HospitalInspections.org

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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that reported safety concerns were investigated and follow-up reviews completed according to hospital policy for 2 of 5 events reviewed.

Failure to investigate reported safety concerns and complete follow-up reviews limits the hospital's ability to implement measures that prevent or mitigate future deviations in practice that cause medical errors and patient injuries.

Findings included:

1. Document review of the hospital's policy titled, "Administrative Outcomes Management Event Reporting (Quantros)," policy VMCPOLICY-1853458269-3, approved 11/21/18, showed that the hospital uses an electronic event reporting system (Quantros) whereby hospital employees can report employee, visitor, and patient safety concerns to the appropriate organizational leaders and patient safety support staff. The policy showed that once notified of an event, the department leader has two business days to assign follow-up tasks to himself or another individual, and once assigned, the department leader or delegate has two weeks to investigate the event and complete a follow-up review in Quantros.

2. On 01/20/21 at 1:15 PM, Investigator #2 reviewed patient safety events reported for the hospital's outpatient clinics between 01/01/20 and 12/31/20, with the assistance of the hospital's Regulatory Compliance Manager (Staff #103). The review showed that hospital staff failed to investigate or complete follow-up reviews for 2 of 5 patient safety event reports (Patients #201 and #202).

3. The Regulatory Compliance Manager confirmed the investigator's findings at the time of the review.
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Item #1 - Staff Orientation and Training

Based on observation, interview, and review of hospital policy and procedures, the hospital failed to ensure that Patient Service Representative staff members were oriented and trained to their assigned job responsibilities for 2 of 2 human resource records reviewed (Staff #101, Staff #102).

Failure to ensure hospital staff members are oriented and trained to their required job responsibilities places patients at risk for delays in treatment and potential ineffective care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "UW Medicine/Valley Medical Center Patient Service Representative (PSR) Competency Based Orientation," no policy number, no date, showed no specific training for patient service representatives on the use of pulse oximeters.

2. Review of the outpatient clinic Patient Service Representative job description, reviewed 01/13, and the documents titled, "Managing a Waiting Room Medical Emergency in Urgent Care," revised 05/15/15, and "Managing a Waiting Room Medical Emergency in Urgent Care - North Benson Urgent," revised 01/04/21, and showed that outpatient clinic PSRs functioned in an administrative capacity, and that "medical training is not required or expected for this position."

3. On 01/19/21 at 1:10 PM, Investigator #3 and the Chief Quality Officer (Staff #301) toured the South Covington Urgent Care Clinic. During the tour, Investigator #3 observed a Patient Service Representative (Staff #302) perform symptom screening of a patient presenting to the clinic. The observation showed Staff #302 obtaining a oxygen saturation measurement using a pulse oximetry machine as part of the screening process.

4. Immediately following the observation, Investigator #3 interviewed Staff #302 about the screening process. Staff #302 stated that the screening begins with a COVID-19 symptom check following by some questions regarding the purpose of the visit. Those questions include asking if the patient is having new or worsening shortness of breath or cough. If the patient answers yes, Staff #302 stated they are instructed to use a pulse oximetry to obtain a oxygen saturation measurement. If the measurement is less than or equal to 95 percent, they are to contact a provider immediately or one of the clinical staff.

5. On 01/20/21 at 2:25 PM, Investigator #1 reviewed outpatient clinic staff personnel files, with the assistance of the hospital's Regulatory Compliance Manager (Staff #103). The review showed that the files for 2 of 2 Patient Service Representatives (Staff #101 and #102) lacked documentation that showed training for the use of pulse oximetry on patients.

6. On 01/20/21 at 4:00 PM, Investigator #2 interviewed the Director of Urgent Care Clinics (Staff # 201) to discuss the training and competency process for PSRs performing pulse oximetry measurements on patients. Staff #201 stated that the back office coordinators began training the clinic PSRs on how to use a pulse oximeter, and that the clinic PSRs were taking pulse oximetry measurements on patients since April 2020. When asked how the investigator could verify that all clinic PSR staff were trained and competent on pulse oximeter use and measurements, Staff #201 stated that they did not have a process to document which staff members had received this training.

