HospitalInspections.org

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Based on document review and interview, the governing body failed to appoint formally an interim chief executive officer (CEO) while recruiting a full time CEO.

Failure to appoint formally a chief executive officer risks inadequate management of the hospital by a responsible individual.

Findings included:

1. Document review of the East Pierce Regional Board meeting minutes from 12/17/19 showed that a search for a new president/Chief Operating Officer was ongoing following the resignation of the previous CEO. Review of the minutes from 07/23/19, 08/27/19, 09/24/19, 10/22/19, 11/19/19, and 12/17/19 did not show any mention of appointment of an interim or new CEO.

Document review of an email sent on 11/14/19 from the Multicare South Sound Region Vice President and CEO (Staff #201) showed the former CEO was leaving and that his oversight of day-to-day operations ended immediately (11/14/19). The email showed that Staff #201 would serve in the interim role.

2. On 02/07/20 at 9:15 AM, Surveyor #2 interviewed the Interim Director of Accreditation (Staff #202) and the Accreditation and Regulatory Affairs Manager (Staff #203) regarding the appointment of an interim CEO by the governing body. Staff #202 and Staff #203 stated that The South Sound Region Senior Vice President was serving as the interim CEO and they were unaware if the governing board had made a formal appointment. They also stated that the new, full time administrator would be starting the following week.
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Based on observation, interview and review of policy and procedures, the hospital failed to ensure a translation service or language assistive device was available to non-English speaking patient (Patients #802, #804 ).

Failure to provide language translation service for non-English speaking patients risks violating the patient's right to decide his/her own care.

Findings included:

1. Document review of the hospital's policy titled, "Interpreter Services for Persons with Limited English Proficiency," no policy number, last revised 7/17, showed the policy was to ensure meaningful, timely, and accessible formats of communication with limited English speaking patients. The procedure states when language, speech, or disability hinders appropriate communication, an interpreter will be used.

Document review of the hospital's policy titled, "Universal Protocol," no policy number, revised 7/17, showed the purpose of the Universal Protocol is to improve patient safety and prevent procedural errors. Universal Protocol consists of five components including Pre-procedural Verification. Staff members are to verify the patient's identity by having the patient state his/her name and planned procedure. Validate patient's identity by using two patient identifiers (e.g. name/date of birth).

The Pre-Operative/Procedural Verification: verifying the patient's identity, verifying and comparing the required documentation is consistent with the plan and contacting the physician for clarification in the event of an inconsistency, and then documenting the verification is complete in the EMR.

2. On 02/04/20 at 9:30 AM, Surveyor #8 observed a right total knee replacement surgery for Patient #802, a 77 year-old with a history of osteoarthritis of the right knee. The observation showed that as the patient was transported into the operating room, she pointed toward the X-Rays on the wall and began to speak fluently in a foreign language, as she looked around at staff.

During the observation, a Registered Nurse (RN) (Staff #809) stated, "the patient speaks no English." The RN (Staff #809) then verbalized this is the "first time-out" and proceeded to read the patient's name, date of birth and planned procedure from a paper form. The RN checked the name against the patient's armband. No translator was present in the room and the RN did not verify the patient's identity by having her state her name and planned procedure.

3. Surveyor #8 also observed that the patient attempted to communicate verbally with the Anesthesiologist (Staff #810) as the Anesthesiologist was placing an oxygen mask on the patient's face and starting induction of anesthesia. There was no translator in the room and the Anesthesiologist did not respond to the patient.

4. On 02/04/20 at 2:30 PM, Surveyor #8 interviewed the Surgical Services Manager (Staff #808) about the observations during the procedure. Staff #808 stated that the hospital did not have a process for having translators in the Operating Room and the Translator had already left the facility.

5. On 02/04/20 at 3:30 PM, Surveyor #8 reviewed the medical record of a non-English speaking patient (Patient #804) that had undergone a right total knee replacement on 02/04/20 at 10:00 AM. Hospital staff failed to document the Pre-procedural verification time out. The intraoperative record did not document if there was an interpreter present to assist staff in communication with the patient in order to complete verification of the patient's identification.
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Based on interview, record review, and review of hospital policies and procedures, the hospital medical staff failed to appropriately monitor the condition of patients in restraints for 2 out of 6 records reviewed (Patients #1001, #1002).

Failure to monitor restrained patients appropriately can lead to the unnecessary use of restraints or seclusion longer then believed to be reflective of the patient's condition and overlooked assessment regarding continued need for the use of seclusion or restraints.

