HospitalInspections.org

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Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that hospital staff members verified that supplies and equipment were immediately available to treat patients during obstetrical emergencies.

Failure to ensure that emergency supplies and equipment are immediately available risks adverse patient outcomes during obstetrical emergencies.

Findings included:

1. On 07/26/17 at 9:00 AM, Surveyor #2 inspected a cart containing emergency equipment and supplies located in the hospital's obstetrical department. The inspection showed an equipment list on the cart titled "Crash C-Section Cart Contents/OB". The list identified emergency supplies and equipment that were to be in the cart. Review of a log located on the cart titled "Crash C-Section Cart Monthly Checklist" showed that the cart had not been inventoried since 05/18/16.

2. During an interview with Surveyor #2 at the time of the observation, a nurse who worked in the obstetrical department (Staff A) confirmed the findings above.
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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a safe process for stocking and storing medications used during medical emergencies.

Failure to develop such a process risks medical errors and patient harm.

Findings included:

1. Review of the hospital's policy and procedure titled "Crash Cart", Policy #3406604 reviewed 03/17, showed that the purpose of the procedure was to standardize carts containing medications, supplies and equipment used during medical emergencies. The policy showed that emergency department (ED) nurses were to restock the ED cart after medications were used according to a medication checklist stored on top of the cart. The hospital's pharmacy staff were to perform an inventory of the drugs stored in the cart each month.

2. On 07/26/17 at 9:55 AM, Surveyor #1 inspected two emergency supply carts located in the hospital's emergency department (ED). The cart in Trauma Room #2 was a "Broslow Cart" that contained color-coded supplies and equipment used during pediatric medical emergencies. The cart also contained medications used during cardiopulmonary resuscitation. The medications included both pediatric and adult strength preparations. The "adult" emergency cart in Trauma Room #1 also included both pediatric and adult strength emergency medication preparations.

3. During an interview with Surveyor #2 at the time of the observation, the ED nurse manager (Staff B) and a nurse who worked in the ED (Staff C) confirmed the findings above. The manager stated that the pharmacy stocked the carts and that there was no medication checklist for nurses to use as described in the "Crash Cart" policy. She stated that the medication drawers of the carts were not routinely opened by nurses so that they would become familiar with their contents.

4. On 07/26/17 at 11:10 AM during a telephone interview with Surveyor #2, the hospital's pharmacy director (Staff D) stated it was not a safe practice to store adult and pediatric medications in the same cart.
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Based on observation and interview, the Critical Access Hospital failed to fully implement the requirements of the 2009 Food and Drug Administration Food Code (FDA).

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings included:

On 07/26/17 at 11:30 AM, Surveyor #1 observed whole pieces of cooked pork (greater than 4 inches thick) in one of the walk-in refrigerators. The dietary cook (Staff O) stated, that meats were normally sliced into smaller pieces to facilitate cooling. The facility did not have a temperature log to ensure that meats greater than 4 inches were cooled in the time frame as required per FDA food code.

Reference: 2009 Food and Drug Administration Food Code (FDA) 3-501.14)Washington State Retail Food Code, WAC 246-215-03515

Based on interview and review of hospitals policy and procedures, the Critical Access Hospital failed to have a system in place that would assure the safety and well being of patients, staff and visitors in the event of a non-medical emergency. More specifically, the hospital failed to have a plan in place that would provide readily available potable water to patients, staff and visitors.

Failure to develop and implement an emergency water preparedness plan places the safety of patients, staff, and visitors of the facility at risk during non-medical emergencies.

Findings included:

1. Review of the hospital's policy titled "Emergency Preparedness Plan", revised 11/14, did not have a water preparedness plan.

2. On 07/25/17 at 1:30 PM Surveyor #1 reviewed the emergency preparedness plan with the hospital's facility's manager (Staff P). The surveyor was informed by the manager that the hospital did not have readily available water supplies or a memorandum of understanding or agreements (MOU's) with a utility company to assure that potable water would be delivered in a timely manner in case of a non-medical emergency event. The facility manager stated that they had a portable water filter system located in the emergency preparedness trailer. In review of the Critical Access Hospital Regulations, this technology did not meet the requirements.

