HospitalInspections.org

Based on observation and interview, the hospital failed to establish a nurse staffing committee as required by Washington state law RCW 70.41, and to post their nurse staffing plan in a public area on each patient care unit.

Failure to do so removes direct patient care nurses from staffing planning and risks inadequate staff levels, potentially resulting in poor patient outcomes.

Reference: RCW 70.41.420 Nurse staffing committee." (1) By September 1, 2008, each hospital shall establish a nurse staffing committee, either by creating a new committee or assigning the functions of a nurse staffing committee to an existing committee. At least one-half of the members of the nurse staffing committee shall be registered nurses currently providing direct patient care and up to one-half of the members shall be determined by the hospital administration. The selection of the registered nurses providing direct patient care shall be according to the collective bargaining agreement if there is one in effect at the hospital. If there is no applicable collective bargaining agreement, the members of the nurse staffing committee who are registered nurses providing direct patient care shall be selected by their peers ...(7) Each hospital shall post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. The staffing plan and current staffing levels must also be made available to patients and visitors upon request. "
Findings:

On 1/6/2012 during human resources records review by Surveyor #2, the CEO (Staff Member #1) stated that the facility had made a decision not to develop a staffing committee. S/he stated that the facility was too small and daily census so low that data gleaned would not be meaningful and could not be used effectively.

On 1/5/2012 Surveyor #2 toured the Emergency Department and did not observe a posted staffing plan or staffing levels for the area. Surveyor #1 had previously reported that staffing information was posted in the acute care unit. On 1/6/2012 Staff Member #1 stated that the posted staffing plan applied to the facility as a whole.



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Based on observation, interview, and record review, the facility failed to consistently ensure that emergency equipment and supplies necessary to meet patient needs were immediately available.

Failure to do so places patients at risk for inadequate care in case of emergency, potentially resulting in permanent disability or death.

Reference:
Facility policy titled " Crash Cart Policy " dated 7/28/11 reads in part:
? The night shift charge nurse and the ER nurses are responsible for daily checking of the crash cart defibrillator, the cart stock status ... and supply status. This is documented on the crash cart record ...
? The integrity of the lock and its number will be checked and recorded daily, along with firing the defibrillators by the night shift nurse ... The endoscopic code cart will be checked each day special procedures is open, and on days when treadmills are performed.
? Medication trays with lids will be on the cart. They will be sealed with a yellow lock. When the medication tray has been used, the tray will go to the pharmacy and another locked tray can be obtained.

Findings include:

Surveyor #2 reviewed the crash cart checking and re-stocking processes in facility areas toured on 1/3-5/2012 with staff in the areas and the CNE (Staff Member #6). Staff Member #8 indicated that medication storage and restocking of the crash cart in the endoscopy and treadmill area, as well as the one on the acute care unit, was handled differently from the carts in the emergency department (ED). Medications in the endoscopy and acute care carts were stored individually in drawers with compartments, rather than a tray that could be taken to Pharmacy for replacement, as called for in facility policy. For these areas staff were required to order replacement drugs from the pharmacist and await their delivery, with the potential for delay in replacement.

The above discrepancies were confirmed by reviewing the contents of crash carts in the endoscopy area and the ED. The difference in medication storage methods resulted in drugs being stored in differing locations in the cart drawers, depending on which cart was being used, and could result in delays in staff locating a given drug in a timely manner. It also raised the potential for delays in re-stocking those carts which did not use tray-switch restocking method.

Review of crash cart performance improvement data demonstrated that the facility was also not following its policy regarding frequency of checking the defibrillator and cart locks. The stated goal was 100% compliance with policy. However, the most recent data, in a report dated 11/8/2011, reflected 87% compliance.

FAILURE TO CHECK DEFIBRILLATORS IS A REPEAT CITATION FROM 2/11/10.



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Based on record review and review of policy and procedure, the hospital failed to ensure that nursing staff performed blood transfusions as ordered by the physician and according to hospital policy and procedure for 2 of 2 patients reviewed (Patient #11, #15).

