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Based on observation and interview the facility failed to provide certain patient care supplies for appropriate care and treatment of patients.

Failure to do so places patients at risk for delays in treatment and the potential for inaccurate laboratory test results.

Findings:

During tour of the ACU on 1/4/11 the surveyor found in patient rooms two containers of urine testing strips which had expired in 8/09 and 11/09. A bottle of rubbing alcohol expired in 9/09 was also found in a patient room. While touring the ICU the surveyor found two expired blood culture specimen containers. These observations were confirmed by staff #S5.



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Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 1/4/2011 - 1/6/2011.

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapters 19.2.9 and 7.9.2.2 Emergency Lighting.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 11/30/2010 - 12/2/2010 (Tag K-0046).

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapter 19.3.2.7.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 1/4/2011- 1/6/2011 (Tag K-0211).

Based on observation, interview, and document review, the facility failed to ensure that medications were labeled in accordance with accepted professional principles and facility policy, and failed to maintain certain emergency supplies in the peri-operative area.

Failure to do these things resulted in specific risks. One placed patients at risk of medication errors. Another failed practice placed patients at risk permanent disability and the potential for death in an emergency situation.

Findings:


Part I
Reference from WA State Hospital Pharmacy Rules:
WAC 246-873-080 Drug procurement, distribution and control. (5) Labeling: (a) Inpatient. All drug containers in the hospital shall be labeled clearly, legibly and adequately to show the drug's name (generic and/or trade) and strength when applicable.

During tour of the peri-operative areas on 1/5/11 the surveyor observed staff #S4 draw up and medication from its original vial but not to label the syringe. The syringe was then placed in a syringe pump.


Part II
MH is a rare but life-threatening emergency reaction to general anesthesia. According to the Malignant Hyperthermia Association of the United States (MHAUS) the syndrome must be identified and treated early in its course in order for there to be a successful outcome. A key factor in successful care is rapid reduction of fever, which can reach 108 degrees Fahrenheit.

During tour of the peri-operative areas on 1/5/11, staff #S1 identified various triggering agents which were used to anesthetize patients in those areas. The reference materials provided for staff and procedural documentation did not refer to use of chilled intravenous fluids, as specified by MHAUS.

Interview with staff #S1 revealed that no chilled intravenous fluids were available in the department. Staff believed that obtaining and packing the patient in ice was adequate in an MH crisis, despite MHAUS ' guidelines.



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Based on observation and interview, the facility failed to develop, implement, and maintain policies and procedures for specific infection prevention issues.

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

Findings:

The following breaches of infection control standards, policies and procedures were observed by two surveyors during the three days of the survey:

? During unit tours on 1/4/11 in three locations (North medication room, Kitchen, and a Clean supply room, hand washing sinks were observed to be directly adjacent to or within inches of patient care supplies, which were not protected from potentially contaminating splatter.
? On 1/4/11 bottles of shampoo and conditioner marked " for patient use " were found stored on a shelf in the ACU soiled utility room
? On 1/5/11 surveyor 17188 observed inappropriate storage of items beneath the sink in the Medical Short Stay unit (coffee, filters, and cups). On 1/6/11 during tour of the same unit surveyor 18001 observed that the filters and cups had not yet been removed.
? On 1/5/11 during tour of the peri-operative areas, the surveyor observed staff #S1 picking up debris from the floor without subsequently performing hand hygiene.
? The surveyor observed on 1/5/11 that the straps used to secure patients to the operating room tables, though cleaned between patients, were long enough to drag on floor, thereby re-contaminating them.
? During meetings on 1/6/11 the surveyor observed #S2 and #S3 repeatedly licking their fingers to assist turning pages while sorting through files.
? On 1/4/2011 using a light weight tissue, surveyor 17188 checked the air flow at the doors of the Respiratory Therapy supply room(s) located in the Medical Records area. The surveyor found that the spaces had a negative air pressure relationship to the adjoining spaces. It should be noted that clean supplies should be stored in rooms having a positive relationship to adjoining spaces.


Based on observation and interview, the facility failed to develop, implement, and maintain policies and procedures for specific infection prevention issues.

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

Findings include:

The following breaches of infection control standards, policies and procedures were observed by two surveyors during the three days of the survey:

? During unit tours on 1/4/2011 in three locations (North medication room, Kitchen, and a Clean supply room, hand washing sinks were observed to be directly adjacent to or within inches of patient care supplies, which were not protected from potentially contaminating splatter.
? On 1/4/11 bottles of shampoo and conditioner marked " for patient use " were found stored on a shelf in the ACU soiled utility room
? On 1/5/11 surveyor 17188 observed inappropriate storage of items beneath the sink in the Medical Short Stay unit (coffee, filters, and cups). On 1/6/11 during tour of the same unit surveyor 18001 observed that the filters and cups had not yet been removed.
? On 1/5/11 during tour of the peri-operative areas, the surveyor observed staff #S1 picking up debris from the floor without subsequently performing hand hygiene.
? The surveyor observed on 1/5/11 that the straps used to secure patients to the operating room tables, though cleaned between patients, were long enough to drag on floor, thereby re-contaminating them.
? During meetings on 1/6/11 the surveyor observed #S2 and #S3 repeatedly licking their fingers to assist turning pages while sorting through files.
? On 1/4/2011 using a light weight tissue, surveyor 17188 checked the air flow at the doors of the Respiratory Therapy supply room(s) located in the Medical Records area. The surveyor found that the spaces had a negative air pressure relationship to the adjoining spaces. It should be noted that clean supplies should be stored in rooms having a positive relationship to adjoining spaces.
? On 1/4/2011 during a tour of the OR unit surveyor 17188 observed a member of the surgical team standing near an table on which open surgical supplies had been placed. The team member was improperly wearing his/her surgical mask as the lower ties were not fastened allowing the masks bottom to hang freely.

