HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and Governing Body bylaws, the Governing Body failed to develop and maintain effective systems that ensured that patients received high quality healthcare that met their needs in a safe environment.

Failure to ensure patients are provided with care that meets acceptable standards of practice and meets the patient's healthcare needs in a safe environment risks deterioration of the patient's condition and poor healthcare outcomes.

Findings included:

The hospital failed to develop a hospital-wide quality assessment and performance improvement (QAPI) plan to monitor, evaluate, and improve the quality of patient care through systematic data collection and analysis.

The hospital failed to develop and implement an effective infection prevention and control program.

Due to these findings and the scope and severity of deficiencies detailed under 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement; and 42 CFR 41 Infection Control, the Condition of Participation for Governing Body was NOT MET.

Cross Reference: Tags A0263; A0747
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Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop and implement a hospital-wide quality assessment and performance improvement (QAPI) plan to monitor, evaluate, and improve the quality of patient care through systematic data collection and analysis.

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:

1. The hospital failed to develop and implement an effective infection prevention and control program as part of its quality plan.

Cross Reference: Tag A0747

2. The hospital failed to develop and implement an effective quality control system to prevent the use of medications and patient care supplies that exceeded the manufacturer's expiration date.

Cross Reference: Tag A0273

3. The hospital failed to ensure that aggregated data regarding patient medication errors and patient injuries in the hospital's provider-based clinics were analyzed for patterns, trends, and common factors through the hospital's quality program.

Cross Reference: Tag A0286

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.21, Quality Assurance and Performance Improvement was NOT MET.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to develop and implement a quality control system to prevent the use of patient care supplies and medications that exceeded the manufacturer's expiration date.

Failure to develop such a system risks ineffective patient care and patient harm.

Findings included:

ITEM #1 - OUTDATED PATIENT CARE SUPPLIES

Based on observation, interview, and document review, the hospital failed to develop and implement a quality control system to prevent the use of patient care supplies beyond the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed their expiration dates risks deteriorated or potentially contaminated supplies being available for patient use.

Findings included:

1. The hospital's policy and procedure titled "Rotation of Stock and Auditing of Outdated Items", approved 06/13, showed that it is the responsibility of the using department to assure outdated supplies are removed from areas that do not use exchange carts. All items that are found outdated will be returned to the manufacturer if possible or will be disposed of appropriately.

2. On 08/22/17 at 10:10 AM, Surveyor #2 inspected a semi-private patient room (Room # 283) on the ASU/Telemetry Unit. Surveyor #2 observed an opened 1500 mL bottle of sterile water irrigation fluid on a shelf positioned between the two patient beds. The product label on the bottle stated it did not contain antimicrobial agents and the unused portion should be discarded. The bottle was not labeled with a patient name or a date and time it was opened. During an interview with Surveyor #2 at the time of the observation, the Senior Director of Critical Services (Staff Member #17) confirmed the findings.

3. On 08/22/17 at 10:20 AM, Surveyor #2 inspected the ASU/Telemetry medication room. Surveyor #2 observed 4 culture swabs with a manufacturer's expiration date of 04/17 and 2 culture swabs expired on 05/17. During an interview with Surveyor #2 at the time of the observations, the Nurse Manager (Staff Member #18) confirmed the findings and discarded the expired items.

4. On 08/22/17 at 10:53 AM, Surveyor #2 inspected the ASU/Telemetry storage room. Surveyor #2 observed 1 culture swab with a manufacturer's expiration date of 04/17. During an interview with Surveyor #2 at the time of the observations, the Nurse Manager (Staff Member #18) confirmed the findings and discarded the expired items.

5. On 08/22/17 at 2:15 PM, during an inspection of the Ellensburg Specialty Clinic, Surveyor #5 noted the following:

a. Two packages of chromic gut 4-0 suture material with an expiration date of 01/15.

b. One package of chromic gut 4-0 suture material with an expiration date of 07/16.

c. Two packages of chromic gut 3-0 suture material with an expiration date of 07/16.

d. Six packages of prolene 6-0 suture material with an expiration date of 07/17.

e. One bottle of MetriCide 28 high-level disinfectant with an expiration date of 08/16.

f. Eight packages of povidone iodine swab sticks with an expiration date of 01/11.

g. One bottle of Kendall Life Trace ultrasound gel with an expiration date of 01/11.

h. Five containers of Boost (a high calorie nutritional drink) with an expiration date of 02/17.