Failure to do so places patients at risk for transfusion related complications.

Findings:

1. The hospital's policy and procedure entitled "Blood Transfusion Protocol" (Policy #10342; Effective 5/2/2007) read as follows:

"The RN [Registered Nurse] will verify physician's order as to type of blood/product to be given, number of units the patient is to receive and rate of infusion."

2. Review of the records of 2 patients who received blood transfusions during their hospital stay revealed the following:

a. Review of Patient #11's physician's order for blood revealed that the order did not contain what type of blood or blood product the patient was to receive. The order stated "transfuse 2 u [units] over 8 hours".

There was no evidence in the medical record that nursing staff had clarified the physician's order prior to giving the patient the first unit of blood.

The physician's order indicated that the patient was to receive two units over 8 hours implying 4 hours per unit. However, there was no order clarification for the rate of infusion for the first unit of blood. The first unit of blood was transfused over 3 hours.

Nursing staff had not followed the physician's order for administration of the first unit of blood.

b. Review of Patient #15's medical record showed that s/he had physician orders to receive two units of blood over a period of four hours each. However, the documentation showed that both units were infused over three hours.

Nursing staff had not followed physician's orders for the rate of infusion for the 2 units of blood infused.

3. The Director of Nursing Services confirmed the above findings.

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 1/3/2012 - 1/6//2012.

Based on record review and interview the facility failed to forward recommendations for clinical privileges to the governing authority in a manner that would assure clinical privileges being requested were appropriate for the petitioner.

Failure on the part of the facility to grant privileges based on recommendations made puts patients at risk of harm from practitioners not qualified to perform certain procedures safely and effectively.

Findings include:

1. On 1/5/2012, the surveyor reviewed the file of a practitioner (MD #1) who had requested privileges for the administration of moderate sedation.

2. On 1/6/2012, the surveyor interviewed the individual responsible (Staff Member #1) for taking medical staff appointment and privileging recommendations to the governing authority. At that time the surveyor was informed by the responsible individual that she/he was unaware that a request for moderate sedation had been made by physician (MD #1). As related to the surveyor it was the expectation that only CRNA's were to administer conscious sedation including moderate sedation at the facility. The facility's policy/procedure titled "Nursing Services 10411" states in part: "Generally, the CRNA is the practitioner who provides procedural sedation ...".

3. On 1/6/2012, the surveyor was informed by the responsible individual that information presented to the governing authority did not include a written recommendation from the medical staff or the individual (MD #2) performing peer review of practitioner(s) files. As put forth to the surveyor, recommendations for appointment / reappointment and privileging were made by "exception".

4. On 1/6/2012, the surveyor was informed that no documentation (peer review and or quality assessment) regarding the performance of CRNA's was used in determining their reappointment.

Part I

Based on interview the facility failed to clearly delineate in writing the duties and expectations of the pharmacists engaged to provide pharmaceutical services to the facility, as required by state law.

Failure to do so risks neglect of essential, patient-centered services, the quality of oversight of services, performance improvement activities, and support of direct care staff who might be in need of consultation and education.

Reference: WAC 246-873-040 Personnel. " (1) ... The patient care and management responsibilities of the director of pharmacy shall be clearly delineated in writing and shall be in accordance with currently accepted principles of management, safety, adequate patient care and treatment ... Hospitals which do not require, or are unable to obtain the services of a fulltime director shall be held responsible for the principles contained herein and shall establish an ongoing arrangement in writing with an appropriately qualified pharmacist to provide the services. Where the director of pharmacy is not employed fulltime, then the hospital shall establish an ongoing arrangement in writing with an appropriately qualified pharmacist to provide the services described herein. "

Findings:

On 1/3/2012 Surveyor #2 requested that the facility provide either a contract or similar list of functions expected from the pharmacists engaged to provide pharmaceutical services to the facility. Staff Member #6 stated that these services were provided by a father and son who operated the town ' s retail pharmacy. On 1/4/2012 Staff Member #6 stated that s/he was unable to locate a contract or other written document outlining services the pharmacists were expected to provide.