Findings included:

1. Document review of the hospital's policy titled "Restraint and Seclusion," approved 02/18, showed that an assessment for a behavioral (violent) restrained patient must have a face-to face evaluation within one hour of applying restraint, either by a licensed independent provider (LIP) or by a qualified trained RN. The face-to-face evaluation includes: a) patient's immediate situation, b) patient's reaction to the intervention, c) patient's medical & behavioral condition, and c) the need to continue or discontinue the restraint or seclusion.

2. On 02/06/20 at 1:40 PM, Surveyor #10 reviewed the medical records for Patients #1001 and #1002. The review showed:

a. Patient #1001 was an 84-year-old patient who was admitted after experiencing a fall at home. His initial assessment suggested he had a stroke and that he was hallucinating. The patient received treatment for hypertension. On 09/17/19 at 11:00 PM, staff placed the patient in violent restraints after exhibiting behaviors that jeopardized his safety and the safety of the staff. After 7 hours and 55 minutes, staff released the patient from the restraints. The surveyor found no evidence in the record that staff completed the required face-to-face evaluation within one hour of applying the restraints.

b. Patient #1002 was a 46-year-old patient who was transported to the hospital's emergency department for altered mental status, on 09/03/19. The record showed that the patient had a history of a mental health disorder. On 09/03/19 at 9:25 PM, the staff placed the patient in violent restraints after she exhibited behaviors that jeopardized her safety and the safety of the staff. Staff members assessed the patient's condition and discontinued restraints at 10:38 PM, a total of 1 hour and 13 minutes. The surveyor found no evidence in the record that staff completed the required one-hour face-to-face evaluation following application of the restraints.

3. On 02/06/20 at 4:00 PM, Surveyor #10 interviewed the Assistant Nurse Manager (Staff #1001) regarding the restraint documentation. Staff #1001 confirmed the missing one-hour patient evaluations completed by a provider.
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure staff developed an individualized plan of care to include all identified problems for 1 of 16 patient care plans reviewed (Patient #1003).

Failure to develop a patient's individualized plan of care to include all stated problems can lead to missed actual identified problems, their corresponding goals, or individualized interventions resulting in poor care continuity and outcome.

Findings included:

1. Document review of the hospital's policy titled, "Patient Plan of Care, Inpatient," approved 05/17, showed that the registered nurse will initiate the plan of care based on subjective, objective assessment, plan, intervention, and evaluation of effectiveness of intervention. Staff will review the plan of care every shift and document every 24 hours. Staff will update the plan of care when there is a change in the patient's condition, treatment, or service.

2. On 02/04/20 at 10:15 AM, Surveyor #10 reviewed the medical record for Patient #1003 that showed a 37-year-old patient who was directly admitted to the intensive care unit (ICU), on 01/13/20. The admission note showed that he was diagnosed with severe sepsis, cardiogenic shock, and acute inflammatory demyelinating polyneuropathy (AIDP), (an autoimmune process that is described as motor weakness and loss of deep tendon reflexes).

Admission records showed that his skin had extensive wounds caused by lesions, skin necrosis, and infection covering the entire left leg, right lower leg, and both arms. Record review showed that the patient received treatment for (not inclusive): sepsis, cardiogenic shock, cardiac arrhythmia, skin necrosis- wounds (wound treatments), gangrene toes, AIDP (leads to low or no-sensory and motor responses), residual weakness (history of previous falls), PTSD, atrial fibrillation, acute kidney injury (on dialysis), acidosis, anemia, potential deep vein thrombosis, and he required nasogastric tube feeding.

A review of the nurse admission records showed an order for a wound care consult after noting a sacrum wound and the lesions to both arms/legs. A review of the patient's admission fall screen showed that he was a high risk for falls and interventions were initiated. A review of provider notes showed that the patient requires hemo-dialysis sessions three times per week for his acute kidney injury. On 02/04/20, he transferred to another acute care hospital for skin debridement and a planned lower extremity amputation.

A review of the patient's individual plan of care showed that the plan did not include the care of his wounds, his need for dialysis, or the high risks for falls.

3. On 02/04/20 at 10:15 AM, Surveyor #10 interviewed the CCU Nurse Manager (Staff #1002) and the CCU Director (Staff #1003) regarding the patient's individualized care plan and confirmed the missing active problems.

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Based on record review and interview, the hospital failed to have a signed Quality Improvement Organization (QIO) agreement for utilization review with the current Beneficiary and Family Centered Care QIO for the region in which the hospital is located.

