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Based on interview, review of clinical records and policies and procedures, the facility failed to assure that medications were managed in accordance with Washington State regulations. (see reference below).

Failure to do so creates risk for omission of controlled substance accountability and risk for diversion of controlled substances.

Reference:Reference: WAC 246-873-080, Drug procurement, distribution and control.
(1) General. Pharmaceutical service shall include:
7) Controlled substance accountability...maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations.
(vii) Signature of the licensed individual who administered the drug. (d) When it is necessary to destroy small amounts of controlled substances following the administration of a dose by a nurse, the destruction shall be witnessed by a second nurse who shall countersign the records of destruction.

Findings:
1 .In review of a document titled " Special Requirements for Controlled Substances " -Policy # 0035, provided by Staff Member # 1 there was no information about required countersignature for wasting narcotics.

2. In review of the records of care related to emergency room care the following omissions were noted and this was discussed/reviewed with RN Staff Member #1:
a. For Patient #2 on 3-13-12, RN Staff Member #6 signed out a vial of 10mg of Morphine Sulfate and recorded patient administration of 4 mg. On the Medication Count Sheet (Controlled Narcotic Medication) there was no documentation or countersignature for wastage of 6mg of Morphine per Washington State regulations.

b. For Patient # 3 on 2-25-12, RN Staff Member # 6, signed out a vial of 10mg of Morphine Sulfate and recorded patient administration of 5 mg. On the Medication Count Sheet (Controlled Narcotic Medication) there was no documentation orcountersignature for wastage of 5mg of Morphine per Washington State regulations.

c. For Patient # 4 on 2-22-12 RN Staff Member # 1 signed out a vial of 10mg of Morphine Sulfate and recorded patient administration of 2 mg. On the emergency room record was written " Remainder of Morphine Sulfate " with " Ambulance Nurse " however there was no ambulance nurse related signatureor documentation. On the Medication Count Sheet (Controlled Narcotic Medication) there was no related documentation for 8mg of Morphine that was not administered by facility staff.

Based on observation, interview, and personnel file review, the facility failed to ensure that personnel performing the duties of the Social Worker Counselor was licensed, certified and/or registered with the Department of Health as required by state rules.

Failure to ensure that personnel have proper credentials to perform their assigned job duties risks provision of health care by unqualified persons and creates a risk for patient harm.

References:
WAC 246 320 156- Hospitals must (5) document verification of staff licensure, certification, or registration.

RCW 18.130.020
Definitions (12) "Unlicensed practice" means: (a) Practicing a profession or operating a business identified in RCW 18.130.040 without holding a valid, unexpired, unrevoked, and unsuspended license to do so; or (b) Representing to a consumer, through offerings, advertisements, or use of a professional title or designation, that the individual is qualified to practice a profession or operate a business identified in RCW 18.130.040, without holding a valid, unexpired, unrevoked, and unsuspended license to do so.


Findings:

1. An interview with the Social Services Counselor, Staff Member #11, on 3-14-12 revealed that he/she provided social services for patients in swing bed status and he/she was licensed in Idaho as a social worker. He/she stated that he/she arranged for patient appointments outside of the facility, accompanied patients to their appointments, completed mental health and cognitive screening exams, completed Social Service Counselor assessments, participated in facility care planning and discharge planning. He/she also assisted in medication selection processes with a psychiatrist for facility patients.

2. Review of Staff Member #11's job description on 3/15/2012 revealed that a job classification of "Social Services Counselor." The summary statement on the first page of the job description read as follows:

"To provide medically related social services in order to allow residents to maintain and improve their everyday physical, mental, and psychosocial needs. "

3. Review of Staff Member #11 ' s personnel file on 3-15-12 revealed that she/he was not licensed in Washington State.

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Based on observation and interview the facility failed to assure security of equipment, supplies and medications in the emergency room during periods of time when it was not staffed by facility personnel and failed assure a process related to the unavailability of emergency medications.

Failure to do so creates risk that equipment, supplies and medications needed for the care of emergency patients may be unavailable as expected by team members. It also creates risk that patinet care items may be tampered with.

Findings:

1. On 3-14-12 when there were no emergency room (ER) patients or facility staff present, it was observed that the main door to the emergency room was not secured. The emergency room contained various items used in the treatment of an emergency patient, including intravenous solutions, an emergency crash cart and unlocked vials of injection solutions, such as lidocaine, marcaine and normal saline.

2. In interview with Staff Member # 1, he/she stated that nursing staff responsible for the ER were also routinely responsible for acute care inpatients located in an adjacent area. When there were no patients present in the ER, that area could be unattended by facility staff for extended periods of time. There was no practice of securing entry to the emergency room to prevent unauthorized access given staffing parameters.