Part II

Based on observation, interview, and record review the facility failed to ensure certain drugs were stored at the proper temperature, as required by state law.

Failure to do so risks administering medications to patients which have deteriorated or become hazardous due to potentially improper storage.

Reference: WAC 246-873-070 Physical requirements. "(4) Drug storage areas. Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. "
Findings:

On 1/5/2012 Surveyor #2 interviewed Staff Member #11 and inspected drug storage within the anesthesia storage room/office. The refrigerator had a temperature log affixed which had been used for daily recording. The log did not document the appropriate temperature parameters for storage of the drugs within. Staff Member #11 stated s/he did not know what the correct parameters were.


Part III

Based on observation, interview, and record review the facility failed to ensure that all units and areas where drugs were stored, dispensed, and administered were inspected monthly, as required by state law.

Failure to do so risks medication errors due to failure to assess storage areas for safety factors and adherence to standards, and administration of medications which may have expired and/or deteriorated.

Reference: WAC 246-873-080 Drug procurement, distribution and control. "(1) General. Pharmaceutical services shall include: (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 1/3-5/12 Surveyor #2 discussed the maintenance of various medication storage areas with the CNE (Staff Member #6) and licensed staff working in those areas of the facility. The consistent information obtained during these interviews was that the pharmacists did not routinely inspect the medication storage areas in any systematic manner. The inspections that did occur were accomplished by facility staff and consisted of examining medications for expiration dates and taking actions to maintain par levels.

Where these inspections occurred, the sole documentation was to sign or initial and date a flow sheet, and at times leave a note in some manner to indicate if a drug was awaiting replacement. There was no documentation found to indicate that any other pertinent actions had taken place, such as evaluation of preparation and administration systems, cleanliness, safety factors, or security measures.

Staff stated that no one but the anesthesia providers (CRNAs), including the pharmacists, had keys to medication carts in the endoscopy area and the operating room. This was confirmed by Staff #6 and #11. Staff Member #11 stated that s/he inspected the medications in the carts at the beginning of each of his/her two-week rotations. S/he also stated that s/he checked anesthesia medication storage elsewhere monthly.

Staff working in areas where crash carts were located stated they inspected those drugs by way of opening the cart monthly, unless used in the interim. The emergency drug box for anti-coagulation therapy in the emergency department was not routinely examined. Staff also stated they checked the acute care unit medication room and the emergency department medication supplies monthly.

In the clinic's clean utility supply room were three large cabinets filled with hundreds of drug samples. The surveyor estimated that varying quantities of approximately 100 different medications were stored in these cabinets. There was no discernable system to the order in which they were stored (alphabetical, classification of the medication, etc) and there was some intermingling of patient information brochures with the medications. Staff Member #15 stated that s/he periodically reviewed the drugs for expiration dates, but did not describe a system for doing so, nor was any documentation of these reviews found. Considering the quantity of drugs stored in these cabinets, the task of reviewing them solely for expiration dates would require a significant amount of staff time. Staff Member #15 stated s/he counted on the drug representatives to review the drug samples.

During a meeting with one of the pharmacists on 1/5/2012 s/he (Staff Member 16) confirmed that neither he nor the other pharmacist performed monthly inspections to oversee the quality and safety of medications and their storage areas. Staff Member #16 stated several times that s/he and the other pharmacist worked full time in their retail pharmacy and so their services were limited and "informal".

Part IV

Based on observation and interview, the facility failed to effectively track and secure certain controlled substances in the emergency department (ED), as required by state law.

Failure to do so risks diversion, and risks medication error and ineffectiveness by administering/dispensing to patients medications which have been tampered with.