Based on interview and review of hospital's policy and procedures, the Critical Access Hospital failed to ensure that staff were provided with sufficient training to properly handle non-medical emergencies.

Failure on the part of the facility to adequately train staff to handle non-medical emergencies puts patients, staff and visitors of the facility at risk should such an emergency present itself.

Findings included:

1. Review of the hospital's policy titled "Emergency Preparedness Plan", revised 11/14, showed the plan did not include a process for tracking and identifying who completed emergency preparedness training.

2. On 07/26/17 at 1:36 PM, Surveyor #1 interviewed facilities manager (Staff P) who was in charge of implementing the emergency preparedness plan. During the review of the plan with the manager, surveyor #1 asked to see who had been trained in emergency preparedness. The manager provided a document that was submitted to Washington State Department of Health titled, " National Incident Management Systems (NIMS) Compliance Survey Healthcare 2017", which Identified that 20 out of 25 recieved training but could not provide documentation who completed the training.

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Based on interview and review of hospital policies and procedures, the Critical Access Hospital (CAH) failed to develop and implement a policy and procedure for annual review of core CAH policies and procedures by a professional group that included one or more physicians.

Failure to review and update hospital policies and procedures risks medical errors and patient harm.

Reference:

§485.635(a)(3) The policies include the following: (i) A description of the services the CAH furnishes directly and those furnished through agreement or arrangement.

§485.635(a)(3)(ii) Policies and procedures for emergency medical services.

§485.635(a)(3)(iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.

§485.635(a)(3)(iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

§485.635(a)(3)(v) Procedures for reporting adverse drug reactions and errors in the administration of drugs.

§485.635(a)(3)(vi) A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

§485.635(a)(3)(vii) If the CAH furnishes inpatient services, procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of §483.25(i) is met with respect to inpatients receiving post CAH SNF care.

Findings included:

1. Review of the hospital's policy titled "Policy Approval, Review and Revision", Policy #2921551 revised 11/14, showed that policies and procedures would be reviewed according to CAH regulations.

2. Review of the hospital's policies and procedures showed that department supervisors annually reviewed policies and procedures for their department. There was no evidence that core CAH policies were reviewed by a professional group that included a physician.

3. On 07/27/17 at 10:15 AM during an interview with Surveyor #2, the chair of the hospital's policy and procedure committee (Staff F) stated that core CAH policies and procedures were not reviewed annually by a professional group that included a physician.

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ITEM #1 - GLOVING AND HAND HYGIENE

Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy and procedure to ensure that all hospital staff members performed gloving and hand hygiene according to acceptable standards of practice, as demonstrated by 3 staff members observed (Staff C, G,H).

Failure to perform hand hygiene while providing patient care risks transmission of infectious diseases to patients and caregivers.

Reference: "Guidelines for Hand Hygiene in Healthcare Settings" (Centers for Disease Control and Prevention, 2008)

Findings included:

1. The hospital's policy titled "Infection Prevention - Hand Washing 3790776 reviewed 07/17" showed that hospital staff members were to either wash their hands or use hand sanitizer before preparing or handling medications and after glove removal.

2. On 07/25/17, Surveyor #2 observed the following:

a. At 10:55 AM, Staff G did not perform hand hygiene before donning gloves and administering intravenous medication to Patient #2.

b. At 11:03 AM, Staff C did not perform hand hygiene before donning gloves and inserting infusion tubing into a unit of blood that was to be transfused into Patient #1's intravenous infusion line.

c. At 1:20 PM, Staff H did not perform hand hygiene after glove removal for 4 of 6 glove changes during wound care for Patient #3. While assisting Staff H during wound care, Staff C did not perform hand hygiene after glove removal for 1 of 2 glove changes.
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ITEM #2 - ENVIRONMENTAL CLEANING PROCEDURES

Based on observation, and review of the hospital's policy and procedures, the Critical Access Hospital failed to ensure housekeeping staff used infection control techniques that prevented cross contamination when cleaning a patient room.