3. On 3-14-12 during a tour of the facility it was observed that 2 bags of lidocaine ( 2 grams in 250 ml) intravenous solution had expired in January 2012 and were ready for use in the crash cart. Lidocaine is a drug that is administered for potentially life threatening heart irregularities.

Per nursing documentation the solution had been initially re-ordered from the pharmacy in December 2011 (including follow-up requests) but was not available from the pharmacy due to a manufacturers drug shortage.

Per Staff Member #1 interview, the facility did not have a procedure for clinician notification/handling of expired medication related to manufacturer's drug shortage. Later that day the facility Medical Director was notified about the drug shortage of Lidocaine solution which had been expired over a month prior to that notification.

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Based on interview and observation the facility failed to demonstrate a system to assure a maximum capacity of 25 inpatient beds for 24 hours a day/7 days a week.

Failure to do so creates a risk that the facility will exceed its eligibility capacity for patient care which may result in poor patient outcomes due to scope of care/resource allocation.

Findings:

1. On 3-13-12 at the conclusion of a bed count with a RN, Staff Member #1, the total number of facility beds prepared (set up with bed linens) for inpatients was determined to be 31. This bed count excluded a total of 5 beds in storage in rooms 114, 121 and 122. There were 22 inpatients in the facility at that time receiving care.

2. On 3-13-12 in discussion with the CEO, Staff Member #3, he/she stated that 6 of 31 beds were observation beds. The surveyor communicated that facility staff did not seem to be aware of the 6 observation bed capacity. When asked if there was a policy and procedure designating the facility's scope of service and observation bed allocation/clinical criteria, he/she stated there was not.

In discussion with the RN Admissions Coordinator, Staff Member #4 on 3-16-12, he/she stated that facility staff were informed verbally to contact the Admission Coordinator after hours or on the weekend for questions related to admission capacity. He/she had not been contacted to date for that issue. Another RN, Staff Member # 2, stated that he/she understood that the observation bed capacity was 3.
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Based on interview the facility 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 include:


1. On 3/15/2012, during a conversation with Staff member #7 the surveyor was informed that a disaster drill had not been performed in over one and one half years. It was further indicated that the "drill" was held in response to an actual event involving a chiller (not planned for the purpose of evaluating staff response).

Based on interview the facility failed to have a system in place that would assure the safety of patients, staff and visitors of the facility during non-medical emergencies. More specifically, the facility failed to have a plan in place that would protect vital supplies of emergency fuel and/or water.


Findings include:


1. On 3/15/2012 during discussions with Staff Member #7 the surveyor was informed that agreements had been made with local suppliers for emergency fuel and water but no written agreements (MOU's) had been entered into to assure the delivery of fuel if needed during an emergency.

Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.


Findings include:


Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 3/13/2012 - 3/16/2012.

A. Based on document review and staff interview the facility failed in the granting of privileges to ensured that requested privileges had been delineated. And, the facility failed to specify in writing what specific privileges were be granted to the applicants.


Failure on the part of the facility to ensure that privileges granted have been delineated puts patients at risk of treatment by individuals not having the necessary qualifications to provide safe and effective patient care.


Findings include:


1. On 3/15/2012, during a review of available medical staff files the surveyor noted that delineated privileges had not been requested by the medical staff for the current appointment period. Subsequent to this finding it was explained to the surveyor that the facility had previously used a "Core" privileging process that included those activities allowed to be undertaken in the various core privileging groups; I.E. Core Emergency Medicine Privileges, Hospital Core Privileges, Core Clinic Privileges and Core Long Term /Swing bed Privileges. It was further indicated that the use of established core privileges had been replaced by a system which grouped allowed activities in one of four categories; I.E. Categories I, II, III and IV. This system fails to delineate specific activities allowed to be performed by the applicants in the "Prerogatives" for each of the four categories.


Section 4.1 Requests of the Garfield County Hospital District #1 Medical Staff Bylaws Adopted January 6, 2010 states in part: "Each applicant for appointment and reappointment to the GCHD Medical Staff must contain a request for specific privileges desired by the applicant....".


2. On 3/15/2012, the surveyor noted that the letter of appointment placed in the applicant's file lacked certain information called for in Section 1.12 of the Medical Staff Bylaws. More specifically, the letter of appoint failed to include the clinical privileges the applicant may exercise.


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B. Based interview and review of facility documents, the facility failed to assure that it reviewed policies annually for updates per their standard.

Failure to so a creates a risk for poor clinical outcomes and patient harm due to confusion among staff and providers about what policy governs current clinical practice.

Findings:

1. A document titled " 2011 Board of Commissioners Standards Checklist " provided by Staff Member # 3 on 3-15-12 indicated that policy review by the Chief Medical Officer was to occur annually. It was noted by the surveyors that there were an abundant number of facility policies. Numerous policies were reviewed in 2011 per a document titled " 2011 Updated Policies and Procedures " . The document did not indicate what level of the organization had updated the policy.