Reference: WAC 246-873-080 Drug procurement, distribution and control. "...(7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations ... (h) Controlled substances, Schedule II and III, which are floor stocked, in any hospital patient or nursing service area shall be checked by actual count at the change of each shift by two authorized persons licensed to administer drugs."
Findings:

During tour of the ED on 1/5/2012 Surveyor #2 evaluated the system for securing and accounting for controlled substances in the area. The cabinet where controlled drugs were stored contained bottles of liquid medications designed as "take home" packages so that patients could begin taking their medication prior to being able to fill their prescriptions.

Staff Member #17 stated that at change of shift the staff counted and recorded the number of bottles present rather than the quantity of drug in the bottles. The surveyor observed that the bottles were not sealed, making it possible to alter the contents without it being apparent. The amount of liquid in three of six bottles differed slightly, though the documentation indicated they should be identical. For the other three bottles, re-supply requisition paperwork was affixed to the bottles in such a way that it was not possible to visualize the liquid level in the bottles. Staff Member #17 confirmed these observations.


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Part V

Based on observation and interview, the hospital staff failed to ensure medications were secured according to Washington State Board of Pharmacy regulations.

Failure to secure medications from unauthorized individuals jeopardizes medication safety related to theft, tampering and/or diversion.

Reference:

WAC 246-873-050 "Absence of a pharmacist" (1) ...If round-the-clock services of a pharmacist are not feasible, arrangements shall be made in advance by the director of pharmacy to provide reasonable assurance of pharmaceutical services. (2) ...whenever a drug is required to treat an immediate need and not available from floor stock when the pharmacy is closed, the drug may be obtained from the pharmacy by a designated registered nurse, who shall be accountable for his/her actions. One registered nurse shall be designated in each hospital shift for removing drugs from the pharmacy.

Findings:

1. On 1/3/2012 at 3:30 PM during a tour of the medication room located on the Acute Care unit, a Licensed Practical Nurse was observed handing a key to the pharmacy to the Director of Nursing Services.

During a tour of the pharmacy on 1/5/2012 at 10:45 AM a pharmacy log was reviewed. Surveyor #1 noted that on 1/4/2012 at 8:30 PM a Licensed Practical Nurse removed 0.25mg of Digoxin from the pharmacy.

2. According to the Washington State Board of Pharmacy regulation, a designated registered nurse should be the only person with access to the pharmacy when the pharmacist is not on site.


Part VI

Based on observation, interview and review of pharmacy records, the hospital failed to ensure that hospital practice met the requirements for removing medications from the pharmacy when the pharmacist was absent in accordance with current state law.

Failure to assure that the pharmacist confirms that the correct medication has been removed from the pharmacy risks administering incorrect medications to patients and could result in patient harm.

Reference:

WAC 246-873-050 "Absence of a pharmacist. (2) Access to the pharmacy. (a) The director of pharmacy shall establish written policy and recording procedures ... (b) The stock container of the drug or similar unit dose package of the drug removed shall be left with a copy of the order of the authorized practitioner to be checked by a pharmacist, when the pharmacy reopens, or as soon as is practicable."

Findings:

1. Review of the hospital policy and procedure entitled "Procurement of Medications when Pharmacist not on Duty" (Effective 8/29/2005; Signed 6/4/2008) revealed that the policy did not clearly define the current process for removing medications from the pharmacy in the absence of the pharmacist.

2. During a tour of the pharmacy on 1/5/2012 at 10:45 AM two medication bottles were found on the counter behind the pharmacy log book. One medication bottle contained Docusate Sodium 250 mg and the other contained Digoxin tablets 250 mcg.

According to the Pharmacy log book Digoxin 0.25 mg was removed from the pharmacy on 1/4/2012 at 8:30 PM and the Docusate 250 mg was removed on 1/5/2012 at 7:30 AM.

There were no physician's orders in the pharmacy for the medications removed from the pharmacy as required by state law.

3. An interview with the Director of Nursing (Staff Member #6) on 1/5/2012 revealed that a memo had been sent to staff on 5/12/2011 stating that nursing staff were to leave the original container along with a copy of the physician's order whenever medications were removed from the pharmacy. Surveyor #1 obtained and reviewed a copy of the memo.

