HospitalInspections.org

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Based on observation, interview and review of hospital policy and procedures, the Critical Access Hospital failed to check and properly maintain emergency equipment and supplies.

Failure to ensure emergency equipment and supplies are properly maintained and ready for use can lead to unusable or outdated supplies for treating emergency cases.

Findings:

1. The hospital's policy and procedure entitled "Crash Carts" (Approved 4/2014, Policy ID 740716) read in part as follows: "Policy: This policy is to establish a guideline for maintenance and standardization of crash carts, equipment and drugs necessary for resuscitation ...Procedure: ...5. The crash cart must be checked monthly for outdates and replacements obtained ..."

2. On 5/12/2015 at 9:35 AM, Surveyor #1 reviewed 6 months of emergency pediatric cart check sheets. There was no evidence of an inventory cart review for 5 of 6 months. The hospital document titled, " PEDIATRIC CRASH CART - ER INVENTORY " listed July, September, October, and December 2014 checked and January and March 2015 checked. No monthly checks marked for August and November 2014 or February, March, and April 2015.

3. The assistant director of patient care services (Staff Member #4) confirmed, on 5/12/2015 at 9:45 AM, the missing monthly cart checks.

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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.

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Based on observation and review of hospital policies and procedures the Critical Access Hospital failed to ensure that opened multidose vial medications were labeled with an expiration date or were discarded every 30 days, as directed by hospital policy.

Failure to maintain a pharmacy inspection and inventory system for medications can lead to outdated, mislabeled or unusable medications available for patient use.

Findings:

1. The hospital's policy and procedure entitled "Medication: Multi-dose Vials" (Approved 06/2014, Policy ID: 947175) read in part as follows: "Scope: All staff at MVH using multi-dose vials, eye-drops, containers of multi-dose antiseptics or sterile solutions will be familiar with this policy. Procedure: MULTI-DOSE VIALS/EYE-DROP CONTAINERS ...MDV is to be dated at first penetration of rubber diaphragm. Penetrated vials are to be considered past the use date thirty days after first penetration date and shall be discarded ..."

2. On 5/12/2015 at 1:30 PM, Surveyor #1 observed an opened 3ml Humalog Insulin multidose vial dated "opened" on 10/24/2014 in the emergency department's Pyxis automated medication-dispensing system. The Surveyor observed two similar 3ml Humalog Insulin multidose vials already opened and punctured on two separate patient care units. All three unusable insulin vials were stored in Pyxis machines and available for patient use.

3. The assistant director of patient care services (Staff Member #4) confirmed, on 5/12/2015 at 2:00 PM, the outdated and unlabeled multidose vials.

THIS IS A REPEAT VIOLATION- PREVIOUSLY CITED STATE SURVEY 10/25/2013.

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Item #1- High-Level Disinfection

Based on observation and interview, the hospital failed to ensure that staff members maintained chemical test strips used for high-level disinfection within their manufacturer's expiration date.

Failure to maintain chemical test strips that measure the efficacy of high-level chemical disinfectants puts patients at risk of infection due to inadequate disinfection of semi-critical devices.

Findings:

On 5/12/2015 at 10:15 AM, Surveyor #2 interviewed an ultrasound technician (Staff Member #1) about the hospital's process for disinfection of trans-vaginal ultrasound transducers. The surveyor observed the bottle of chemical test strips used to assess the efficacy of the chemical disinfectant expired in April 2015. The staff member indicated that s/he was unaware that the bottle contained a stamped expiration date.

Item #2- Decontamination of Surgical Equipment

Based on interview and observation, the hospital failed to ensure that staff members cleaned re-usable brushes used to decontaminate surgical instruments at least daily.

Failure to adhere to practice standards for decontamination of surgical instruments puts patients at risk from infection.

Findings:

1. In the document "Standards of Practice for the Decontamination of Surgical Instruments" by the Association of Surgical Technologists, it stated under "Standard of Practice IV, 2 E (1): "Reusable brushes create a risk for cross-contamination. Reusable brushes should be cleaned and decontaminated at least daily or when heavily soiled. Brushes that show wear should be discarded."

2. On 5/12/2015 at 12:30 PM, Surveyor #2 interviewed a surgical technician (Staff Member #2) about the decontamination process for surgical instruments. The surveyor observed several cleaning brushes hanging in a rack over the decontamination sink. The surveyor asked the staff member if s/he cleaned reusable brushes between uses. The staff member indicated that the brushes only received cleaning when immersed in the enzymatic cleaner during the decontamination process.

Item #3- Hand Hygiene

Based on observation, the hospital failed to ensure that dietary staff members performed hand hygiene between glove changes when shifting from dirty to clean tasks in the kitchen.

Failure to implement hand hygiene policies consistent with the Washington State Retail Food Code (WAC 246-215), puts patients, staff and visitors at risk of food-borne illness.

Findings:

On 5/13/2015 at 9:45 AM, Surveyor #2 observed a member of the dietary department (Staff Member #3) placing dirty dishes in a dish rack. After leaving the dishwashing area, the staff member changed gloves and began working the breakfast line. The staff member failed to perform hand hygiene between glove changes.

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Based on record review and interview, the Critical Access Hospital failed to ensure staff members develop an individualized patient plan of care for two of the four records reviewed (Patients #1 and #2).

Failure to develop an individualized plan of care can lead to missed patient nursing care needs and inappropriate nursing interventions and treatment goals.

Findings:

1. The hospital's policy and procedure entitled "Care Planning" (Approved 12/2014, Policy ID: 1211459) read in part as follows: "Policy: ...Each patient admitted to the hospital for more than twenty-four hours will have an individualized plan of care initiated by a Registered Nurse. ...Procedure for Care Planning IMPLEMENTATION ...2. A plan of care will be initiated for patients admitted to Mid-Valley Hospital. The plan of care is initially generated from the admission nursing assessment ..."

2. On 5/13/2015 at 1:15 PM, Surveyor #1 reviewed the patient care records of four patients who received care in the hospital's obstetrical unit. Record review revealed Patients #1 and #2 were admitted to the obstetrical unit for a normal vaginal delivery and discharged 48 hours later. There was no evidence of a plan of care for either patient.
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Based on observation and review of quality assurance data, the critical acces hospital failed to ensure that systems were in place to monitor corrective actions, regarding previously identified inspection deficiencies and robust enough to keep the identified problem at an acceptable level of compliance.

Failure to adequately monitor corrective action and implement new or revised action plan when it is shown that compliance levels are not being maintained places all patients at risk of harm related to potiential, negative outcome associated with previous non-compliance.

Findings:
The hospital received a defieiency related to outdated medications during the state inspection 10/23/2013. The hospital was cited again for outdated medications 5/12/2015.

Refer to Tag C276.

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Based on interview and review of hospital documents, the Critical Access Hospital failed to ensure "swing bed" residents received the required notice in writing prior to transfer or discharge.

Failure to discharge or transfer residents without proper notification, preparation or information can result in an unsafe or dis-orderly transfer or discharge from the hospital.

Findings:

1. On 5/12/2015 at 1:15 PM, an interview between Surveyor #1 and the hospital's discharge planner (Staff Member #5), revealed a hospital document labeled "Mid-Valley Hospital Omak, WA Transfer Authorization Form." The staff member stated the transfer form is given to residents before their transfer from the hospital. The contents of the document lists four of the seven required elements but lacked the remaining three:

a. The name, address and telephone number of the State long term care ombudsman; b. For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and c. For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The discharge planner stated he/she was not aware of required contents for a resident's transfer or discharge notice.
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