6. During an interview with Surveyor #5 at the time of the observations above, a registered nurse (Staff Member #69) stated that each service that uses the Ellensburg Specialty Clinic is responsible for checking the supplies that they use for expiration dates. She was unaware of any systematic check for outdates of patient care supplies and medications for the clinic.

7. On 08/23/17 at 9:15 AM during an inspection of the North Star Lodge clinic's emergency cart, Surveyor #5 noted the following:

a. Two 10 ml normal saline flush syringes with an expiration date of 04/15.

b. Four 18 gauge intravenous catheters with an expiration date of 01/15.

c. Two 20 gauge intravenous catheters with an expiration date of 07/15.

d. Two 22 gauge intravenous catheters with an expiration date of 06/16.

e. Two 24 gauge intravenous catheters with an expiration date of 12/15.

f. Two "IV [intravenous] Start Kits" with an expiration date of 01/16.

8. During an interview with Surveyor #5 at the time of the observations above, the nurse manager (Staff Member #66) confirmed the findings above and removed the items from the emergency cart.


ITEM #2 - OUTDATED MEDICATIONS

Based on observation, interview, and document review, the hospital failed to ensure all drug storage areas were inspected monthly to prevent administration of outdated medications.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, or stability.

Reference: WAC 246-873-080 (1) Drug procurement, distribution and control. General: Pharmaceutical service 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 included:

1. Review of the hospital policy and procedure titled "Medication Storage Area Inspections," approved 01/26/17, showed that a pharmacy technician would inspect at least monthly all nursing units and other areas of the hospital where medications are dispensed, administered, or stored.

Review of the hospital's policy titled "Multiple Dose Vials Expiration," No Policy Number; Reviewed 01/01/15, showed that unless contamination is apparent or suspected, the multiple dose vials should be discarded when empty or within 28 days of first use.

2. On 08/22/17 at 2:15 PM, Surveyor #5 inspected the Ellensburg's Specialty Clinic. The observation showed the following items in unlocked cabinets:

a. Six cartridges of 2% lidocaine with epinephrine for injection with an expiration date of 12/16.

b. One bottle of CiproDex otic suspension with an expiration date of 02/17.

c. One vial of bacteriostatic sterile water for injection with an expiration date of 07/01/17.

d. One 10 ml vial of Kenalog-40 for injection opened and dated with a do not use after sticker of 02/24/17.

e. One 10 ml bottle of neomycin, polymixin, and hydrocortisone otic suspension with an expiration date of 11/16.

f. One open single dose 2 ml vial of dexamethasone 10 mg/ml for injection.

g. One 15 gm tube of Bacitracin antibiotic ointment with an expiration date of 12/16.

h. One bottle of Hurricane anesthetic spray with an expiration date of 12/16.

i. One bottle of Hurricane anesthetic spray with an expiration date of 06/16.

3. An interview on 08/24/17 at 9:00 AM with the Director of Pharmacy (Staff #63) revealed that the Ellensburg Specialty Clinic was currently not on their list of areas that were inspected monthly by pharmacy staff members.

4. On 08/22/17 at 10:20 AM, Surveyor #2 inspected the ASU/telemetry medication room. Surveyor #2 observed six pre-drawn syringes containing 0.2 to 0.4 ml of normal saline labeled with an expiration date of 07/10 and one open 5 ml heparin flush syringe 100 units/ml with an expiration date of 08/09/13.

5. At the time of the observation in the ASU/telemetry unit, the Senior Director of Critical Care Services (Staff Member #17) and the Nurse Manager (Staff Member #18) confirmed the findings and removed the expired medications.

6. On 08/23/17 at 10:52 AM, Surveyor #2 inspected the automated medication dispensing cabinet in the main surgery department's pre-surgical holding area. Surveyor #2 observed one open and not dated multi-dose vial of Novolog-R insulin with an expiration date of 06/27/17.

7. During this same observation, Surveyor #2 observed one open multi-dose vial of Novolog insulin with a sticker labeled with an expiration date of 09/24/17. This date exceeds the 28-day expiration date requirements of the hospital policy for multi-dose vials.

8. At time of the observations in the pre-surgical holding area, the Senior Surgical Services (Staff Member #19) confirmed the finding and removed the expired medications.

9. On 08/24/17 at 11:42 AM, Surveyor #2 inspected the automated medication dispensing cabinet at the Ridgeway Clinic. Surveyor #2 observed one 20 ml vial of 1% lidocaine with an expiration date of 08/23/17. The Assistant Nurse Manager (Staff Member #20) confirmed the finding and removed the expired medication at the time of the observation.
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Based on interview and review of the hospital's quality improvement program and performance data, the hospital failed to ensure that aggregated data regarding patient medication errors and patient injuries in the hospital's provider-based clinics were analyzed for patterns, trends, and common factors through the hospital's quality program.

