HospitalInspections.org

Item #1 Hand Hygiene

Based on review of policy and procedure and observation, the facility failed to assure that hand washing standards were adhered to.

Failure to assure adherence to hand washing standards creates a risk for cross-contamination of organisms and subsequent infections among patients and staff members.

Findings:

1. In review of policy titled "Handwashing " (reviewed 8/03/2012), item E. identified situations for required hand hygiene. Under #3 it stated, "Before gloving and immediately after glove removal." Under #6 it stated "Immediately before handling medications" and under #9 it stated "Immediately after...wiping the nose."

2.a. Glove Change

On 6/17/2014 at 2:45 PM Surveyor #2 observed a wound care specialist nurse (Staff Member #1) provide care to Patient #1. The patient had surgery (below the knee amputation) performed on her/his right leg and required dressing changes to a thigh and groin incisions. While wearing protective gloves, the nurse removed the old dressings. Then s/he removed her/his protective gloves and discarded them. The nurse did not perform hand hygiene prior to donning a clean pair of protective gloves and then proceeded to complete the dressing change.

2 b. Handling Medication

On 6/19/2014 at 9:20 AM Surveyor #2 observed a RN (Staff Member #2) at the medication dispensing machine withdrawing medications for patient care. After s/he withdrew some medications s/he touched below her/his own nostrils with her/his index finger with an ungloved hand then immediately touched the computer screen and keyboard of the dispensing machine. Prior to performing hand hygiene s/he donned protective gloves to further handle medications. Then s/he removed her/his gloves and, prior to performing hand hygiene, accessed packageed medications from the machine drawers.

Another nurse (Staff Member #3) was observed immediately subsequent to that time walking to the medication dispensing machine and touched her/his own nostrils with her/his ungloved index finger. S/he then touched the computer screen and keyboard of the medication dispensing machine for patient medications.

It was noted by Surveyor #2 at that time period that there was no hand washing facilities or hand sanitizer gel available in the area of the medication dispensing equipment or in the adjacent nursing station (where the medication dispensing machine was located).

Item #2 Cleaning Patient Care Equipment

Based on review of policy and procedure and observation, for 1 of 2 medication administration events staff did not clean a wheeled computer station with a disinfection product at the required interval after use in a patient room.

Failure to assure adherence to the disinfecting procedure creates risk for cross contamination of organisms among patients and staff members.

Findings:

1. In review of facility policy titled, "Medication Administration Process" (reviewed 3/31/2014) on page 2 of 5, under II. d. xi., it stated "Wipe down all contact surfaces on COW [computer on wheels] with disinfecting towelette (for example CaviWipes)". This step was to be performed upon completion of medication administration and just prior to hand hygiene.

2. On 6/19/2014 at 10:00 AM Surveyor #2 observed a RN (Staff Member#6) complete medication administration for Patient #3. The patient was in the hospital for care related to cancer which required medication administration intravenously, subcutaneously (under the skin), to the surface membranes of the mouth and into an external tube placed through the abdominal wall into the intestinal track.

The RN confirmed that all medications had been administered and then cleaned her/his hands prior to exiting the room. However s/he did not wipe down the COW prior to sanitizing hands. Subsequently, the RN pushed the COW to the nursing station and medication dispensing machine area to return unused medications and touched the medication dispensing machine screen and keyboard.


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Item #3 Proper Use of Testing Disinfection Solutions

Based on observation, interview and documentation review facility staff failed to follow manufacturer's instructions for use (IFU) for disinfection.

Failure to adhere to manufacturer's instructions for use puts patients, staff and visitors at risk for infectious diseases.


Use of Test Strips
Reference: Rapicide OPA/28 test strips ML02-0137 manufacturer's instructions for use states, "Test strips are good for 6 months once opened. The date opened should be written on the test strip bottle."

Reference: Cidex OPA manufacturer's instruction for use indicates, "date the bottle of test strips when opened (expires at 90 days or the expiration date on the bottle of test strips, whichever comes first)."

Findings:

1. On 6/17/2014 at 3:30 PM, Surveyor #1 observed a bottle of Rapicide test strips and a bottle of Cidex test strips without a written opened date or a discard date on either of the bottles that were located in the endoscope/sterile processing room. In an interview with the manager of the endoscope department(Staff Member #7) s/he stated, that they only use the Rapicide test strips for processing endoscopes and did not use the Cidex test strips and wasn't sure why they were there. S/he confirmed that the Rapicide test strips did not have a written or discard date when the bottle was opened.

2. On 6/18/2014 at 2:00 PM in an interview with ultrasound technician (Staff Member #8) s/he stated that the Cidex test strips were used in the process of disinfecting vaginal probes. After review of documentation from the manufacturer it was determined that facility staff did not follow manufacturer's labeling instructions for both products.


Use of Cleaning Solution
Reference: Clorox Germicidal Bleach Product Solutions states in part . . . Dispensing pumps delivers- 1 fl. oz of bleach per pump. . .1:9 ratio is equal to 1 part bleach to 8 parts water or 2 cups (16 fl. oz. with 1 gallon water gives 8700ppm available chlorine). . . To kill Clostridium difficile spores [highly infectious organism], a 1:9 bleach dilution (8700ppm available chlorine) is required.