The director of Nursing (Staff Member #6) confirmed that staff had not followed recent direction from administration for removing medications from the pharmacy.


Part VII

Based on observation, interview, and review of policy and procedure, the hospital failed to ensure that drugs brought into the hospital by patients were identified, examined and labeled by a pharmacist prior to administration as required by chapter 246-873 WAC, PHARMACY - HOSPITAL STANDARDS and hospital policy and procedure.

Failure to follow pharmacy hospital standards and hospital policies and procedures places patients at risk for harm due to medication errors.

Reference:

WAC 246-873-090 Administration of Drugs. (3) Patient's drugs. The hospital shall develop written policies and procedures for the administration of drugs brought into the hospital by or for patients. (a) Drugs brought into the hospital by or for the patient shall be administered only when there is a written order by a practitioner. Prior to use, such drugs shall be identified and examined by the pharmacist to ensure acceptable quality for use in the hospital.

Findings:

1. The hospital policy and procedure entitled "Medications Brought in with Patients" (Effective 8/29/2005; signed 6/4/2008) read as follows:

"All medications brought into the hospital with the patient shall either be returned to the patient's family or, if needed for administration to the patient, sent to the pharmacy for labeling. The Pharmacist will verify the contents and relabel appropriately."

"The Pharmacist will label the medication and return the medication to the nursing unit for administration to the patient as ordered by the physician."

2. On 1/3/2012 during a tour of the medication room located on the acute care unit, a Licensed Practical Nurse (Staff Member #18) was observed to have a tray containing 11 different medications that belonged to Patient #11.

An interview with Staff Member #18 on 1/3/2012 at 2:30 PM revealed that one of the medications had been administered to the patient (Dipyridamole 50 mg oral tablet). Staff Member #18 stated that she/he had called the local pharmacy to verify the medications over the phone prior to administering any of the patient's own medications. The pharmacists at the local pharmacy also served as the hospital's on-site pharmacists.

The pharmacist had not phsyically examined and labeled the medications prior to nursing staff administering the medications.

3. During observation of medications being administered to Patient #11 by Staff Member #19 on 1/5/2012 at 9:00 AM it was noted that one medication bottle had a yellow circular sticker on it with the date and signature of the pharmacist. Staff Member #19 stated that the pharmacist had come in the night before and examined the medications and put the sticker on the side of the medication tray. Staff Member #19 had removed the sticker from the medication tray and placed it on the top of one of the medication bottles.

The medications were not individually relabeled after examination by the pharmacist as required by policy.

4. The nursing staff and the pharmacist had not followed hospital policy and Washington State Board of Pharmacy regulations for administration of patient's own medications while being cared for in the hospital.

Based on observation, interview, and record review the facility failed to develop and/or implement and maintain policies and procedures for specific infection prevention practices.

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.

Reference:
Facility policy titled " Hand Hygiene " dated 1/4/2012 reads in part:
" PROCEDURE: ...A readily accessible alcohol-based hand-rub product is provided. "
" A. Indications for hand washing and hand disinfection:
? 2. Decontaminate hands before having direct contact with patients.
? 5. Decontaminate hands after contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).
? 6. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings ...
? 8. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
? 9. Decontaminate hands after removing gloves. "

Findings:

