HospitalInspections.org

Based on observation, interview, and personnel file review, the Hospital failed to ensure that personnel performing the duties of a Social Worker and Nursing Assistant were properly licensed, and certified or registered with the Department of Health as required by state rules.

Failure to ensure that personnel have the proper credentials to perform their assigned job duties risks provision of health care by unqualified persons.

Reference:

Chapter 18.225 RCW
Chapter 246-809 WAC Licensure for mental health counselors, marriage and family therapists, and social workers

Washington State law states that a person must not represent himself or herself as a licensed advanced social worker, a licensed independent clinical social worker, a licensed mental health counselor, a licensed marriage and family therapist, a licensed social work associate-advanced, a licensed social work associate-independent clinical, a licensed mental health counselor associate, or a licensed marriage and family therapist associate, without being licensed by the department [RCW 18.225.020].


Chapter RCW 18.88A
WAC 246-841 Nursing Assistant

Washington State law states that no person may practice or represent himself or herself as a nursing assistant-registered by use of any title or description without being registered by the department pursuant to this chapter [RCW 18.88A.040].

Washington State law states that no person may use any title or description, practice or represent himself or herself as a nursing assistant-certified without applying for certification, meeting the qualifications, and being certified by the department pursuant to this chapter [RCW 18.88A.040].

Findings:

1. Unlicensed Social Worker with expired Nursing Assistant Registration

a. An interview with the social worker, Staff Member #9, on 5/24/2011 by Surveyor #29784 revealed that S1 provided social work services for patients in the emergency department, clinics, acute care, and swing bed (long term care patients).

b. Review of Staff Member #9's job description on 5/25/2011 revealed that the job classification was "Social Services Director." The summary statement on the first page of the job description read as follows:

"To provide Social Service to attain or maintain the highest practical physical, mental, and psychosocial well-being of each patient and resident.

In addition to current job description, (Staff Member #9) has proven her expert abilities providing activities of daily living care of patients and residents. She has a history of being a certified nursing assistant and has been taught and delegated the tasks of feeding residents with normal swallow, simple stand-pivot transfers including to and from the toilet, perineal care including patients/residents with indwelling urinary catheters, dressing and undressing of street and bed clothes, linen changes of the bed, assisting with repositioning of residents/patients in bed, recliner, wheelchair, or any standard chair, contact guard or standby assist with ambulation, transporting patients/residents on and off the unit/facility, verbal and physical assist with personal hygiene needs beyond toileting assist, and emptying urinals and catheters.

Staff #9 has not been authorized to do any skilled nursing tasks such as medication administration, physical assessment, wound dressing, or any other treatments requiring a physician's order."

b. Review of Staff Member #9's personnel file on 5/25/2011 revealed that she/he was not licensed as a social worker nor was she/he certified or registered as a nursing assistant.


2. Emergency Department Technician performing duties of Nursing Assistant

a. Review of Staff Member #11's job description on 5/25/2011 revealed that the job classification was "Emergency Room Technician". The summary statement read as follows:

"The Emergency Room Technician will function under the direct supervision of the Registered Nurse as assigned. Duties will include admitting services (clerical and receptionist), direct and in-direct patient care mostly in the Emergency Room, but may occur on the Acute Care Unit, therefore contributing to the daily operations of the Emergency Room as a unit, and [the hospital] as a whole. Flexibility is required to facilitate patient care in the Emergency Room, Acute Care Unit, and the Admitting Department."


Review of Staff Member #11's competency checklist on 5/25/2011 revealed that many of the skills required of the Emergency Room Technician fall under the category of Nursing Assistant as defined by Washington State law [Chapter 246-841 WAC] and require a registration or certification.

b. Review of personnel files on 5/25/2011 revealed that Staff Member #11 had a Health Care Assistant "A" certification allowing Staff Member #11 to perform venous and capillary blood withdrawals but Staff Member #11 was not certified or registered with the Washington State Department of Health as a nursing assistant.

SEE FIRE & LIFE SAFETY REPORT

Based on observation, the hospital failed to install alcohol based hand rub (ABHR) dispensers such that they were not installed over or adjacent to an ignition source. Failure to place ABHR dispensers such that they are not over or adjacent to an ignition source in increases the risk of fire should the flammable liquid be ignited by the source.

Findings:

During a tour of the hospital, ABHR dispensers were found installed over or within 6 inches of electrical light switched through out the hospital.

Item #1: Physician's order for Restraint Use

Based on record review, and review of policy and procedure, the hospital failed to follow its policy and procedure for restraint use for 2 of 2 patients reviewed (Patients #12, #13).

Failure to follow hospital policy and procedure for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Restraint Policy" (policy #6070-219; effective 5/3/2010) read as follows:

"Restraint is used upon the order of a physician" and "In an emergency situation, if a physician is not available to issue such an order, a Registered Nurse (RN) may initiate a physical restraint based on an appropriate assessment of the patient. The physician is notified as soon as possible to obtain a verbal or written order."