Failure to have an up to date contract with the current QIO risks inadequate review of services by the hospital and medical staff for patients entitled to those services.

Findings included:

1. Record review of the utilization review contract between the hospital and the QIO showed that the contract was with Livanta, which was the former designated QIO for the region in which the hospital was located. The contract had an effective date through 2021.

Record review of the document titled, "Important Message from Medicare," revised 05/19, which is provided to inpatients informing them of their rights to report care quality concerns and appeal discharges, listed the QIO as Kepro.

2. On 02/06/20 at 12:00 PM, Surveyor #2 interviewed the Interim Director of Accreditation (Staff #202) regarding the utilization review contract with the QIO. Staff #202 stated that the hospital did not have a contract with the new QIO. Staff #202 stated that patients receive information about the current QIO to report care concerns or appeal discharge via the "Important Message from Medicare" notice and the hospital submits patient record information to the QIO as requested. Staff #202 stated that the hospital also conducts its own utilization review. Staff #202 provided a signed agreement with the current QIO, Kepro, which was dated 02/06/20.
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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to the deficiencies written on the Medicare Life Safety inspection report dated 02/04/2020 .

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Based on observation, interview, and review of policies and procedures, the hospital failed to have an effective process in place for checking and maintaining emergency crash carts and equipment (1) and failed to have an effective process in place for securing mobile Intravenous (IV) supply carts (2).

Failure to maintain supply carts and emergent carts risks delay in patient care and even death.

Findings included:

Item #1- Crash Carts Equipment Checks

1. Document review of the hospital's policy titled, "Code Blue-Crash Cart and Emergency Equipment Locations, Maintenance and Exchange," no policy number, reviewed 2/20, showed that staff are to ensure all items on the crash cart are in proper working order and to document the daily checks on the MultiCare Hospital System, (MHS) Crash Cart Readiness Checklist (form 88-2177-2 and 88-2180-2).

2. On 02/03/20 at 2:00 PM, Surveyor #8 inspected the crash cart located in the Emergency Department (ED) with the ED Registered Nurse Manager (RN) (Staff #801) and the ED Director (Staff #802). The observation showed there was no checklist to indicate that staff had checked the cart to confirm that it was ready for use.

3. Surveyor #8 interviewed the ED Nurse Manager (Staff #801) at the time of the observatgion and asked how the staff knew if the equipment and the supplies were ready for use. Staff #801 stated that the crash carts were checked each day and the information was input into a computer program called Eoscene. The surveyor asked for the crash cart policy as well as evidence that the staff had checked the ED crash cart.

4. Review of the Eoscene printout and the Emergency Crash Cart Maintenance policy showed the following:

a. The 1/03/20 printout showed staff had not checked the emergency cart.

b. The 01/17/20 printout showed an exclamation mark. The legend indicated that it meant "needs attention."

4. At the time of the observation, the Accreditation RN (Staff #806) verified the documentation and stated there is no written policy or procedure for a process to follow when the crash cart is not checked or needs attention and acknowledged that the policy does not reflect the current use of the Eoscene program.

ITEM #2- Security of Mobile IV Supply Carts

1. On 02/03/20 at 2:45 PM, Surveyor #8 toured the ED. The observation showed:

a. An unlocked/open IV supply cart at the Patient entrance/Greeter station

b. An unlocked/open IV supply cart in the storage room between two observation/seclusion rooms

c. An unlocked/open IV supply cart in the hallway near room 25

d. An unlocked/open IV supply cart in the hallway near room 39

2. At the time of the observations the ED Manager (Staff #801) stated that the carts were supposed to be closed and locked when not in use .
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Based on observation, interview and review of policy and procedure, the hospital failed to ensure staff wore personal protective equipment per hospital policy during surgical procedures.

Failure to wear protective eyewear or face shields risks exposure to potentially infective materials.

Findings included:

1. Document review of the hospital's policy titled, "Surgical Attire," no policy number, approved 9/15 showed that staff should wear protective eyewear or face shields during all surgical procedures and that acceptable protective eyewear includes disposable mask/shield combinations, reusable goggles, or personal prescription glasses with side shields.

2. On 02/04/20 at 1:30 PM, Surveyor #8 observed an Esophagogastroduodenoscopy (EGD) (endoscopic procedure that allows the doctor to examine the esophagus stomach and duodenum) surgical procedure for Patient #803. The observation showed that the anesthesiologist (Staff #803) wore no mask or face shield during the procedure.

3. At the time of the procedure, Staff #807 confirmed the observation of staff not wearing protect shielding..
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