HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to implement policies & procedures to ensure compliance with the Washington State Retail Food Code (Chapter 246-215 WAC).

Failure to comply with food safety standards puts patients, staff, and visitors at risk of food borne illness.

Findings included:

1. Document review of the hospital's policy titled, "Food Handling Guidelines (HACCP)," policy number B007, revised 01/21 showed that during cold food preparation:

a. Staff are to chill potentially hazardous ingredients to 41 degrees Fahrenheit for foods that will be eaten without further cooking. Staff are to chill the foods again after preparation to 41 degrees Fahrenheit.

b. Staff are to cool potentially hazardous foods prepared from room temperature ingredients within 4 hours to 41 degrees Fahrenheit and use a cooling log to document temperature of the food.

c. Cold-held foods should be held cold for service at a temperature of 41 degrees Fahrenheit or less.

2. On 06/01/21 at 10:00 AM, during a inspection of the walk-in refrigeration unit, Surveyor #6 observed that twelve plates assembled for the lunch Salad Special (1 scoop each of tuna salad, chicken salad, and egg salad) were covered with polycarbonate plate covers. The surveyor used a thin stemmed thermometer to assess the temperature of the salads. The temperature of the various salads ranged from 45 to 51 degrees Fahrenheit.

3. At the time of the observation, Surveyor #6 interviewed the Director of Food & Nutrition (Staff #603) about the temperature control procedures for cold-held potentially hazardous foods (PHF). Staff #603 stated that the salads were prepared about 9:45 AM for lunch service from 12:30 PM - 12:45 PM. There was no temperature log for the salad plates. Dietary staff immediately removed the covers, moved the salad plates to the walk-in freezer unit, and began a temperature log. By 11:30 AM all salads assessed temperatures were below 41 degrees Fahrenheit.

Reference: Washington State Retail Food Code, WAC 246-215-03525 (2009 FDA Food Code 3-501.16)

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Item #1 Procedural Time Outs

Based on document review and interview, the Critical Access Hospital failed to follow their policy and procedures to ensured that all of the procedure room staff followed an effective "time-out" process and ensured accurate identification of the patient and the procedure by all members of the procedural team.

Failure to ensure that all members of the procedural team implemented a uniform process for identifying and ensuring accurate identification of the patient and intended procedure risked patient health and safety.

Findings included:

1. Document review of the hospital policy and procedure titled, "Procedural Sedation and Analgesia," policy number 10796, last reviewed 06/04/20, showed that the team is to perform a "time out" including pre-procedure assessment, patient teaching, equipment checklist, as well as verifying the pre-procedure, diagnosis, procedure to be performed, and patient identification.

2. On 06/03/21 at 09:24, Surveyor #10 observed a colonoscopy procedure for Patient #1005. The procedure room attendance included; Gastroenterology Physician (Staff #1008), Gastroenterology Technician (Staff #1009) and a Procedural Sedation Registered Nurse (Staff #1011). During the procedural time-out Staff #1011 verified with the patient, the patient's name, date of birth, allergies diagnosis, and the procedure. During the timeout, Staff #1008 and Staff #1009 were completing other tasks in the procedure room and not pausing in the verification of the time-out process.

3. On 06/03/21 at 10:20 AM, Surveyor #10 interviewed the Director of Nursing (Staff #1002) about procedural time-outs. Staff #1002 stated that all member should be "pausing" and engaging in the time-out procedure.

Item # 2 Informed Consents for Procedural Sedation

Based on document review and interview, the hospital failed to ensure that informed consents were properly verified according to hospital policy and procedure for 4 of 4 records reviewed (Patients #1001, #1002, #1003, #1004).

Failure to properly verify informed consent prior to procedures places patients at risk of harm related to receiving care and services that may not be the patient's desires.

Findings include:

1. Document review of the hospital policy and procedure titled, "Procedural Sedation and Analgesia," policy number 10796, last reviewed 06/04/20, showed the following:

-That staff are to verify that informed consent has been obtained.

-Appropriate hospital informed consent, including the risks, benefits and alternatives both for the procedure and planned sedation must be obtained and documents by the treating provider prior to procedural sedation/analgesia.

-That the staff are to verify the presence of a "Special Consent to Treatment" for procedures outside the emergency room.

a. Document review of the hospitals consent titled, "Consent to Operation, Administration of Anesthetics and Rendering of Other Medical Services," showed no evidence that the risks, benefits and alternatives both for the procedure and planned sedation were written or explained to the patient.