Failure to prevent cross contamination during the cleaning process places patients and staff at risk of infection.

Findings included:

1. The hospital's policy titled "Infection Prevention - Hand Washing" policy 3790776 reviewed 7/17 showed that hospital staff members were to either wash their hands or use hand sanitizer after touching patient surroundings and before donning gloves.

2. On 07/25/17 at 10:00 AM, Surveyor #1 observed a housekeeper (Staff M) clean a patient room after the patient discharged, from room #106. During the process, the housekeeper removed the garbage from the room, disposed of the debris, then did not remove gloves, perform hand hygiene, and don clean gloves before cleaning the patient's table. This risks contaminating the table's surface.

ITEM #3 WATER MANAGEMENT PROGRAM

Based on interview and document review the Critical Access Hospital failed to develop water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the hospital water systems.

Failure to develop and implement a water management program places patients, staff and visitors at risk for waterborne illness.

Findings included:

On 07/26/17 at 1:00 PM, Surveyor #1 interviewed the Infection Prevention Nurse (Staff R) regarding the hospital's water management program. The nurse stated that the hospital did not have a water management program to reduce risk of legionella and other waterborne illness.

ITEM #4 SINGLE USE CONTAINER

Based on observation, interview and document review, the Critical Access Hospital failed to prevent contamination of ultrasound transmission gel used during diagnostic testing procedures.

Failure to discard single use items places patients at risk of infections.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012), states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings included:

On 07/26/17 at 12:00 PM, Surveyor #1 observed a small squeeze bottle of "Aqua Sonic Gel" in the physical therapy department. During an interview with the physical therapist supervisor (Staff Q) stated that the department staff rountinely refill bottles of aqua sonic gel.

ITEM #5 - REPROCESSING COLONOSCOPY SCOPE

Based on observation, interview and document review, Critical Access Hospital staff failed to follow the manufacturer's instructions for use when reprocessing colonoscopy scopes.

Failure to follow the manufacturer's instructions for reprocessing colonoscopy scopes puts patients at risk of infection from inadequately cleaned and disinfected semi-critical devices.

Findings included:

1. The Manufacturer's instructions for use for Pentax EC38-i10L Colonoscopy Endoscope contained the following instructions: Page 22, Suction Channel Cleaning (4)"Insert the blue tip of cleaning brush (CSbos1T) into the opening of the suction nipple, and gently pass the brush until it appears in the suction cylinder. (5) Grasp the blue tip of the brush shaft, and gently pull the brush from the suction until the brush heads exit the suction cylinder, and clean debris off the brush head by rubbing them with fingers. (6) Repeat steps 4 and 5 three additional times.

Page 41, titled "Drying" "Warning statement" "Regardless of the quality of the rinse water used, it is essential to perform a final alcohol rinse followed by forced air in order to completely dry the endoscope channels and prevent bacterial colonization and/or infections associated with waterborne microorganisms. . . Gently dry all external surfaces of the endoscope, components, and accessories with sterile gauze."

2. On 07/26/17 at 8:00 AM, Surveyor #1 observed an endoscope reprocessing technician (Staff N) clean a Pentax EC38-i10L endoscope after it was used during a colonoscopy procedure. During the cleaning process, the technician inserted the cleaning brush (Pentax CSbos1T) through the suction nipple one time instead of three times as indicated in the manufacturer instruction manual.

During the interview, the technician stated that the hospital's Automated Endoscope Reprocessor (AER) did not provide a final alcohol rinse and that a manual alcohol rinse was not performed after each time the endoscope was reprocessed. A manual alcohol rinse was performed only at the end of the day.