Failure to systematically collect, aggregate, and analyze data regarding adverse patient events limits the hospital's ability to develop action plans to prevent medical errors and patient injuries.

Findings included:

On 08/23/17 at 1:25 PM, Surveyor #1 interviewed the hospital's Director for Quality, Safety, and Performance Improvement (Staff Member #14). During the interview, the surveyor reviewed adverse patient events data, including medication errors and patient injuries, for the hospital's provider-based clinics. The interview revealed that adverse patient events were analyzed individually. Data was not aggregated and analyzed according to the individual clinic where the events occurred. Aggregate data regarding medication errors and patient injuries included the total number of events in all of the clinics. Analysis of patient injury data was limited to the number and severity of the events (i.e. non-injury to moderate severity). Analysis of medication errors did not include the types of errors and common factors between the occurrences.
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Based on observation, interview, and document review, the hospital failed to develop and implement an effective infection prevention and control program.

Failure to develop and implement an effective infection prevention and control program puts patients, staff and visitors at risk of illness from communicable diseases.

Findings included:

The hospital staff failed to prevent cross contamination and exposure to infectious agents when pre-cleaning cystoscopes.

The hospital failed to reprocess flexible endoscopes after use.

The hospital failed to properly use high level disinfectants when reprocessing semicritical devices.

The hospital failed to ensure that medical instruments and devices were properly reprocessed prior to being reused.

The hospital staff failed to ensure that biological indicators were read and documented within the required time frame.

The hospital failed to ensure that healthcare providers disinfected the tops of medication vials prior to withdrawing medications according to hospital policy and accepted standards of practice.

The hospital failed to ensure that surgical staff members followed hospital policy regarding surgical attire.

The hospital failed to ensure that hospital staff members performed hand hygiene as directed by hospital policy

The hospital failed to ensure that linen used in the pediatric and neonatal intensive care unit (NICU) were reprocessed according national standards

The hospital failed to ensure that staff performed between-case cleaning of operating rooms in a top-to -bottom manner.

The hospital staff failed to develop and implement processes and procedures to assure compliance with the Washington State Retail Food Code (246-215 WAC) to prevent foodborne illness

The hospital failed to follow manufacturer instructions for use when installing kitchen equipment.

Cross Reference: Tag A0749


Due to the scope and severity of deficiencies cited under §42 CFR 482.42, the Condition of Participation for Infection Control was NOT MET.
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ITEM #1 - ENDOSCOPE PRE-CLEANING

Based on interview and document review, the hospital staff failed to prevent cross contamination and exposure to infectious agents when pre-cleaning cystoscopes.

Failure to follow infection control practices places patients and staff members of the facility at risk from infections and/or communicable diseases.

References:

Association of Surgical Technologists (AST) Standards of Practice for the Decontamination of Surgical Instruments: Standard of Practice IX. "The decontamination room should be a room that is physically separate from areas where clean instruments, supplies and equipment are undergoing preparation for sterilization to prevent the risk of contamination. 1) Scrub sinks and hand-washing stations should not be used for cleaning instruments. Cleaning dirty instruments in the scrub or hand-washing sink will contaminate the faucet, sides and bottom of the sink thus contributing to cross contamination when Health Care Workers use the sinks for hand washing or performing the surgical hand and arm scrub."

"Guidelines for Environmental Infection Control in Health-Care Facilities"; Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC); Centers for Disease Control and Prevention (CDC) 2003; Table 15. Water and point-of-use fixtures as sources and reservoirs of waterborne pathogens. "Prevention and control. Use separate sinks for handwashing and disposal of contaminated fluids."

Findings included:

On 8/22/17 at 3:45 PM, Surveyor #3 interviewed the Ridgeview surgery center clinic manager (Staff Member #4) about reprocessing procedures for the center's cystoscopes (Olympus Model CYF-V2). The manager stated the pre-cleaning process of flushing and wiping down the scope occurs in the patient's examination room hand sink.


ITEM #2 - ENDOSCOPE HIGH-LEVEL DISINFECTION

Based on observation, interview, and record review, the hospital failed to reprocess flexible endoscopes after use.

Failure to reprocess flexible endoscopes places patients at risk of infection.

Reference: Centers for Disease Control and Prevention, "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008"; pg 87. - "7. High Level Disinfection of Endoscopes. k. Process endoscopes and accessories that contact mucous membranes as semicritical items, and use at least high-level disinfection after use on each patient.