Findings:

3. On 6/18/2014 at 9:30 AM Surveyor #1 interviewed housekeeping staff (Staff Member #9) on the use of premixing bleach dispenser located in housekeeping closet. S/he stated that s/he would remove the dispensing tube from the Clorox container (disconnecting the premix dispensing unit) and replace it with a dispensing pump. S/he would then pump the bleach 8 times into a container and then fill the rest of the container with water. This was for the purpose of disinfecting Clostridium difficile (a highly infectious organism).

S/he then stated for the purpose of disinfecting all other rooms excluding Clostridium difficile, s/he would then pump the bleach 4 times into a container and fill the rest of the container with water. The containers were of different sizes and there were no "marked levels" to indicate how much water was needed to give the desired concentration.

Then Surveyor #1 asked the house keeping staff (Staff Member #9) for test strips to test the concentration of bleach solution. The housekeeper (Staff Member #9) handed Surveyor #1 test strips that were for a different chemical compound. S/he verified that the facility did not have test strips to determine concentration for that particular chemical compound.

After reviewing manufacturer's instructions for use, it was determined that the facility staff did not follow the manufacturer's guidelines to assure proper concentrations.

Based on observation,staff interview and documentation review, the facility staff failed to ensure compliance with the Rules and Regulations of Washington State Retail Food Code (246-215 WAC).

Failure to maintain compliance with the Washington State Retail Food Code puts patients, staff and visitors of the facility at risk for health and safety.

Reference: Product Specification Document
O a s is 1 4 6 M u lt i- Q u at S a n it iz e r 910787
CLASSIFICATION: Quat sanitizer. . . DIRECTIONS FOR USE:
Oasis 146 Multi-Quat Sanitizer is an effective sanitizer against Escherichia coli and Staphylococcus aureus on food contact surfaces when used at 0.25 oz-0.67 oz. per 1 gallon of 400 ppm hard water (150 ppm to 400 ppm active quat).

Findings:

1. On 6/17/2014 between 10:00 AM and 11:00 AM, Surveyor #1 tested the concentration of quaternary ammonium solution in the sanitizer bucket located in the kitchen, the concentration tested over 400ppm. It was found that the concentration was higher than the manufacturer's instruction for use and therefore potentially toxic to the digestive tract.

Reference: Washington State Retail Food Code Working Document Chapter 246-215 Washington Administrative Code (WAC) Modification of 2009 FDA Food Code
Chapter 4-501.114 (3).

2. On 6/17/2014 between 10:00 AM and 11:00 AM, Surveyor #1 observed mold growth in the juice machine dispenser. This finding was confirmed by the dietary cook (Staff Member #10)

Reference: Washington State Retail Food Code Working Document Chapter 246-215 Washington Administrative Code (WAC) Modification of 2009 FDA Food Code
Chapter 4-601.11.

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Based on review of policy and procedure and interview, the facility failed to assure that contracted services for patient care were evaluated.

Failure to do so creates risk that service provision from contractors may not be adequate for the needs of the critical access hospital and its' patients.

Findings:

1.Review of a facility policy and procedure titled, "Contracts Policy & Procedure" (reviewed 6/2/2014) indicated that it did not address a system for evaluating the provision of contract services.

2. On 6/18/2014 at 10:00 AM during an interview between Surveyor #2, a pharmacist (Staff Member #4) and a physician (Staff Member #5), it was confirmed that there was not a system for evaluation of contracted after-hours pharmacy services. At that time it was discussed that the facility was in the planning phases of implementing a process but that it had not been implemented yet.

This finding was confirmed on 6/19/2014 at 2:00 PM with the facility's Chief Operating Officer (Staff Member #6) as related to additional contracts, including laboratory services, echocardiogram services, teleradiology services and intravenous nursing services.

Based on review of policy and procedure and record review, 1 of 2 medical records reviewed demonstrated that documentation for inpatient pain assessments and treatment did not meet the facility standard.

Failure to complete pain assessments creates risk that patients may be over-medicated or under-medicated and/or may experience negative health outcomes related to pain management.

Findings:

1. In review of policy and procedure titled "Pain Management" on page 3 of 5 it stated, "Every patient will be assessed for pain each shift and at the following intervals: a. With each new report/rating of pain. . . c. Reassess and measure pain intensity after each pain management intervention. . ." 1. General guidelines . . ." ". . .60 minutes for po [oral]. " Item C. described the three required elements of documentation.

2. Record review of Patient #2 indicated that the patient was admitted on 6/2/2014 for recovery after a right hip replacement. The patient received narcotic pain medication 7 times between 6/5/2014 at 8:45 AM and 6/10/2014 at 5:28 AM. All 7 pre-medication and post-medication administration events during that time period were missing the required documentation elements. Also, for 7 of the 7 events noted in the medical record pain ratings were not completed after medication administration to assess adequacy of the treatment for pain.