Part I

Throughout the four days on-site in the course of touring various facility areas Surveyor #2 observed breaches of infection control policy and procedure, and professional standards of practice:
? On 1/3/2012 Staff Member #8 picked an item up from the floor and did not perform hand hygiene (HH) afterwards.
? On 1/4/2012 Staff Member #9 licked his/her fingers repeatedly to facilitate turning pages without performing hand hygiene afterwards. Similar observations were made for Staff Member #6 on 1/5/2012 and Staff Member #3 on 1/6/2012. Surveyor #1 also observed similar actions by Staff Member #10 on 1/5/2012.
? On 1/4/12 Staff Member #11 wore a skull cap while participating in an endoscopy procedure. Hair and scalp was not fully contained by the cap. S/he stated that s/he and the surgeons all wore skull caps during surgical procedures. These head coverings risk contamination of sterile fields in the operating room by shedding of hair and epithelial cells.
? During tour of the clinic on 1/5/2012 a staff member's lunch bag was found in a clean supply room, resting on the edge of the hand washing sink, subject to splash contamination.
? On 1/5/2012 during pharmacy tour with Staff Member #6, Surveyor #1 found 5-6 bottles of alcohol on the floor lined up against the wall by the door of the pharmacy. Interview with the pharmacist revealed the bottles contained whiskey, were approximately 25 years old, and were not used within the hospital anymore. Surveyor #2 reviewed minutes from the Pharmacy and Therapeutics Committee meeting dated 4/21/2011 in which the Board of Pharmacy inspector was reported to have expressed concerns about lack of cleanliness of the pharmacy.
? On 1/3/2012 unwrapped laryngoscope blades were laid out on the operating room (OR) anesthesia cart covered by a towel, rather than wrapped to prevent contamination. No procedures were planned for the OR until the following week. Inspection of the anesthesia cart in the endoscopy room revealed two unprotected blades and other similarly unprotected instruments. The CRNA also showed Surveyor #2 unprotected laryngoscope blades is the kit which s/he maintained to grab quickly if needed in an emergency. During tour of the emergency department the surveyor observed numerous similarly unprotected blades in the crash cart. Staff Member #12 advised the surveyor that s/he always sterilized the blades after use, wrapped in a protective packaging, but that these appeared to be removed after leaving his/her custody far in advance of their use.


Part II

Surveyor #2 observed breaches of infection control standards and policies during an endoscopy procedure on 1/4/2012 between approximately 11:45AM - 12:30PM:
? Staff Member #12 dropped a glove on the floor, retrieved and discarded it, but did not perform hand hygiene (HH) before donning new gloves.
? Staff Member #13 performed the patient ' s intravenous venipuncture (IV), removed gloves, but did not perform HH before donning another pair, injecting saline, and connecting the IV fluid line. S/he again removed gloves without doing HH and went on to other patient care/contact tasks.
? Staff Member #13 donned a pair of gloves, picked up an item from the floor, then removed the gloves but did not perform HH.
? Staff Member #13 wore gloves to assist with specimen collection, then removed them but without doing HH put on another pair of gloves and assisted with cleaning up the room. With the same contaminated gloves s/he untied his/her mask and worked on the patient record.
? The only available method for performing HH in the room was a hand wash sink, the use of which necessitated walking a distance from the procedure area to reach the sink and do hand washing with soap and water. Hand washing, done to standard, including drying time requires approximately 30 seconds, plus the time taken to walk there and return to patient care tasks. There were no hand sanitizer containers in the room, which would significantly decrease the time and energy required to perform HH, though their availability is specified in policy.

Staff Member #14, the Infection Preventionist Consultant confirmed that the above practices were not consistent with facility policy and professional standards.



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Part I

Based on observation 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 its own policies and procedures for food service puts patients, staff and visitors of the facility at risk of food borne illness.

Findings include:

1. On 1/4/2012 the surveyor noted that a colander of pasta had been placed in one of the compartments of a two compartment sink although the specific compartment being used had been posted to be used as a "Meat" sink.


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Part II

Based on record review, review of policies and procedures, and interview, the hospital failed to develop a systematic process for referring patients at nutritional risk to a 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. Review of a medical record for nutritional risk screens revealed the following:

Patient #10 was a 79 year-old patient admitted on 12/31/2011 for evaluation of altered mental status. Review of the nursing admission assessment for nutritional concerns revealed that the patient was on a sodium restricted diet and had a poor appetite. There was no referral in the medical record for a dietary evaluation and there was no documentation in the medical record indicating that the dietician had performed an assessment of the patient's nutritional status.

2. An interview with Staff Member #10 on 1/5/2012 confirmed that a referral for a dietary consult had not been completed for Patient #1. RN #1 stated that she/he knew that the hospital had recently hired a dietician but she/he did not know the dietician's name or how to contact him/her.