2. The following policies and procedures provided by administrative staff between 3-13 & 3-15-12 had not been updated in the past year and were available for use:
Death of a Resident-Skilled Nursing: 1-1-2005
Scope of Services-Dietary: March 1999
Unanticipated Outcomes: 11-29-2006
Adverse Event Reporting: 6-7-2006
Physicians Medication Orders: 1-1-2005
Documentation Standards-Providers: 1-1-2007

A. Based on observation and interview the facility failed to employ a system that would assure the control of infections and communicable diseases of patients and personnel of the facility. More specifically, the facility failed to develop and implement methodologies for the disinfection of environmental surfaces.


Failure on the part of the facility to develop and implement methodologies for the disinfection of environmental surfaces puts patients, staff and visitors of the facility at risk of hospital acquired infection.


Findings include:


1. On 3/14/2012, the surveyor interviewed a housekeeper on the methods and products used for the disinfection of environmental surfaces within the facility.


2. On 3/14/2012, staff indicated that a quaternary ammonium product (Nutra Quat 64) was mixed at a ratio of 1 ounce of product to approximately 1 3/4 quart of water. The mixture was then poured into a container of Wet Task towels.

3. The manufacturer's directions for mixing the Nutra Quat 64 states in part: "DISINFECTION - To disinfect inanimate, hard non-porous surfaces add 2 ounces of this product per gallon of water." These directions were not being followed.


4. Directions for using the Wet Task towel system call for the filling out of the side panel on the container. Information required included but was not limited to the type of disinfectant being used and other pertinent information about the disinfectant product. At the time of the finding side panel information was not being placed on the container.


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B. Based on observation and interview, the facility failed to demonstrate effective infection control measures during recreational therapy activities with patients and staff.


Failure to so creates risk that participation in facility recreational activities may put patient and staff at risk for contacting a communicable disease(s), including potential life threatening ones.


Findings:


1. In observation of recreational activities on 3-13-12 the facility Activities Coordinator, Staff Member # 5, was leading a group session during which a large plastic ball was tossed back and forth among approximately 7 patients and the staff member. Patient #1 had a medical condition that resulted in involuntary frequent tongue protrusions. During the session, it was observed by the surveyor that the patient's tongue/saliva came in direct contact with the ball each time he/she handled it and then the ball was touched by other group members.
Just prior to that event, each group member was holding onto a portion of a large parachute and tossing a ball among each other while holding onto the parachute. During that activity, Patient#1 's tongue/saliva was observed on multiple occasions to make contact with his/her section of the parachute and/or ball.


Tongue/saliva contact with facility equipment was also observed at that time by the facility Infection Control Officer, Staff Member #1, and he/she spoke directly with the Activities Coordinator who ceased the activity and cleaned the equipment ball.


Human saliva is considered to be a potentially infectious agent by the Center for Disease Control for various conditions, including potentially life threatening ones.


2. According to Staff Member #1, there were no procedures related to infection control practices during facility recreational activities.


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Based on document review and interview the facility failed to maintain policies and procedures for the radiology services provided. And, the facility failed to provide in writing a list of radiological services approved by the medical staff and governing body (or responsible individual).


Failure on the part of the facility to maintain policies and procedures for radiology services and to have such services approved by the medical staff and governing body puts patients and staff at risk from the provision of unsafe care or practices.


Findings include:


1. On 3/15/2012, the surveyor reviewed policies and procedures (P&P's) of the radiology department. It was determined during the review that the P&P's had not been reviewed or updated since 1995.


2. On 3/15/2012, the surveyor discussed with staff wether or not the radiology department had certain safety policies called for in the regulations. The surveyor was advised that the following issues were not addressed in policy: Radiation shielding for patients, personnel and facilities; Testing of equipment for hazards (done by General Electric); and Maintenance of personal radiation monitoring devices


3. On 3/15/2012, the surveyor was informed that the medical director was charged with the review of P&P's for radiology services and was performing that function. It was further indicated that the completed review was not necessarily being documented.


Examples of documentation that is lacking includes but is not necessarily limited to the following: P&P's that list those tests needing the interpretation of a radiologist; and a designation of which personnel are qualified to use radiological equipment and administer radiological procedures.

Based on review of facility policy and procedure and medical records the facility failed to assure that verbal orders for medications were authenticated within 48 hours of receipt .

Failure to do so creates risk that errors related to the verbal order process will not be corrected in a timely manner to prevent patient harm from medications.

