chicken breast on the grill and assembling with condiments. S/he touched the condiments with no gloves.

3. During a tour of the kitchen on 7/14/10, a staff member was observed at approximately 2:00 PM preparing a meat sandwich.. S/he donned gloves to place chicken on the grill, removed gloves, and delivered a prepared item to a customer. S/he returned to the kitchen collected containers and utensils and then donned clean gloves to assemble the bread and condiments for a sandwich without washing hands.

4. The kitchen manager (Staff Member #B) did not have evidence of attending an approved course to meet the certification criteria of the PIC, was not able to explain the food employee restrictions for illness, did not have knowledge of the food code requirements for highly susceptible populations, could not answer what the Critical Control Point are in the preparation of raw eggs, and did not have any records of HACCP plans.

No Description Available

Tag No.: A0628

Based on interview, and review of hospital policies and procedures, the hospital failed to develop a systematic process for referring patients at nutritional risk to the dietician for a nutritional assessment.

Failure to assess, plan, and provide nutritional care for patients with inadequate intake risks malnutrition of patients and impaired healing.

Findings:

1. The hospital's policy entitled "Standard of Care, Medical-Surgical-Rehabilitation (Policy and Procedure #3810; Revised 7/31/2009) stated under XII. Nutrition (1)(C) that nursing staff would obtain an order for a dietary consult as indicated by the patient's condition.

2. On 7/13/2010 at 3:00 PM, an interview with the inpatient unit charge nurse (Staff Member #4) revealed that nursing staff members documented the nutritional status of medical patients on the nursing admission assessment in a section entitled "The Braden Scale". Nurses were to rate the patient's usual food intake pattern as "Excellent", "Adequate", "Probably Inadequate", and "Very Poor".

The interview revealed that there was no systematic process for referring patients who rated "Probably Inadequate" or "Very Poor" to the hospital dietician for further evaluation.

The interview also revealed that surgical patients admitted through the hospital's same-day surgery unit were not screened for nutritional risk.

3. Staff Member #C stated in an interview with surveyor #14867 on 7/15/10 that there was no systematic method to screen patients for nutritional status on admission to ensure a nutritional consultation could be requested based on acceptable dietary practice. S/he stated nutritional consultation could be requested at the discretion of the nurse or physician.

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EMERGENCY GAS AND WATER

Tag No.: A0703

Based on interview and review of hospital documents, the hospital failed to develop and implement a plan for an emergency water supply. Failure to have a plan for provision of critical utilities risk patient safety and sanitation during an emergency.

Findings:

The hospital Emergency Coordinator (Staff Member #A) stated on 7/15/10 at 3:15 PM that the hospital had no plan for a loss of water supply. S/he also stated that the hospital had no disaster plan but the each department has their own evacuation plan.

No evidence of an emergency/disaster plan including water supply was found in review of hospital documents.

LIFE SAFETY FROM FIRE

Tag No.: A0709

SEE ATTACHED FIRE AND LIFE SAFEY REPORT

VENTILATION, LIGHT, TEMPERATURE CONTROLS

Tag No.: A0726

Based on observation, review of hospital construction documents, and interview with hospital staff, the hospital failed to maintain BRONCHOSCOPY room ventilation with negative airflow to adjacent areas consistent with Center for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health Care Facilities, 2003, Table B.2 and the American Institute of Architects (AIA) Guidelines for Design and Construction of Hospitals and Health-Care Facilities, 2001 and 2006.

Failure to maintain ventilation relationships consistent with CDC guidelines increases cross contamination potential and places patients at risk of infection.

Findings:

During a tour of the Endoscopy Unit on 7/14/10, observation of a light weight tissue showed the air flow for all three rooms positive to the adjacent spaces. One of these rooms was in use for Brochoscopy. Hospital nursing staff confirmed these observations.

Review of construction documents confirmed that "converting 3 endoscopy rooms from an approved hospital Chapter 3.9 Gastrointestinal Endoscopy Facility to hospital Chapter 3.8 Office Surgical Facility Class A Operating rooms" had been approved. Project (CRS#60123234) approval 7/15/2010 DID NOT INCLUDE BROCHOSCOPY and stated " recommended location of laminar flow diffuser directly over procedure table for airflow to create a sterile field consistent with engineering standards." The air balance data on the construction plans showed more supply air and less exhaust air confirming the design and installation positive air flow for the room design.

Hospital facilities staff stated "recent construction was approved to have all three rooms on this unit with positive air flow, but air flow for the bronchoscopy room is adjustable to negative." Hospital facilities and infection prevention staff confirmed that the bronchoscopy room CANNOT be adjusted to negative.

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POST-ANESTHESIA EVALUATION

Tag No.: A1005

Based on record review and interview, the hospital failed to ensure that anesthesia providers peformed and documented a post-anesthesia evaluation for 4 of 7 patients reviewed (Patients #5, #6, #7, #8).

Failure to evaluate patients for adverse outcomes related to anesthesia risks patient harm.

Findings:

Review of the records of 7 patients who received anesthesia during surgical procedures revealed that 4 of 7 records had no evidence that the anesthesia provider evaluated the patient for anesthesia recovery.

An interview on 7/15/2010 at 11:00 AM with the nurse manager of the post-anesthesia recovery unit (Staff Member #5) revealed that the hospital had no policy and procedure that ensured all patients who received anesthesia were evaluated by the anesthesia provider for anesthesia recovery within 48 hours and/or prior to the patient's discharge.

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