The hospital had two endoscopes, and there were four colonoscopy procedures that day. The technician stated that endoscopes are left in the reprocessor machine until the next procedure.

The actions above did not comply with the manufacturer's instructions for use.


ITEM #6 - DISINFECTING FREQUENCY OF MEDICAL EQUIPMENT

Based on interview and document review the Critical Access Hospital failed to follow manufacturer's instructions when cleaning the hydrocollator.

Failure to adhere to manufacturer's instructions for use places patients at risk of infections.

Findings included:

1. Reference: In review of "Chattanooga Hydrocollator User Manual" on page 19-20 part 6, states, "Regularly clean and drain the tank (every two weeks minimum)."

2. On 07/27/17 at 11:50 AM, Surveyor #1 interviewed a physical therapist (Staff Q) about the process for cleaning and disinfecting the hydrocollator. The physical therapist indicated that the hydrocollator is cleaned monthly.

CONDITION FOR COVERAGE - NOT MET

Based on observation, interview, document review, and review of hospital policies and procedures, the Critical Access Hospital failed to implement its quality improvement plan to ensure safe and effective patient care.

Failure to systematically collect and analyze hospital-wide performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

Condition-level non-compliance was present due to the following:

1. The hospital failed to include all patient care services and other services affecting patient health and safety in its quality monitoring process as directed by its quality improvement plan.

2. The hospital failed to provide evidence that data for selected quality indicators were analyzed, compared to performance benchmarks, and that action plans were developed, implemented, and tracked when goals were not met.

3. The hospital failed to perform a Critical Access Hospital program evaluation for 2016.

Cross-reference: Tags C0331, C0337, C0342
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital (CAH) failed to perform a program evaluation according to hospital policy.

The purpose of the program evaluation is to determine whether the utilization of services was appropriate, that established policies were followed, and if any changes to the CAH program are needed.

Reference: 42 CFR 485.641(a)
The evaluation includes review of (1)(i)The utilization of CAH services, including at least the number of patients served and the volume of services; (ii) A representative sample of both active and closed clinical records; and (iii) The CAH's health care policies.

Findings included:

1. The hospital's policy and procedure titled "Annual Program Evaluation - Critical Access", Policy #2179838 revised 05/14, showed that the hospital would perform an annual CAH program evaluation to evaluate the quality and appropriateness of the treatment provided to patients.

2. On 7/27/17 from 9:00 AM to 10:00 AM, Surveyor #2 interviewed the hospital's quality program manager (Staff I) regarding the hospital's quality improvement program. During the interview, the manager stated that the hospital did not complete a CAH annual program evaluation for 2016.
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Based on interview and review of the Critical Access Hospital's quality plan, the hospital failed to implement its plan to monitor and evaluate the quality of patient care services through data collection and analysis.

Failure to systematically collect and analyze facility performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Review of the hospital's policy titled "Continuous Quality Risk Management (CQI/RM) Plan Endorsement", Policy #3580191 approved 06/17, showed that the quality program was to be hospital-wide and include all hospital departments. Departmental indicators were to be reviewed quarterly by the quality program manager. Data was to be compared with a standard benchmark. Significant issues were to be reviewed by the quality council and/or hospital board and prioritized for development of quality improvement action plans.

2. On 7/27/17 from 9:00 AM to 10:00 AM, Surveyor #2 interviewed the hospital's quality program manager (Staff I) regarding the hospital's quality improvement program. During the interview, the manager presented a list of quality indicators that were currently being tracked through the hospital's quality program. The list did not include indicators that reflected the quality of all patient care services. The manager stated that due to recent changes in program staff members, the hospital was not tracking department-specific quality indicators.
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Based on interview and review of the hospital's quality plan, the Critical Access Hospital failed to implement its plan to improve patient care services by analyzing quality indicators and developing action plans for improvement as necessary.

