HospitalInspections.org

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

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.
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Based in observation, review of policy and procedure and staff interview, the facility failed to assure that medications were stored properly.

Failure to do so creates risk that patients may receive medications that are potentially ineffective and/or harmful.

Findings:

1. In review of facility policy and procedure titled, "Medication Administration" (Revision Date: 12/15/2015), on page 7 it stated, "Multidose products (i.e. insulin, creams, etc.) will be given a beyond use date no greater than 28 days unless otherwise noted. . .The individual's initials and beyond use date (month + date + year) will be clearly written on the product and will not exceed the product expiration date. "

2. a. On 1/20/2016 at 2:15 PM Surveyor #1 toured the Family Health Clinic. While on site, the following medications were found to be opened and have beyond use date problems:

a. Kenalog 40 milligrams/milliliter (5 milliliter vial for injection)-no beyond use date

b. Xylocaine 1% vial (20 milliliters) for injection-no beyond use date

2b. Similarly on 1/20/2016 at 2:30 PM Surveyor #1 toured the Eye Clinic. While on site, the following medications were found to be opened and have beyond use date problems:

a. Azopt 1% - opened and unlabeled

b. Tobradex - opened and unlabeled

c. Erythromycin ophthalmic ointment - opened and unlabeled

d. Unknown brown liquid medication in a small plastic dropper - opened and unlabeled

3. On 1/21/2016 at 2:30 PM during an interview between Surveyor #1 and the Director of Diagnostics and Therapeutics (Staff Member #7), s/he acknowledged that the above medication storage practices were not aligned with the facility's policy and procedures. Additionally, the policy did not identify guidelines specific for clinic-based practices and types of staff.
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Item #1 - Hand Hygiene

Based on observation and review of policy and procedure, the facility failed to demonstrate that staff adhered to hand hygiene standards.

Failure to perform hand hygiene places patients, staff and visitors at risk for acquiring communicable diseases.

Findings:

1. In review of facility policy titled, "HAND HYGIENE" (Review Date: 6/4/2015), section A. contained information about indications for handwashing and hand disinfection for decontamination. It stated per item; 5. . . after contact with a patient's intact skin. . . 6. . . after contact with body fluids or excretions, mucous membranes. . .if hands are not visibly soiled. 7. . .if moving from a contaminated-body site to a clean body site during patient care 8. . . after contact with an inanimate object (including medical equipment) in the immediate vicinity of the patient. 9. . . after removing gloves."

2. The following hand hygiene omissions were noted:

a. On 1/20/2016 between 9:00 AM and 9:30 AM Surveyor #1 observed a nurse (Staff Member #1) provide care to an intensive care unit patient (Patient #1). The patient required administration of several medications (over 10), one of which was subcutaneous and another that was intravenous. During the course of care and after the nurse had donned a pair of protective gloves the patient required assistance with clearing mucous production from her/his lungs. The nurse used a tissue paper to remove the mucous from the patient's mouth.

Then without doing hand hygiene the nurse proceeded to handle the patient's oral medications and perfrom an insulin injection. Subsequently the nurse removed the gloves and, without doing hand hygiene, s/he donned another pair of gloves and then administered an intravenous diuretic.

b. On 1/21/2016 at 9:15 AM Surveyor #1 observed care of a surgical patient (Patient #2) in an operating room suite. The circulating nurse (Staff Member #2) was observed setting up an adaptor for elevating the patient's leg on the surgical table. The adaptor was located on the floor of the operating room. The nurse, while wearing protective gloves, picked the adaptor up off the floor, positioned it on the table and then without removing gloves/performing hand hygiene, s/he made contact with the skin on the patient's surgical leg. Then the nurse removed gloves and, without doing hand hygiene, put on another pair of protective gloves.

Item #2 - Transmission Based Precautions and Personal Protective Equipment (PPE)

Based on review of policy and procedure, observation and staff interview, the facility failed to adhere to policy to prevent transmission of infection among patients, staff and visitors.

Failure to do so may result in transmission of infections and potential for harm.

Findings:

1. In review of facility policy titled, "Transmission Based Isolation Precautions" (Review Date: 6/4/2015) under item #2 it stated, ". . .These transmission-based isolation precautions are to be used for patients known or suspected to be infected or colonized with pathogens that can be transmitted by contact with dry skin, contaminated surfaces, airborne or droplet. These include: Contact Precautions. . ."