Findings:

1. Per facility policy " Documentation Standards-Providers (1-1-2007 ) from Staff Member # 8, section 4 stated " ...all verbal orders must be completed within 48 hours. " Given the 48 hour time frame, date and time would be required in the initial transcription and in the subsequent documentation of provider verification.
In the section of the same policy titled, " Standard Charting Guidelines " on page 6 it stated "Documentation of Physician entries shall include: 1. Date 2. Time .... "

2. In review of medication verbal orders in the medical record the following full or partial authentication omissions were noted:

a. Verbal orders for Patient# 5:3-13-12 at 1600 verbal order (VO) for 2 medications-full; 3-6-12 at 0810 VO for a vaccine-full; 1-13-12 at 1145 VO for sliding scale insulin-full; 1-17-12 at 1530 VO for medication-no provider date to time with initials ; 3-16-11 VO for sliding scale insulin with no provider date and time with initials ; 1-28-11 at 1535 VO for long acting insulin with no provider date and time with initials.

b. Verbal orders for Patient # 6:12-29-11 @ 1411 VO for medication-no provider date and time with initials; 2-2-12 at 1515 VO for medication-full .

c. Verbal orders for Patient # 7: 2-17-12 at 1400 VO for antibiotics-full; 3-13-12 (untimed transcription) VO for antibiotics-full.

Based on interview, review of dictated notes and review of policy and procedure, the facility failed to assure the patient records were accurate, complete and finalized.

Failure to do so creates risk for an inaccurate, unfinalized medical record and a record that can be altered because it was not finalized by the provider. Quality of care could be compromised based upon the quality of the medical record.

Findings:
1. During an interview with a facility medical transcriptionist, Staff Member # 9 he/she verified the mechanism for determining whether a dictated note had been authenticated by the provider. The section of the record that stated " Electronically Signed By: " underneath a line in the chart did not signify that that the record had been authenticated. Rather a horizontal entry stating " at the conclusion of the note stating " Electronically signed by: " with a name, date and time meant the record had been fully authenticated.

2. In facility policy titled " Documentation Standards-Providers " (1-1-2007) section 3. stated " Entries in the medical record must be legible and complete and must be authenticated by the person ....is responsible for ordering, providing, or evaluating the service furnished. "

3. During an interview on 3-15-12 with a Physician Assistant, Staff Member #10, he/she was not certain of the process to assure authentication of a medical record entry after it had been dictated.

4. In a review of the following patient records it was determined that the records were not authenticated by the provider of the service. Therefore, the records had not been reviewed for accuracy and finalization by the provider and were alterable.
a. Patient # 8: 2-06-12 LTC Progress Note
b. Patient # 7: 3-17-11 Observation Admission
c. Same Patient: 3-18-11 Observation Discharge and LTC Readmission note
d. Same Patient: 3-30-09 LTC Admission History and Physical note
e. Patient # 1: 03-01-12 LTC Progress Note
f. Same Patient- 2-29-11 Long Term Care Progress Note
f. Patient # 9: (undated) Long Term Care Admission Orders
g. Patient #10: 2-23-12 Longterm Care Progress Note and Observation Admission Note; (undated) Hospital Admission Orders.

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Based on interviews and review of facility documents, the facility failed to demonstrate provision information related to their visitation rights to all inpatients.

Failure to do so creates risk that patients may be unaware of their visitation rights and therefore unable to exercise those rights.

Findings:

1. In interview on 3-14-12 with the Social Service Counselor, Staff Member # 11, stated that the swing bed patients were informed of their rights (including visitation rights) in a group process completed by the Activities Coordinator, Staff member #5, using a large poster located in the hallway. The poster referenced nursing home resident visitation rights. According to the Staff Member #11, there was no related documentation in the medical record about informing residents of their visitation rights.

Per discussion with Staff Member # 1, a triple fold document titled " Patients Rights and Responsibilities " was given to patients upon admission and in the emergency room to inform them of their patient rights. It contained no language related to patient visitation rights.

2. Between 3-14-12 to 3-15-12 a review of the facility documents revealed:
a. A policy titled " Visitation Rights " (8-1-2011), section (1) stated " On admission or as soon as possible thereafter, Garfield County Hospital shall inform each patient (or support person, where appropriate) of his/her visitation rights, including any clinical restriction or limitation on his/her rights. "

b. A document titled " Resident Admission Agreement " in the section titled " Resident Bill of Rights " on page 14 in the section " a. Federal Bill of Rights " of the 12 items listed there was no language related to patient visitation rights. This document was provided to residents in swing beds status.

c. A document titled " Quarterly Nursing Assessment Form " (dated 1-13-12) which was presented by Staff Member #4 as an ongoing assessment form contained no reference to patient orientation to their rights, including patient visitation rights.

In summary the facility failed to demonstrate the mechanism to assure that all patients were informed of their visitation rights per their policy titled " Visitation Rights. "