Findings included:

1. Record review of the hospital policy titled, "Endoscope Reprocessing & Surveillance," reviewed 12/15, shows that staff are to follow Lippincott procedures for reprocessing. Lippincott states that endoscopes are semi-critical devices and must be high-level disinfected.

2. On 08/23/17 at 3:00 PM, Surveyor #4 conducted a tour of the Memorial Specialty Clinic in Ellensburg. During the tour, the surveyor observed a nasopharyngoscope in a storage case. The surveyor did not observe any high-level disinfectants or sterilization equipment at the facility.

3. On 08/24/17 at 10:20 AM, Surveyor #4 observed the reprocessing area for Yakima Ear Nose and Throat, a hospital clinic. The surveyor observed a flexible nasopharyngoscope and asked the medical assistant (Staff Member #60) how the endoscope is reprocessed. The assistant indicated that the protective sheath is removed, the device is wiped with a Cavi-wipe (a surface disinfectant), and then allowed to air dry.

4. The surveyor asked the medical assistant if staff use endoscopes at the Memorial Specialty Clinic in Ellensburg. The assistant stated that scopes are used there and the cleaning procedure is the same.


ITEM #3 - APPROPRIATE USE OF HIGH LEVEL DISINFECTANTS

Based on observation, interview, and record review, the hospital failed to properly use high level disinfectants when reprocessing semicritical devices.

Failure to properly use high level disinfectants places patients at risk of infection.

Reference: Centers for Disease Control and Prevention, "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008"; pg 90. - "Even if probe covers have been used, clean and high-level disinfect other semicritical devices ...Use a high-level disinfectant at the FDA-cleared exposure time."

Findings Included:

1. Record review of hospital policy titled, "Sterilization and Disinfection," revised: 07/16, showed that staff are to monitor temperature of gluteraldehyde solutions used for high level disinfection, test efficacy with test strips, and document product expiration dates. The policy also stated that staff should follow Lippincott procedures for disinfection of semicritical devices. Lippincott instructs staff to follow manufacturer's instructions for use for high level disinfectants.

2. Record review of the manufacturer's instructions for use for MetriCide 28 gluteraldehyde showed that equipment must be immersed in solution for 90 minutes at 25 degrees Celsius to achieve high level disinfection. The instructions also state that the product expires 28 days after activation and that test strips must be used to verify the effective concentration.

3. On 08/24/17 at 10:20 AM, Surveyor #4 made the following observations at the Yakima Ear, Nose, and Throat clinic:

a. Surveyor #4 observed rigid probes being immersed in a chemical solution. The surveyor asked a medical assistant (Staff Member Member #60) what disinfectant was used for high level disinfection. The assistant showed the surveyor the cabinet with MetriCide 28 solution. No disinfection log book or sheet was observed.

b. The surveyor asked the medical assistant (Staff Member #60) if temperature monitoring of the disinfectant occurred. The assistant stated that it did not.

c. The surveyor asked the medical assistant (Staff Member #50) if test strips were used to monitor the effective concentration of the solution. The assistant stated that test strips were normally used, but that none were currently present for use.

d. The surveyor asked the medical assistant (Staff Member #60) if the expiration date of the product was recorded. The assistant stated that the expiration date is not recorded and the product is discarded at the beginning of the month rather than the 28 day expiration date.

e. The surveyor asked another medical assistant (Staff Member #62) how long items are immersed in the high level disinfectant. The assistant stated that the items were immersed for 12 minutes rather than the 90 minutes required by the manufacturer.


ITEM #4 - MEDICAL INSTRUMENT STERILIZATION

Based on observation, interview, and record review, the hospital failed to ensure that medical instruments and devices were properly reprocessed prior to being reused.

Failure to properly reprocess medical instruments and devices places patients at risk of infection.

Reference: Centers for Disease Control and Prevention, "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008"; pg 59, 91-93.

Findings included:

1. Record review of hospital policy titled, "Sterilization and Disinfection," revised: 07/16, showed that hospital clinics are to transport their medical instruments and devices to the central services department for reprocessing.