Additionally, on page 9 the policy provided information that "Contact Precautions" were to be implemented for methicillin resistant staphylococcus aureus (MRSA) and included the need to employ hand hygiene, gown, gloves and dedicated equipment.

Another policy titled, Personal Protective Equipment (PPE) provided information about donning PPE on page 6. In section #1 under "Gown" it stated, "Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist."

2. On 1/20/2016 between 10:00 AM and 11:30 AM, Surveyor #1 observed a wound care procedure for Patient #3 in the Ambulatory Care Area. The patient's medical history indicated that the patient had methicillin resistant staphlococcus aureus (MRSA) however the status of the infection (or colonization) was not provided.

Surveyor #1 observed that there was no isolation signage located outside of the patient's room. There were 2 nurses in the patient's room (Staff Members #3 and #4). Staff Member #3 was wearing a gown and gloves. The gown was fastened at the neck and the waist however, it was not positioned to cover the back from the shoulder blade area downward. When first observed in the patient's room, Staff Member #4 was not wearing any PPE. Then s/he was observed to be wearing a gown. It was fastened at the neck but was not fastened at the waist and was open in the back. S/he was not wearing protective gloves.

3.On 1/20/2016 at 11:30 AM Surveyor #1 interviewed Staff Member #4 about the room set-up, specifically about isolation signage. S/he stated s/he was not sure that the patient needed isolation precautions although she could not ascertain that it was not needed (typically not needed "after one year"). Staff Member #3 stated that they "usually" do not post isolation signage outside of patient rooms in that patient care area because the wound specialists were usually the only staff in the room.

On 1/20/2016 at 2:45 PM during an interview between Surveyor #1 and the Infection Preventionist (Staff Member #6) , s/he acknowledged that staff did not demonstrate adherance to the policy for care of a patient with suspected MRSA infection.

Item #3 - Cleaning Procedure for Isolation Rooms

Based on review of policy and procedure, observation and staff interview, the facility failed to assure that staff adhered to isolation room cleaning procedures.

Failure to do so results in risk of transmission of infectious disease and harm from subsequent illness.

Findings:

1. In review of facility policy titled, "Cleaning Procedure for Isolation Rooms" (Review Date: 4/10/2014) under the section about "Contact" isolation it stated, "You must wear a gown and gloves when cleaning. All personal protective equipment (PPE) should be changed after [what action] each room or when they become compromised."

2. On 1/20/2016 at 11:30 AM Surveyor #1 interviewed the housekeeper (Staff Member #5) about the procedure for cleaning a Contact Isolation room. S/he stated that s/he only wore a gown for removing garbage from the room and discarding it. After garbage was discarded, she removed the gown and gloves and then put on a new pair of gloves (no gown) to clean the room.

3. On 1/20/2016 at 3:00 PM during an interview the Infection Preventionist (Staff Member # 6) acknowledged that staff were required to wear gowns and gloves to clean Contact Isolation rooms.

Item #4 - Surgical Attire

Based on observation, staff interview and review of policy and procedure, the facility failed to ensure that surgical attire standards were adhered to.

Failure to do so may create risk for transmission of infectious disease among patients, staff and visitors.

Reference: 2015 Edition Guidelines for Perioperative Practice, Association of periOperative Registered Nurses, Surgical Attire, Recommendation 1.h.2 "The surgical mask should cover the mouth and nose and be secured in a manner to prevent venting at the sides of the mask. (Figure 4). [1: Strong Evidence]"

Findings:

1. In review of facility policy titled, "Attire-Operating Room" (Revision Date:12/18/2015) item 3 stated, "All head and facial hair is to be covered while in restricted areas of the surgical suite. . . Skull caps are not to be worn in the surgical suite."

2. On 1/21/2016 at 9:40 AM Surveyor #1 interviewed the Director [nursing] of Surgery (Staff Member #9) about the Association of peri-Operative registered Nurses (AORN) standards. S/he acknowledged that the surgical department followed those standards.