3. Review of the hospital's policy entitled "Nutrition Care" (Effective 5/6/2010; Approved 5/6/2010) revealed that there was not a clearly defined process for referring patients to the dietician for a nutritional assessment based on a nutritional risk screen.

Based on interview and record review, the facility failed to conduct periodic staff performance reviews per policy, and failed to conduct training for a specific potential emergency situation.

Failure to do so risks patient care by staff unprepared or unable to competently perform their duties according to standards of practice, resulting in the potential for poor patient outcomes and death.

Findings:

Part I

During review of human resource records by Surveyor #2 on 1/6/2012 the human resources staff (Staff Member #3) stated that facility policy stipulated that performance reviews were to be conducted annually. Review of human resource records found that annual performance reviews were not performed in 2011 for two of six staff reviewed for the issue (Staff Member #4, #5). Nor was a performance review found for 2010 for Staff Member #5.

Part II

During tour of all clinical areas by Surveyor #2 on 1/3-5/2012 the issue of training to meet an emergency known as malignant hyperthermia (MH) was discussed with Staff Member #6 and Staff Member #12, who routinely works in the peri-operative area. MH is a rare but life-threatening emergency caused primarily by triggering agents such as medications used for anesthesia and intubation. To successfully rescue a patient experiencing MH the response must be immediate and ongoing until the patient is stabilized. The syndrome could occur in most areas of the facility, including peri-operative, acute care, and emergency departments.

According to the Malignant Hyperthermia Association of the United States, training of respondent personnel should be conducted annually. During review of human resource records on 1/6/2012 the CEO (Staff Member #1) confirmed that most direct care staff were cross-trained and worked in all areas of the facility. Therefore they might all be faced at some point with working to rescue a MH patient. The human resources staff (Staff Member #3) could find no record of MH response training in four of four records reviewed for the issue. The CNE (Staff Member #6) stated that there had been no drills to his/her knowledge, and that the response process had not been operationalized by determining which staff should respond or what their individual duties should be.
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Part I

Based on interview and record review, the facility failed to ensure that all medical record entries were complete, signed, dated, and timed.

Failure to do so results in incomplete records, makes it difficult to determine the sequence of events, and risks treatment error.

Reference:
Facility policy titled "Physician's Orders" dated 12/30/2009 reads in part:
? " PROCEDURE: ...B. When the physician write the orders, which are dated and timed ... "
? " MEDICATIONS: ...C. All medication orders must state the name of the medication, strength, route and time of administration or time interval between doses. "

Findings include:

On 1/5-6/2012 Surveyor #2 reviewed records for patients who had received services in the surgical, endoscopy, and emergency departments. Nine of 21 records reviewed for the issue contained physician orders for drugs and testing which lacked signature, date and/or time (Patients #1 - 9). In summary:

? Two orders were not signed by the prescribing practitioner.
? Four orders were not dated.
? Seven orders did not document the time they were written.
? Seven orders for intravenous fluid administration pre- and post-procedures did not specify the type of fluid to be infused and the rate at which to infuse the fluid.

The above omissions were confirmed by Staff Member #6 to be breaches of facility policy.



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Part II

Based on interview, record review, and review of policy and procedure, the facility failed to ensure requirements, of chapter 246-873 WAC, PHARMACY - HOSPITAL STANDARDS were met, more specifically, the hospital failed to ensure that medications were dispensed and administered only upon orders of a physician in 1 of 5 patient records reviewed.

Failure to follow pharmacy hospital standards places patients at risk for harm due to medication errors.

Reference:

WAC 246-873-080 (6) Medication Orders. Drugs are to be dispensed and administered only upon orders of authorized practitioners. A pharmacist shall review the original order or direct copy thereof, prior to dispensing any drug, except for emergency use or as authorized in WAC 246-873-050.