2. On 8/22/17 at 2:15 PM, during a tour of the Family Medicine of Yakima clinic with the clinic manager (Staff Member #5), Surveyor #3 noticed 6 sterilized instruments in peel packs that did not have chemical indicators or integrators placed inside. On 8/23/17 at 9:00 AM, Surveyor #3 interviewed the central sterile services manager (Staff Member #2) about the process of instrument sterilization. The manager stated it was a requirement that every peel pack have a chemical integrator inside the pack

3. On 08/23/17 at 3:00 PM, Surveyor #4 conducted a tour of the Memorial Specialty Clinic in Ellensburg. During the tour, the surveyor observed medical devices that were packaged in peel packs that did not have an internal indicator or integrator placed inside. The surveyor observed additional medical instruments and devices in carts utilized by visiting Yakima Ear, Nose, and Throat staff members. These devices were lying in drawers of the cart unpackaged. The surveyor was unable to locate any sterilizers or high level disinfectants at the clinic.

4. On 08/24/17 at 10:20 AM, Surveyor #4 observed the following at the Yakima Ear, Nose, and Throat clinic:

a. Surveyor #4 asked a medical assistant (Staff Member #60) how medical instruments are cleaned and reprocessed. The assistant stated that items are cleaned with an enzymatic cleaner, air dried, and placed in an autoclave for sterilization.

b. Surveyor #4 observed items inside peel packs without internal indicators. The observation also showed that speculums were stacked within each other when loaded into the autoclave rather than allowing the entire surface of the medical device to be exposed to the sterilization process. The Surveyor asked the medical assistant (Staff Member #60) how sets are loaded. The assistant stated that open loads had a chemical indicator placed on the tray. Instruments packaged in peel packs did not receive an internal indicator. Wrapped packages used autoclave tape as an external indicator, but no internal indicators were used.

c. Record review of a document titled, "Autoclave Test Pack and Culture Reports," showed that the last biological or culture tests on the autoclaves were conducted on 04/20/16 and 4/26/16 for autoclaves #1 and #2, respectively. The surveyor asked the medical assistant (Staff Member #60) if biological tests were performed. The assistant indicated that they were not.

d. Items were not labeled as to when they were reprocessed and a log book or tracking system was not employed.

5. On 08/24/17 at 10:20 AM, Surveyor #4 interviewed a medical assistant (Staff Member #60) about the reprocessing of medical instruments and devices at the Memorial Specialty Clinic in Ellensburg. The assistant stated that instruments are cleaned with enzymatic cleaner and air dried. The instruments are not sterilized or high level disinfected.

6. On 08/24/17 at 3:45 PM, Surveyor #4 interviewed the Clinical Engineering Manager (Staff Member #61) regarding preventative maintenance of the autoclaves used at Yakima Ear, Nose, and Throat. The manager stated that the items were in the hospital's inventory, but the equipment was not being maintained yet. No preventative maintenance records could be produced by the clinic or the hospital's clinical engineering department.


ITEM #5 - STERILIZATION - BIOLOGICAL INDICATORS

Based on observation, hospital policy review, and document review, the hospital staff failed to ensure that biological indicators were read and documented within the required time frame.

Failure to ensure that biological indicators have met the incubation times can result in inaccurate readings and compromise sterility of surgical instruments.

Reference: 3M Attest Auto-Reader 490H Operator's Manual page 2, "Read Rapid Readout Biological Indicator final fluorescent result at 24 minutes."

Findings included:

1. The hospital's policy titled, "Sterilization and Disinfection" (Reviewed 8/2015) stated on page 6 that all test results were to be recorded in the biological monitoring record book by designated clinic personnel.

2. On 8/22/17 between 9:45 AM and 10:30 AM in the main hospital's central processing area, Surveyor #3 reviewed the hospital's biological indicator log. The following logs revealed missing read times, results of the test, or read times documented before the 24-minute time frame:

7/26/17 at 1:16 AM (no out time or results of pass or fail recorded)
7/26/17 at 2:07 AM - 6:45 AM (no results of pass or fail recorded)
8/16/17 at 12:33 AM -12:55 AM (read at 22 minutes)
8/17/17 at 12:00 AM - 12:20 (read at 20 minutes)
8/18/17 at 12:00 AM - 12:06 (read at 6 minutes)


ITEM #6 - ANTISEPSIS - MEDICATION VIALS

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that healthcare providers disinfected the tops of medication vials prior to withdrawing medications according to hospital policy and accepted standards of practice.

Failure to disinfect the diaphragm of a medication vial prior to inserting a needle and withdrawing the medication into a syringe risks contamination of the medication and transmission of infectious diseases to patients.

Reference: Association for Professionals in Infection Control and Epidemiology (APIC) position paper: "Safe injection, infusion, and medication vial practices in health care" (2010) - "Cleanse the access diaphragm of vials using friction and a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab. Allow the diaphragm to dry before inserting any device into the vial."