3. On 1/21/2016 between 8:50 AM and 9:35 AM the following surgical attire omissions were noted:

a. The surgical mask of the anesthesia provider (Staff Member #10), the circulating nurse (Staff Member #11) and a nurse facilitator (Staff Member #12) were placed but the lower ties were loosely secured and did not prevent venting from the sides along facial contours. Venting occurred to a even greater extent when staff were looking downwards during tasks.

b. The circulating nurse (Staff Member #11) wore a skull cap that did not contain all hair. Two nurses (Staff Members #12 and #13) were wearing a cloth cap that did not contain all hair from the lower hairline down the back of the neck. A physician (Staff Member #14) was wearing a paper bouffant cap however it was positioned at the height of the top of the ear on the right side and did not cover hair and sideburns.

Item #5 - Surgical Skin Preparation

Based on observation, review of policy and procedure and staff interview the facility failed to ensure that an antiseptic solution was used in manner to assure efficacy.

Failure to do so creates risk for surgical site infections.

Findings:

1. In review of facility policy titled., "Surgical Skin Preparation Protocol" (Revision date: 6/26/2015) page 2 provided information about the "Procedure For Clean Areas". Item 6 instructed staff to repeat the scrub addressed in item 4 and 5. Item 4 and 5 instructed staff to start at the site of the incision and move to the periphery. However, item 5 stated "(This does not apply to Chloraprep)" but it did not provide information about how to perform the scrub with ChloraPrep or direct staff to follow manufacturer's instructions.

2. In review of the manufacturer's instructions of ChloraPrep One-step/ChloraPrep With Tint it stated, "dry surgical sites . . .:use gentle back-and-forth strokes for 30 seconds."

3. On 1/21/2015 at 9:20 AM Surveyor #1 observed a circulating nurse (Staff Member #11) perform a surgical skin scrub for knee surgery to be performed on Patient #2. The nurse performed the 1st Chloraprep scrub on the top surface of the knee area for 5-10 seconds and then proceeded to cover the back of the knee, front and back of thigh and then moved to the calf/foot (without re-contacting the top/sides of the knee) and ended between toes.

Then on the second application with a fresh applicator the nurse applied Chloraprep to the top surface of the knee for another 5-10 seconds and then proceeded to cover the same areas as with the first application, except for between the toes. The total back and forth application motion over the surgical site (with the first and second application) was less than 30 seconds.

4. On 1/21/2016 at 9:40 AM Surveyor #1 interviewed the Director [nursing] of Surgery (Staff Member #9) about the antiseptic preparation, specifically the 2nd application of Chloraprep. When asked what s/he considered to be the "surgical site" (area requiring 30 seconds of continuous back-and-forth motion) for Patient #2, s/he stated that is was the top and side surface of the knee.
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31312

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Based on observation, the hospital failed to ensure that dietary staff members maintained cold-holding temperatures of potentially hazardous foods in compliance with the Washington State Retail Food Code (WAC 246-215).

Failure to maintain temperatures of potentially hazardous foods in compliance with the Washington State Retail Food Code puts patients, staff and visitors at risk of foodborne illness.

Findings:

On 1/20/2016 at 4:00 PM, Surveyor #2 used a thin-stemmed thermometer to assess the temperature of potentially hazardous food items on the cafeteria salad bar. The following foods had a cold-holding temperature that exceeded 41 degrees Fahrenheit, as required by the Washington State Retail Food Code:

a. Raw spinach leaves: 50 degrees Fahrenheit

b. Hummus: 46 degrees Fahrenheit

c. Mixed leafy greens: 47 degrees Fahrenheit
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Based on review of policy and procedure, the facility failed to assure that policies were reviewed annually.

Failure to do so creates risk that staff will not adhere to up-to-date standards which may diminish the quality of services delivered.

Findings:

In review of facility policy and procedures the following last review dates were noted, as of 1/20/2016:

Steps for Cleaning and Processing Instruments - 10/23/2014

Confidential and Hazardous Waste Removal - 4/18/2014

Emergency Room Cleaning Procedure - 4/17/2014

Exam Room Cleaning Procedure - 4/17/2014

IV Pump PCA Cleaning - 4/16/2014

Release of Information Process - 3/25/2014

Laundry Infection Control - 8/1/2009

Air Handling and Ventilation System - 11/21/2014

Failure of Medical Gas and Oxygen System - 3/3/2010

Cleaning Procedures for Isolation Rooms - 4/10/2014

These findings were confirmed upon identification by the Director of Acute Care Services (Staff Member #3).
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