Findings:

1. Review of 5 medical records of patients admitted to the hospital revealed the following:

a. Patient #11 was a 60 year-old patient who was admitted on 12/9/2011 for observation related to low blood sugars. On 12/10/2011 the decision was made to admit Patient #11 to the hospital.

b. Review of Patient #11's medical record for medication orders revealed that MD #3 wrote admission orders on 12/10/2011 at 10:50 AM that included an order for medications that instructed nursing staff to "continue current medications." The physician did not specifically order each individual medication.

c. Review of the patient's Medication Administration Record (MAR) revealed that the patient had 19 medications listed for administration and nursing staff had administered 13 of the medications. There were no physician's orders in the inpatient medical record for the medications administered by nursing staff.

2. Review of Medical Staff rules and regulations revealed that there was no definition of a complete medication order nor was there a description of what was required in admission medication orders when patients are transferred from observation status to hospital inpatient.

3. The Director of Nursing Services (Staff Member #6) confirmed the above findings.

Based on record review, interview, and review of policy and procedure, the hospital failed to develop an individualized plan for patient care according to hospital policy for 4 of 4 observation patient records reviewed (Patient #16, #17, #12, #11).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. The hospital's policy and procedure entitled "Inpatient Admissions" (Effective 3/21/2003; Approved 5/31/2008) stated that within 24 hours of admission nursing staff must initiate a plan of care. The hospital did not have a policy and procedure that addressed the nursing plan of care for observation patients.

2. Review of the medical records of four (4) observation patients revealed the following:

a. Patient #16 was a 63 year-old patient admitted on 12/15/2011 for observation following a severe seizure while at home. The patient was discharged on 12/17/2011. Review of the medical record on 1/52012 revealed that no patient care plan had been developed and implemented.

b. The same was found in the patient record of patient #17, #12, and #11.

3. An interview with the Director of Nursing Services (Staff Member #6) on 1/6/2012 revealed that the hospital did not require a care plan for observation patients.

Based on interview and record review, the facility failed to implement policies and procedures that addressed post anesthesia evaluations which met professional standards.

Failure to do so placed patients at risk for poor outcomes related to complications from anesthesia administration.

Reference:
Practice Guidelines for Postanesthetic Care, Anesthesiology, Vol 96, No 3, March, 2002, provides the recommendations of the American Society of Anesthesiologists for routine postanesthesia assessment and monitoring, including but not limited to:
? respiratory function, including respiratory rate, airway patency, and oxygen saturation
? cardiovascular function, including pulse rate and blood pressure
? mental status
? temperature
? pain
? nausea and vomiting
? postoperative hydration


Findings:

On 1/5-6/2012 Surveyor #2 reviewed a selected cross section of six outpatient surgical and endoscopy patient records from November and December, 2011. Documentation of post-anesthesia evaluations for these patients were reviewed (Patients #1-4, #18-#19).

For each of the six patients the documentation found was brief and essentially identical. The anesthesia record form contained a box approximately 1" X 3" for the anesthesia provider (CRNA) to document the evaluation. In each case the record only documented "no complications" had been detected related to anesthesia. Since the majority of entries were not timed, it was not possible to determine at what point following anesthesia administration the entries were made.

Interview with Staff Member #8 and #11 indicated that the facility's practice was to record post-anesthesia evaluations on the anesthesia record unless a progress note was used. No post-anesthesia progress notes by CRNAs were found in any of the six patient records reviewed.

Based on interview and review of performance improvement documentation, the hospital failed to systematically assess medication errors and incidents, patient deaths, patient injuries, and patient grievances for patterns and trends.

Failure to do so limits the hospital's ability to prevent future errors or injuries and reduce risk of patient harm.

Findings include:

During review of performance improvement data and an interview on 1/6/2012, it was found that the hospital did not systematically analyze aggregate data on medication errors, patient injuries, patient deaths, and patient grievances to determine if the issues found or reported had a common cause or if certain types events or errors were increasing in number and frequency.

These findings were confirmed by the Chief Executive Office(Staff Member #1).