Findings included:

1. On 08/22/17 at 12:45 PM in Operating Room #2 of the hospital's obstetric surgery unit, Surveyor #1 observed an anesthesia provider (Staff Member #6) prepare anesthetic medications for Patient #1 during a caesarian section. The anesthesia provider did not disinfect the top of the medication vial after removing the cap and prior to inserting a needle into the vial's diaphragm and withdrawing the medication into a syringe.

2. On 08/23/17 at 9:27 AM in the hospital's main Operating Room Department Surveyor #2 observed a Registered Nurse (Staff Member #42) prepare 0.25 % Plain Marcaine (a medication used to numb the skin) for Patient #6. Staff Member #42 did not disinfect the top of the medication vial after removing the cap and prior to inserting a needle into the vial's diaphragm and withdrawing the medication into a syringe.

3. On 08/23/2017 at 12:30 PM, Surveyor #1 interviewed the hospital's Clinical Quality Manager (Staff Member #7). During the interview, the surveyor requested the policy and procedure for disinfecting medication vials prior to preparing intravenous medications. The manager stated that the hospital used the Lippincott Manual of Nursing Practice for hospital procedures. The manager gave the surveyor a procedure titled "Lippincott Procedures - Intramuscular Injection," revised 8/18/17, and stated this procedure included instructions for disinfecting medication vials prior to medication preparation. The procedure stated that healthcare providers were to disinfect the diaphragm of medication vials with alcohol and allow it to dry completely prior to inserting a needle and withdrawing the medication into a syringe.


ITEM #7 - SURGICAL ATTIRE

Based on observation, interview, and review of the hospital's policies and procedures, the hospital failed to ensure that surgical staff members followed hospital policy regarding surgical attire.

Failure to follow hospital policy and practice standards for surgical attire increases the risk for patient infections.

Findings included:

1. The hospital's policy titled, "Surgical Attire," revised 01/29/15, showed that all head and facial hair must be completely covered and all hair must be contained within the surgical scrub hat. "Skull Cap" (a close-fitting brimless cap) type head covers are not allowed. Surgical masks are to be worn in restricted areas and applied to prevent "venting"

2. On 08/22/17 at 12:45 PM in Operating Room #2 of the hospital's obstetric surgery unit Surveyor #1 observed a surgical team perform a caesarian section procedure for Patient #1. Surveyor #1 observed:

a. Staff Member #12 wore a surgical cap that did not contain all of her hair.

b. Staff Member #13 wore a surgical mask that was not tied at the bottom to prevent venting.

3. On 08/23/17 at 9:18 AM in the hospital's Main Operating Room Department, Surveyor #2 observed preparation for a surgical procedure for Patient #6. Surveyor #2 observed:

a. Staff Member #32, wore a surgical cap that did not contain all of her hair including long hair falling to the sides of the head and at the nape of the neck.

b. Staff Member #33 wore a "Skull Cap" that did not cover his hair and a mask that did not cover his beard or sideburns.

c. Staff Member #34, wore a surgical cap that was tied in the back as part of a hair bun, the hair bun was not covered and the cap did not contain all of her hair at the nape of the neck.

d. Staff Member #35, wore a surgical cap that did not contain all of her hair at the side of the head or at the nape of the neck.

4. On 08/23/17 at 2:24 PM in the hospital's Surgi-Center, Surveyor #2 observed preparation for a surgical procedure for Patient #8. Similar findings were observed as noted above.

5. At the time of the observations under #3 and #4, the Senior Surgical Services Director (Staff Member #19) confirmed the findings and told Surveyor #2 that all hair should be covered


ITEM #8 - HAND HYGIENE

Based on observation and record review, the hospital failed to ensure that hospital staff members performed hand hygiene as directed by hospital policy.

Failure to perform hand hygiene when indicated places patients and staff at risk for infection.

Findings included:

1. Record review of the hospital policy titled, "Hand Hygiene," reviewed 06/01/17, showed that staff are to follow Lippincott hand hygiene procedures. The Lippincott procedure manual shows that hand hygiene must be performed before direct patient contact, before putting on gloves, before inserting invasive devices, after contact with a patient, and after removing gloves, and after touching environmental surfaces in the patient environment.

2. On 08/22/17 at 10:38 AM, Surveyor #4 observed a daily cleaning procedure of a patient room. During the procedure, the surveyor observed a nurse (Staff Member #51) drop a bag of saline on the floor, pick the bag up off the ground, and proceed to continue patient care without changing gloves and performing hand hygiene.