2. Review of the records of 2 patients who had been restrained during their hospitalization revealed the following:

a. Patient #11 was a 59 year-old patient admitted on 12/6/2010 for treatment of a pulmonary embolism. On 12/7/2010 at 8:44 PM, Patient #11 became combative and dislodged an intravenous catheter in the right hand and was attempting to pull off his/her oxygen mask. At that time the patient was placed in upper extremity restraints. Review of Patient #11's medical record revealed that there was no physician's written or verbal order for restraints.

b. The same was found in the medical record of Patient #12.


Item #2: Patient notification of limited obstetrical services

Based on interview and document review, the hospital failed to inform obstetrical patients, in writing, of the hospital's limited obstetrical services, and transportation and transfer agreements as required by Washington State law [WAC 246-320-251(1)(b)].

Failure to inform patients of limited obstetrical services risks patients that do not have the knowledge to make informed decisions about their care, and risks patient health and safety.

Findings:

1. During a tour of the Operating Room on 5/24/2011 it was discovered that Staff Member #14 was the only physician who performed cesarean sections. A note posted on a board above the nurses' station in the pre-op area stated that Staff Member #14 was planning to be out of town from June 10th to June 19th , leaving the hospital without the capability to perform cesarean sections.

2. An interview with the manager of Labor and Delivery (Staff Member #13) on 5/24/2011 confirmed that when Staff Member #14 was out of town or unavailable the hospital would be unable to perform cesarean sections should the need arise.

Staff Member #12 stated that the hospital had been working on a hand-out for obstetrical patients but at the time of the survey the hospital had not developed a process for informing patients in writing regarding the limited obstetrical services or of transportation and transfer agreements.


Item #3: Written agreement for transfer of obstetrical patients

Based on interview, the hospital failed to maintain a written agreement for 24-hours per day ambulance or air transport of obstetrical patients as required by Washington State law [WAC 246-320-251(1)(c)].

Failure to do so risks the health and safety of obstetrical patients.

Findings:

An interview with the manager of Labor and Delivery (Staff Member #13) and the Director of Nursing Services (Staff Member #12) on 5/26/2011 revealed that the hospital did not have a written agreement for 24-hours per day ambulance or air transport of obstetrical patients.


Item #4: Written agreement with another hospital to admit transferred obstetrical patients

Based on interview, the hospital failed to maintain a written agreement with another hospital to admit transferred obstetrical patients as required by Washington State law [WAC 246-320-251(1)(d)].

Failure to do so risks the health and safety of obstetrical patients.

Findings:

An interview with the manager of Labor and Delivery (Staff Member #13) and the Director of Nursing Services (Staff Member #12) on 5/26/2011 revealed that the hospital did not have a written agreement with another hospital to admit transferred obstetrical patients.

Based on interview and policy and procedure review, the facility failed to ensure that access to the pharmacy by a single nurse after hours.


Failure to secure after-hours access to the pharmacy, places medications at risk for altered quality and the potential for tampering and/or diversion which may compromise safe patient care.


Findings:

1. Based on facility policy titled, " Entering The Pharmacy " , item c states, "Only a single Charge Nurse can be designated at a single time in the Hospital, and only that single Charge Nurse may enter the Pharmacy if appropriate (described above) + a single witness if removing a controlled medication. "


2. Based on interview with the pharmacist, Staff Member #10, there were eight registered nurses with current knowledge of the pharmacy access code with the potential to enter the pharmacy. Staff Member #10 also stated that on a typical day 2-4 charge nurses have access to the pharmacy and there is one access code for all charge nurses to use to access the pharmacy. The pharmacist also stated that a camera located in the pharmacy provided visual information about activities in the pharmacy and the key code on the door recorded access code information.


3. Based on interview with the pharmacist, Staff Member #10, the main door pharmacy access code is changed every 3 months or sooner as needed. The pharmacist stated that the pharmacy is accessed after hours for approximately 2-3 medications per day.The combination to the narcotics cabinet is not changed to limit access. Therefore, the narcotics access code is generally more available than the access code to the pharmacy.


4. On 5-23-11, two vials of meperidine 50 mg were removed but the sign-out log was not completed to indicate the times of the removal. At 11:00pm on the same date, fentanyl was also removed for the same patient. The log contained initials that indicated a total of 5 persons participated in the removal of the 3 containers controlled substances. On 5-24-11 when Staff Member #10 was asked about the related identity of the individuals' initials on the medication sign out form, s/he was unable to identify the individuals or locate a master signature list that would indicate staff identity. The discussion indicated that there was limited knowledge by the pharmacist of individual staff members that accessed the pharmacy after hours for those controlled substances, including those who had provided incomplete documentation. The pharmacy failed to follow its' own policy related to limited after hours access.