Based on observation and interview the facility failed to implement policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC). Failure on the part of the facility to comply with the food service codes puts patients of the facility at risk of food borne illness.

References:

Washington State Retail Food Code Working Document; Chapters 2-301.15 Where to Wash; 2-402.11 Effectiveness; 4-301.16 Designated Food Preparation Sinks; and 4-501.16 Warewashing Sinks, Use Limitation .

Findings include:

1. On 1/6/2011 the surveyor noted that a food worker was preparing vegetables (celery) in utility sink located at a stainless steel work station. The sink was not being used exclusively for food preparation as is required. In the sink was a container of sanitizing solution. It was further noted by the surveyor that the sink had not been cleaned and sanitized between different uses. During discussion with the Person in Charge the surveyor was advised that the sink would also be used for staging dirty utensils although this practice wasn't observed at the time of the inspection.

Based on record review, the facility failed to ensure that orders for care and treatment of patients were written and authenticated according to facility policy in 8 of 14 records reviewed for this issue (Patients #1 - 5, 7 - 9).

Failure to write and authenticate orders for medications and treatment risks provision of incorrect and/or inadequate patient care.

Findings:

The facility policy titled " Verbal Orders " , dated 5/2010, reads in part:
? " The ordering provider or the designated (covering) provider must sign, date, and time a verbal telephone order as soon as possible, and no later than 48 hours after the verbal/telephone order is received. "

Surveyor 18001 reviewed 8 patient records for this issue. Three were for current patients and five were for patients discharged during the month of December, 2010. Incomplete documentation or lack of authentication of verbal orders was found for five of the eight (Patients #1 - 5).

? Patient #1 ' s record contained three verbal orders which had not been authenticated, though the 48 time frame had passed.
? Patient #2 ' s record contained a verbal order dated 12/11/10 and not authenticated. The record also contained an order dated 12/12/10 which had not been signed by the practitioner.
? Patient #3 ' s record had three verbal orders which had not been authenticated (dated 12/23/10, 12/24/10, and 12/25/10).
? Patient #4 ' s record had a verbal order which had been signed, but not dated or timed, so it was not possible to determine if the authentication had been done within the specified 48 hour time frame.
? Patient #5 ' s record contained two verbal orders dated 12/29/10 which had not been authenticated. Another verbal order dated 12/29/10 had been signed, but not dated or timed.
Similar issues were found for Patients #7 - 9.



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Based on record review and review of policy and procedure, the hospital failed to ensure that the initial operative reports are consistently complete and legible for the purposes of ensuring continuity of patient care.

Failure to perform complete and legible initial operative reports places patients at risk for poor outcomes because it restricts continuity of care and transferability of care among professional team members. Furthermore, it restricts patient access to information about their own health status and may impede their involvement in making informed decisions.

Findings:

1. Per Jefferson Healthcare Bylaws (7-16-2010) titled Rules and Regulations, item #4 under Medical Records states, " Following surgery, a progress note shall be written immediately describing the operative findings, surgical procedures and condition of the patient. Per the policy above and per 1-6-11 review of records, operative findings were not noted or legible in 2 of 6 initial operative reports (#6, 7, 10,11,12,& 14) and condition of the patients was not noted in 1 of 6 initial operative report.

2. On review of the medical record on 1-6-11, 2 of 6 initial operative reports did not contain a notation about the post-operative diagnosis, the type of anesthesia or any notation of tissue removed or altered. In 4 of 6 initial operative reports there was no description of the operation or techniques used. In 1 of 6 initial operative reports there was no notation about the patient condition (i.e. stable ...). In 1 of 6 initial operative reports, the notation of the operative findings was fully illegible. In 2 of 6 initial operative reports, information about the name of assistant(s) (including " n/a " ) was missing.

3. In the initial operative report for patient #14, there were 5 handwritten numbers noted on the form and their relevance was not indicated. The numbers were 8, 4, 3, 38 and 16257. This patient had a total knee replacement and there was no notation of tissue removed.


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Based on record review, the hospital failed to ensure that post anesthesia evaluation components were consistently completed.

Failure to complete a full post-anesthesia evaluation places patients at risk for a poor outcome related to complications of anesthesia and may prevent patient access to relevant clinical care.

Findings:

1. The content of the post anesthesia evaluation for CAHs is defined as having the following components: cardiopulmonary status, level of consciousness, any follow-up care and/or observations and any complications occurring during post-anesthesia recovery. The post-anesthesia follow-up report must be documented in the patient ' s medical record, whether the patient is an inpatient or outpatient of the CAH.

2. On 1-4-11 and 1-5-11, upon review of records from patients who had surgery for the month of December 2010, 4 of 5 patients (#6, 7, 11, 12, & 13) did not have complete post anesthesia evaluations per the components listed above. This included 1 of 5 patients (#6) for whom there was no post anesthesia evaluation and 1 of 5 (#12) who only had pain relief addressed. Many post-anesthesia evaluations were procedurally specific and did not include a review of systems. Per the American Society of Anesthesiology, " elements of an adequate post anesthesia evaluation should be clearly documented " and seven core components are identified.

3. Upon review of policy and procedure, titled " Rules and Regulations " , in the Bylaws (7/16/2010), anesthesia services requirements are not addressed.


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