3. On 08/22/17 at 2:11 PM, Surveyor #4 observed a discharge cleaning of a patient room. During the procedure, a housekeeper (Staff Member #52) failed to perform hand hygiene during glove changes on two separate occasions.

4. On 08/22/17 at 4:35 PM, Surveyor #4 observed a terminal cleaning of an operating room. The housekeeper (Staff Member #53) failed to perform hand hygiene between glove changes on six separate occasions.

5. On 08/23/17 at 9:18 AM, in the hospital's Main Operating Room department, Surveyor #2 observed preparation for a surgical procedure for Patient #6. Surveyor #2 observations included:

a. Staff Member #32, wore a surgical cap that did not contain all of her hair including long hair falling to the sides of the head and at the nape of the neck. When prompted by the Senior Director Critical Care Services (Staff Member #19) to contain her hair, Staff Member #32 tucked her hair under cap and then continued to assist with the surgical procedure set up. Staff Member #32 did not perform hand hygiene after touching her hair.

b. Staff Member #33 failed to perform hand hygiene prior to donning gloves in preparation to intubate Patient #6.

c. Staff Member #26 failed to perform hand hygiene prior to donning gloves in preparation to perform a surgical site prep for Patient #6. Staff Member #26 failed to perform hand hygiene after doffing gloves after completing the surgical site preparation for Patient #6. Additionally, immediately after doffing the gloves, Staff Member #26 assisted the surgeon tie his sterile gown. Staff Member #26 then donned another pair of gloves and again failed to perform hand hygiene.

6. On 08/23/17 at 2:24 PM in the hospital's Surgi-Center, Surveyor #2 observed preparation for a surgical procedure for Patient #8. Surveyor #2 observations included:

a. Staff Member #36 failed to perform hand hygiene prior to donning gloves in preparation to perform a surgical site prep for Patient #8.

b. Staff Member #37 failed to perform hand hygiene after picking up and reconnecting the oxygen reservoir bag which had become disconnected from the anesthesia machine circuit and fallen to the floor.

7. At the time of the observations in the hospital's main operating room and in the Surgi-Center, the Senior Surgical Services Director (Staff Member #19) confirmed the findings.
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ITEM #9 - LAUNDRY PROCESSING

Based on observation, interview, and record review, the hospital failed to ensure that linen used in the pediatric and neonatal intensive care unit (NICU) were reprocessed according national standards.

Failure to properly reprocess linens places patients at risk for infection.

Reference: Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004. Pg. 152. - "Recommendations. G.IV. Laundry Process. A. If hot-water laundry cycles are used, wash with detergent in water greater than or equal to 160°F (71°C) for greater than or equal to 25 minutes."

Findings included:

1. Review of the hospital policy's titled, "Laundry and Linen Handling Policy," revised 08/15, shows that laundry is to be reprocessed at 120 degrees Fahrenheit or higher.

2. On 08/22/17 at 3:02 PM, Surveyor #4 toured the linen storage and reprocessing area. The surveyor noted that residential laundry machines were present and asked the Assistant Director of Environmental Services (Staff Member #55) what linens are cleaned on site. The assistant director stated that some linens for the pediatric and NICU units were washed on site. The surveyor asked the assistant director if the temperature of the water in the washing machines was monitored to ensure that it met industry standards for reprocessing patient laundry. The assistant director stated that there are no regular checks or documentation kept.

3. On 08/23/2017 at 11:40 AM, Surveyor #1 interviewed a registered nurse (Staff Member #8) who was working in the hospital's NICU. The nurse stated that effective 08/23/17 a laundry contractor would be laundering patient care items used in the NICU. The nurse stated that prior to that date the hospital linen department was laundering NICU patient care items.

4. Record review of item washing logs showed that the hospital was laundering pediatric items and blankets used in the NICU.


ITEM #10 - SURGICAL SUITE CLEANING

Based on observation, interview, and record review, the hospital failed to ensure that staff performed between-case cleaning of operating rooms in a top-to -bottom manner.

Failure to clean an operating room in a top-to-bottom manner can risk recontaminating surfaces that were recently cleaned.

Reference: Association of Perioperative Registered Nurses. Guidelines for Perioperative Practice. Vol 1, 2017. "Guideline for Environmental Cleaning. Recommendation VI.b. Cleaning and disinfection activities should be performed in a methodical pattern that limits the transmission of microorganisms. VI.b.2. Cleaning should progress from top to bottom areas."