2. Medical record review 4 of 4 patients (Patient #1002, #1002, #1003 and Patient #1004) showed 4 of 4 patients signed a "Consent to Operation, Administration of Anesthetics and Rendering of Other Medical Services". There was no evidence in the consent that the patients' risk, benefits and alternatives both for the procedure and planned sedation were written or explained in 4 of 4 patients consents reviewed.

3. Medical record review 4 of 4 patients (Patient #1002, #1002, #1003 and Patient #1004) showed 4 of 4 patients signed a "Consent to Operation, Administration of Anesthetics and Rendering of Other Medical Services". The review showed that there was no "Special Consent to Treatment" form for 4 of 4 patients, all 4 patients received their procedure outside the emergency room setting.

4. On 06/02/21 at 8:25 AM, Surveyor #10 interviewed Lead Registered Nurse (Staff #1010) about the informed consents for Patient #1001 and #1002. Staff #1010 verified that the risks, benefits and alternatives both for the procedure and planned sedation were not present in the consent documents provided and signed by the patients.

5. On 06/03/21 at 8:45 AM, Surveyor #10 interviewed the Director of Nursing (Staff #1002) about the informed consents for Patient #1003 and #1004. Staff #1002 reviewed the patients informed consents and verified that the risks, benefits and alternatives both for the procedure and planned sedation were not present on the consent for 2 of 2 patients reviewed.

a. Director of Nursing (Staff #1002) presented Surveyor #10 with a copy of the " Special Consent to Treatment", and stated that the hospital will implement this consent in the future.
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Based on document review and interview, the Critical Access Hospital failed to ensure a complete pre-operative medical history and physical (H&P) was completed within 30 days of surgery for 4 of 4 patient records reviewed (Patient #1001, #1002, #1003, and #1004).

Failure to complete a history and physical exam prior to procedural sedation places patients at risk for poor outcomes due to changes in unknown or known co-morbid conditions.

Findings include:

1. Document review of the hospital policy and procedure titled, "Procedural Sedation and Analgesia," policy number 10796, last reviewed 06/04/20, showed the following:

-A pre-procedure assessment must include a review of objective data, and an interview with the patient to discuss the patient's:

-For elective procedural sedation and analgesia: physical, medical history, current medication list with in 30 days to procedure.

-Anesthesia/sedation history

2. Medical record review showed no History and Physical completed for 4 of 4 patients (Patient #1002, #1002, #1003 and Patient #1004) prior to the elective procedure.

3. On 06/02/21 at 8:15 AM Surveyor #10 interviewed Lead Registered Nurse (Staff #1010) about the missing History and Physical. Staff #1010 confirmed that the History and Physical were not completed prior to the procedure for Patient #1001 and Patient #1002.

4. On 06/03/21 at 8:30 AM Surveyor #10 interviewed the Director of Nursing (Staff #1002) about the missing History and Physicals. Staff #1002 researched the electronic medical records and was unable to produce History and Physicals for Patient #1003 and #1004.
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Based on observation, medical record review and interview the Critical Access Hospital failed to ensure that physicians properly executed Informed Consents for procedures by not dating and timing the forms for 4 of 4 (Patient #1001, #1002, #1003 and #1004).

Failure to ensure that informed consents are properly executed creates a risk for lack of understanding to what and when a patient consented to a particular procedure.

Findings include:

1. On 06/02/21 and 06/03/21, Surveyor #10 observed the informed consent for 4 of 4 patients did not have a date nor time recorded on the informed consent by the gastroenterologist physician, (Staff #1008).

2. Medical record review 4 of 4 patients (Patient #1002, #1002, #1003 and Patient #1004), showed 4 of 4 patients signed a "Consent to Operation, Administration of Anesthetics and Rendering of Other Medical Services,". There was no evidence the gastroenterology physician, ( Staff #1008) dated and timed the informed consent prior to the procedure.

3. On 06/02/21 at 8:30 AM, Surveyor #10 interviewed Lead Registered Nurse (Staff #1008) about the informed consents for Patient #1001 and #1002. Staff #1008 verified that gastroenterologist physician (Staff #1008) did not date or time the informed consent.

4. On 06/03/21 at 8:55 AM, Surveyor #10 interviewed the Director of Nursing (Staff #1002) about the informed consents for Patient #1003 and #1004. Staff #1002 reviewed the patients informed consents and verified that the gastroenterologist physician (Staff #1008) did not date or time the informed consent.
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Item #1 - Hand Hygiene

Based on observation, document review, and interview, the hospital failed to ensure staff performed proper hand hygiene.