Failure to systematically collect and analyze facility performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Review of the hospital's policy titled "Continuous Quality Risk Management (CQI/RM) Plan Endorsement", Policy #3580191 approved 06/17, showed that the quality program was to be hospital-wide and include all hospital departments. Data was to be compared with a standard benchmark. Significant issues were to be reviewed by the quality council and/or hospital board and prioritized for development of quality improvement action plans.

2. On 7/27/17 from 9:00 AM to 10:00 AM, Surveyor #2 interviewed the hospital's quality program manager (Staff I) regarding the hospital's quality improvement program. During the interview, the manager stated that the hospital did not currently have a process for documenting analysis of quality indicators and developing, implementing, and tracking action plans for improvement.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed an individualized activity plan in accordance with interests identified in the patient's activities assessment for 3 of 3 long-term care ("swing bed") patients reviewed (Patients #1, #4, #5).

Failure to develop and implement an individualized activities plan for long-term care patients risks impairment of physical, mental, and psychosocial well-being.

Findings included:

1. Review of the medical records of two long-term care patients currently hospitalized under the hospital's long-term care "swing bed" program (Patients #1, #4) and one long-term care patient who had been hospitalized from 03/20/17 to 05/5/17 (Patient #5) showed that hospital staff members had performed an assessment of each patient's activity interests. The records did not include plans for providing activities that met the patients' individual needs.

2. Review of the hospital's policy titled "Activities Assessment" showed that the policy did not include directions for developing and implementing an activity plan based on the patient's activities assessment.

3. On 07/25/17 at 2:25 PM during an interview with Surveyor #2, the hospital's activities program director (Staff J) stated that although activity program staff members conducted an assessment of each swing bed patient's activity interests, the staff members did not develop an individualized activities plan for the patient based on the assessment findings.
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Based on interview and document review, the Critical Access Hospital failed to develop and implement a process for performing a comprehensive assessment of the needs of long-term care patients within 14 days of admission.

Failure to perform a comprehensive assessement of the needs of long-term care patients risks deterioration of the patient's health and adverse patient outcomes.

Reference: 42 CFR 483.20(b)(2) Comprehensive assessment - when required ...a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section...(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.)"

Findings included:

1. Review of a list of long-term care ("swing bed") patients who had been hospitalized between 06/01/16 and 07/25/17 revealed that 23 of the patients had been hospitalized 14 days or longer.

2. On 07/25/17 at 2:25 PM during an interview with Surveyor #2, the hospital's swing bed program coordinator (Staff K) stated that the hospital did not have a policy and procedure for performing a comprehensive assessment of swing bed patient's needs within 14 days of admission.
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Based on interview and document review, the Critical Access Hospital failed to develop and implement a process for developing and implementing a comprehensive care plan for long-term care ("swing bed") patients within 7 days of completion of a comprehensive patient assessment.

Failure to develop a comprehensive plan of care based on comprehensive assessement of the long-term care patient's needs risks deterioration of the patient's health and adverse patient outcomes.

Findings included:

1. Review of a list of long-term care ("swing bed") patients who had been hospitalized between 06/01/16 and 07/25/17 revealed that 23 of the patients had been hospitalized 14 days or longer.

2. On 07/25/17 at 2:25 PM during an interview with Surveyor #2, the hospital's swing bed program coordinator (Staff K) stated that the hospital did not have a policy and procedure for developing and implementing a comprehensive plan of care based on a comprehensive assessment of the long-term care patient's needs.
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Based on interview and review of the hospital's patient rights information, the Critical Access Hospital failed to develop a process for informing patient's of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f).

Failure to inform patients of their rights according to visitation policies and procedures limits the patient's ability to exercise those rights and may result in violation of the patient's right to have visitors of their choice.

Findings included:

1. On 07/26/17 at 9:05 AM during an interview with Surveyor #2, a staff member working at the hospital's reception desk (Staff L) stated that all patients were given a brochure to read entitled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient and outpatient care.

2. Review of the contents of this brochure showed that the brochure did not include the patient's visitation rights identified under 42 CFR 485.635(f)(2).
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