Item #2 - Emergency Equipment and Patient Care Supplies

Based on observation, interview, and document review, the hospital failed to ensure that emergency equipment and patient care supplies were properly maintained and available for use.

Failure to maintain emergency equipment and patient care supplies risks patient injury and/or delays in emergency treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Cardiopulmonary Resuscitation (CPR) Procedure," Document ID # VMCPOLICY-12269025-9267, last approved 11/17/20, showed that all emergency equipment and the medication box are to be checked daily.

2. On 01/19/21 between the hours of 1:00 PM and 2:50 PM Investigator #1 toured the South Covington Urgent Care Clinic with the Clinic Manager (Staff # 104). During the tour, Investigator #1 observed a small emergency medication box mounted on the wall. Investigator #1 requested to see the emergency equipment logs which included the emergency medication box. A review of the emergency equipment log for the month of January 2021 showed that the equipment was not checked on 01/02/21. The Clinic Manager (Staff #104) confirmed the checking of emergency equipment and supplies was not documented.

3. On 01/19/21 between the hours of 3:00 PM and 4:15 PM, Investigator #1 toured the North Covington Dermatology Clinic with the Clinic Manager (Staff # 105). During the tour, Investigator #1 inspected the clinic's automated external defibrillator and oxygen tanks. Investigator #1 requested to see the emergency equipment logs. A review of the January 2021 emergency equipment log showed that the equipment was not checked on the 14th and 15th of the month. The Clinic Manager (Staff #105) confirmed that those dates were missed.

4. On 01/19/21 at 2:49 PM, Investigator #7 and a Medical Assistant (MA) (Staff # 701) toured the Cascade Medical Clinic. During the tour, Investigator #7 inspected the clinic's emergency equipment and supplies. The investigator observed that the clinic's adult bag-valve-mask Ambu bag contained an unidentified liquid and particles in the tubing and the face mask. Later in the tour, Investigator #7 and another MA (Staff #702), observed a second adult bag-valve-mask containing an unidentified liquid in the tubing.

5. On 01/19/21 between 3:00 PM and 4:15 PM, Investigator #3 toured the North Covington Rheumatology and Allergy Clinics with the Clinic Manager (Staff #303). During the tour, Investigator #3 inspected the clinic's emergency equipment and supplies. A review of the December 2020 and January 2021 emergency equipment check list logs showed that the clinic's adult and pediatric bag-valve-mask ambu bags had not been check for availability (presence of items) for the last 59 days.

An inspection of the medication room showed the following expired items:

One box containing thirty 0.2% Ipratropium inhalation unit dose solutions with an expiration date of 11/20

Three intravenous start kits with an expiration date of 02/29/20

Two 1000 ml intravenous bags of 0.9% normal saline with an expiration date of 12/01/20

6. On 01/20/21 at 9:05 AM, Investigator #7 and a Medical Assistant (Staff #703) toured the hospital Urology Clinic. During the tour, Investigator #7 inspected the clinic's emergency equipment and supplies. The investigator observed that the clinic's adult bag-valve-mask Ambu bag contained an unidentified liquid in the tubing.

7. On 01/20/21 at 9:30 AM, Investigator #3 toured the Kent Clinic with the Clinic Manager (Staff #304). During a tour of the Nephrology Clinic, Investigator #3 inspected the clinic's emergency equipment, including their oxygen tanks. A review of the January 2021 emergency equipment check list log showed that the oxygen tanks were documented as checked only on the 19th and 20th. Staff #304 stated that this was a new process for the clinic and had not been formally documented previously.

8. On 01/20/21 at 12:40 PM, Investigator #7 toured the Valley Professional Center's Rheumatology Clinic. During the tour, Investigator #7 inspected the clinic's emergency equipment and supplies. A review the emergency equipment check list logs for the last four months (October 2020, November 2020, December 2020, and January 2021) showed that staff failed to document that the medication box had been checked for three continuous months (October, November, and December), and documentation that staff completed the medication box checks occurred only 4 of 21 clinic days in January 2021. An interview with the Clinical Supervisor (Staff #704) and Clinic Manager (Staff #705) confirmed the findings described above.