Failure to perform proper hand hygiene puts patients, staff, and visitors at increased risk of exposure to harmful microorganisms.

Findings included:

1. On 06/02/21, between 7:50 AM and 8:25 AM, Surveyor #8 observed a terminal clean in the Emergency Department.

2. Document review of the hospital policy "Hand Hygiene" policy number 11269, no revision date, showed that hand hygiene should be performed before and after removing gloves.

3. EVS housekeeper (Staff #802) put on a double set of gloves. The housekeeper did not apply hand sanitizer prior to donning the first set of gloves. On two occasions the housekeeper did not use sanitizer when changing the outside set of gloves.

4. Following the cleaning of the room Surveyor #8 and Staff # 802 discussed the use of sanitizer. Staff #802 stated that sanitizer is needed between complete glove changes.

5. On 06/03/21 at 3:15 PM, Surveyor #8 interviewed Director of Nursing (Staff #803) during the infection prevention meeting. Surveyor #8 discussed the observation of not disinfecting between changes of outer gloves. Staff #803 confirmed that disinfection should take place between changes of the outer glove.

Item #2 - Disinfectant Contact Time

Based on observation, document review, and interview, the hospital failed to ensure staff had knowledge of the contact time (time required to effectively reduce the amount of pathogens) for disinfectant chemicals used in patient care areas, as evidenced by 2 of 4 observations.

Failure to allow adequate time for disinfection of surfaces places patients, staff, and visitors at increased risk of exposure to harmful microorganisms.

Reference: Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), updated 07/19: Recommendations VI. Standard Precautions F. Care of the Environment 3. Use EPA-registered disinfectants in accordance with manufacturer's instructions.

Findings included:

1. Document review of the product label for Clorox Bleach Healthcare Germicidal Wipes, showed that for multipurpose, broad spectrum cleaner disinfectant, all surfaces must remain wet for 3 minutes.

2. On 06/02/21 at 2:55 PM, the Facilities Director (Staff #601) and Surveyor #6 observed the turnover cleaning of Emergency Room (ER) Bay #1 by an ER technician (Staff #602).

3. At the time of the observation, Surveyor #6 interviewed Staff #602 about the terminal cleaning procedures and proper use of the chemical disinfectant. Staff# 602 named the disinfectant as bleach wipes and indicated the container of Clorox Bleach Healthcare Germicidal Wipes. Staff #602 stated that the contact time was about a minute and a half.

4. Record review of the manufacture's instruction for use for Super Sani-Cloth Wipes showed the contact time was 2 minutes.

5. Surveyor #8 interviewed a Registered Nurse (RN) (Staff #801) about the cleaning of reusable equipment between patient use. She stated that Super Sani-Cloth wipes were used and the contact time was a couple minutes or 5 minutes.

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Based on interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30, subject line, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings included:

1. Record review of the hospital water management plan showed that the plan did not include specific testing protocols and acceptable ranges for control measures.

2. On 06/03/21 at 9:45 AM, Surveyor #6 interviewed the Director of Facilities (Staff #601) regarding the hospital's water management program. The director stated that all environmental testing was conducted to create a benchmark and if future testing indicated changes, the hospital would take corrective action. Staff #601 stated he had requested guidance from a variety of sources regarding testing protocols and acceptable ranges of control measures.

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Based on document review and interview the Critical Access Hospital failed to provide information to swing bed patients about their right to receive/send mail, work and receive visitors.

Failure to adequately inform patients of their healthcare rights limits the patient's ability to exercise those rights.

Findings include:

1. Document review of the hospital, "Patients' Rights for Swing Bed Resident", policy number 10877, last reviewed 02/21 showed the following:

a. Patients have a right to perform or refuse services for the hospital.

b. Patients have a right to send and receive mail.

c. Patients have a right to be informed of his/her visitation rights, including any clinical restrictions of limitations on these rights.

d. Patients have a right to share a room with his or her spouse when married patients are admitted to the same facility, and both patients consent to the arrangement.

Document review of the facility's "Patient Rights and Responsibility" pamphlet that is given to patients upon admission to Snoqualmie Valley Hospital showed no evidence of the above patients' rights.

2. On 06/01/21 at 1:30 PM, Surveyor #10 interviewed the Director of Nursing (Staff # 1002). Staff #1002 confirmed the missing rights in the Patients' Rights and Responsibility pamphlet provided to their swing bed patients. Staff #1002 also confirmed that their policy addresses all the rights and that the facility failed to update the Patient Rights and Responsibility pamphlet given to patients upon admission.