Findings included:

1. Record review of the hospital policy titled, "Cleaning of the Surgical Suites 1st Case Opening and Terminal," revised 06/25/15, shows that staff are to perform between case cleanings in a top to bottom manner."

2. On 08/24/17 at 11:40 am, Surveyor #4 interviewed a surgical technologist (Staff Member #54) regarding between case cleaning procedures. The technologist performed a mock cleaning of the operating room. The technologist first cleaned the anesthesia machine, then the surgical table, then the overhead lights that hang above the surgical table. This order was confirmed when the surveyor asked if a top-to-bottom approach was employed.


ITEM #11 - FOOD SANITATION

Based on interview and document review, the hospital failed to develop and implement processes and procedures to assure compliance with the Washington State Retail Food Code (246-215 WAC).

Failure to follow Washington State Food Code places patients, staff, and visitors at risk for foodborne illness.

Findings included:

ITEM #11a - EQUIPMENT CLEANING FREQUENCY

On 8/23/17 between the hours of 11:00 AM and 12:15 PM in the main hospital's kitchen, Surveyor #3 interviewed the dietary manager (Staff Member #3) regarding the process of sanitizing the soft serve ice cream machine (Taylor Soft Serve). During the interview, the dietary manager stated that the soft serve ice cream machine was sanitized on a weekly basis. The manufacturer's instructions for use stated users must follow all federal and state codes for equipment cleaning. Washington State Food Code requires a cleaning frequency of every 24 hours.

Reference: Washington State Retail Food Code, WAC 246-215-04605(4)


ITEM #11b - FOOD STORAGE

Based on observation and interview, the hospital staff failed to develop and implement processes and procedures to assure compliance with the Washington State Retail Food Code (246-215 WAC).

Failure to follow Washington State Food Code places patients, staff, and visitors at risk for foodborne illness.

Findings included:

On 8/23/17 between the hours of 11:00 AM and 12:15 PM in the main hospital's kitchen, Surveyor #3 observed foods stored in containers stacked on top of each other without lids or protective barriers between the containers to prevent foods from touching bottom of container. This was confirmed by dietary manager (Staff Member #3) at the time of the observation.

Reference: Washington State Retail Food Code, WAC 246-215-03306(1)(d)


ITEM #11c - GLOVE USE

Based on observation, the hospital staff failed to implement processes and procedures to assure compliance with the Washington State Retail Food Code (246-215 WAC).

Failure to follow Washington State Food Code places patients, staff, and visitors at risk for foodborne illness.

Findings included:

On 8/23/17 between the hours of 11:00 AM and 12:15 PM in the main hospital's cafeteria, Surveyor #3 observed a cook (Staff Member #1) prepare food at the grill, then then go to the cash register to exchange cash with customers, then return to the grill and resume cooking. The cook continued to handle ready-to-eat food without changing gloves and hand washing between tasks.

Reference: Washington State Retail Food Code, WAC 246-215-03342(1)


ITEM #11d - REFRIGERATOR TEMPERATURES

Based on observation, interview, and record review, the hospital failed to ensure that items were held at the proper cold holding temperature in nourishment room refrigerators.

Failure to properly cold hold food items places patients at risk of food born illness.

Findings included:

1. Record review of the hospital policy titled, "Temperature Record Log for Refrigerators/Freezers," approved 03/17/16, shows that food refrigerators are to be maintained at a temperature of 34 degrees to 40 degrees Fahrenheit.

2. At 2:40 PM on 08/22/17, Surveyor #2 inspected the nourishment room of the pediatric unit. Record review of the document titled, "Temperature Log," found in the pediatric unit, shows that the food refrigerator temperature was 42 degrees Fahrenheit on 08/01/17, 08/20/17, and 08/21/17. The unit secretary (Staff Member #57) confirmed the finding.

Reference: Washington State Retail Food Code, WAC 246-215-03525 (1) (b)


ITEM # 12 - KITCHEN EQUIPMENT INSTALLATION

Based on observation and document review, the hospital failed to follow manufacturer instructions for use when installing kitchen equipment.

Failure to install kitchen equipment according to the manufacturer increases the risk of microorganism growth in the equipment, which places patients, staff and visitors at risk of foodborne illness.

Reference: "Blendtec Rapid Rinser and Rapid Rinse Station Owner's Manual" states, Install unit with appropriate backflow protection.

Findings included:

On 08/23/17 at 3:00 PM at the main hospital's espresso bar, Surveyor #3 observed that the "Rapid Rinse" (blender container rinse machine) drain line terminated in the hand sink. The hospital did not install a drain line according to manufacturer's instructions for use.
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