HospitalInspections.org

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Based on observation the hospital failed to maintain appropriate air pressure relationships in the laboratory.

Failure on the part of the hospital to maintain appropriate air pressure relationships puts patients, staff and visitors at risk from airborne contaminates and/or pathogens.

References: ASHRAE/ASHE Standard 170-2008; Ventilation of Health Care Facilities, Table 7-1 Design Standards; and American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities 2006 ed., Table 2.1-2 Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities.

Finding:

On 3/8/2016 at 9:30 AM Surveyor #1 used a light weight string (flutter strip) to determine the direction of air flow between the laboratory and adjacent spaces, i.e. the corridor. The flutter strip remained neutral indicating that the laboratory was not negative as required per federal code.

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Based on observation, interview and review of hospital policies and procedures the critical access hospital failed to ensure that all drug storage areas were inspected to prevent administration of outdated or unusable medications.
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Failure to assure medication storage areas are void of outdated or otherwise unusable medications put patients at risk of receiving medications with compromised sterility, integrity, or stability.
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Findings:
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1. The hospital's policy and procedure titled, "MULTI-DOSE VIALS " (Effective 5/20/2007, Revised 10/15/15) stated in part ". . . All multi-dose vials of medications shall be dated and initialed upon initial use and discarded after 28 days. . . Insulin vials shall be signed out in the patient's name. . .Insulin vials shall be discarded 28 days after opening. The nurse opening the insulin vial shall date and initial the vial."
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2. On 3/9/2016 at 11:15 AM, during inspection of the medication preparation room, Surveyor #2 found two opened vials of insulin in the stock medicine cabinet without dates or initials indicating when the vial was initially opened and the vials did not have patient names on them.
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3. During discussion on 3/10/2016 at 9:00 AM with the Pharmacy Manager (Staff Member #2) s/he confirmed that the insulin vials should have a beyond use date and patient name attached to the vials.
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ITEM #1 REPROCESSING OF CRITICAL EQUIPMENT

Based on observation, interview, and document review, the hospital failed to ensure that staff members documented results of the biological incubation times for the steam sterilizer used for reprocessing critical instruments.

Failure to follow manufacturer's instructions for use places patients and staff at risk for infection.

Reference: 3M Attest Biological Monitoring System Page 11 part 3. Stated, "The recommended incubation time for 1262P Attest (Trademark) biological indicators is 48 hours. A final determination of sterility can be made after the stated incubation time. Part 4. Record results."

Findings:

On 3/9/2015 at 12:20 PM, Surveyor #1 reviewed the biological indicator logbook used for the hospital's steam sterilizer (Ritter M11 UltraClave). The biological indicator (3M Attest) used in the facility requires a 48 hour incubation time prior to reading the result. Review of the biological indicator logbook revealed that the central sterile technician (Staff Member #6) documented the results before the 48-hour incubation time.

ITEM #2 DIETARY

Based on observation, the hospital failed to fully implement the requirements of the Washington State Retail Food Code WAC 246-215.

Failure to comply with food service codes puts patients, staff, and visitors of the hospital at risk from food borne illnesses.

Findings:

1. On 3/9/2016 between the hours of 11:00 AM and 12:00 PM, Surveyor #1 observed a carton of eqqs in the reach-in refrigerator that were not pasturized. In an interview with the food service manager (Staff Member #7) Surveyor #1 asked the food service manager how they prepared scramble eggs for patient meals. The food service manager stated in part that the staff would crack multiple eggs into a large bowl (pooling) and then scrambling them for multiple patients. As per food code when using non pastuerized eggs, egg must be combined for one consumer; for one meal and served immediately.

Reference: Washington State Retail Food Code, WAC 246-215-03800 (6)(a)Additional safeguards-Pasteurized foods, prohibited reservice, and prohibited food (2009 FDA Food Code 3-801.11).

2. On 3/9/2016 between the hours of 11:00 AM and 12:00 PM Surveyor #1 observed a kitchen cook (Staff Member #8) performing a glove change after coughing. At the time of the glove change the kitchen cook did not wash hands before donning gloves as required per food code.

Reference: Washington State Retail Food Code, Chapter 246-215-02310 (4) Hands and arms - When to wash (2009 FDA Food Code 2-301.14).

3. On 3/9/2016 between the hours of 11:00 AM and 12:00 PM, Surveyor #1 observed an open beverage container in the designated drink area of the kitchen. To prevent cross contamination, a employee may drink only from a closed beverage container.

Reference: Washington State Retail Food Code, WAC 246-215-02400

ITEM #4 CROSS CONTAMINATION

Based on observation and hospital policy review, the facility failed to prevent cross contamination of medical equipment items in specific circumstances.

Failure to do so placed patients at risk of infection.

Findings:

1. The hospital policy and procedure entitled "Hand Hygiene" (Revised 8/2013) reads: "If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands in all other clinical situations...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

2. On 3/10/2016 at 11:35 AM Surveyor #1 observed a medical assistant (Staff Member #9) reprocessing an endoscope. During the process, surveyor #1 observed a medical assistant cleaning the contaminiated endoscope with gloves on. During this time, she/he continued to touch the operation manual with the contaminated gloves on. After placing the endoscope into the disinfectant solution the medical assistant changed gloves and continued to touch the operations manual thereby contaminating the clean gloves, she/he then preceded to remove the endoscope from the disinfectant solution; changed gloves, and continued to touch the operations manual. After the scope was processed the technician picked up the scope with the contaminated gloves and hung it in the procedure room for the next patient. The facility only had one endoscope.
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3. The hospital's policy and procedure titled, "Cleaning of Patient Care Equipment" (Effective 3/9/2014, Revised 5/2012) stated in part, ". . .D. All medical equipment used for patient care must be cleaned and disinfected using an approved disinfectant or wipes before use on another patient."
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4. On 3/9/2016 at 10:45 AM, Surveyor #2 observed a registered nurse, (Staff Member #1) use a pair of scissors to remove an arm band from Patient #4 prior to discharge. S/he did not wipe the scissors with disinfectant before placing the scissors in his/her uniform pocket thus creating the risk of contamination of their uniform and cross contamination if used on another patient. In a subsequent conversation with the Director of Nursing (Staff Member #3) s/he confirmed that it was an expectation that patient care items be disinfected prior to removal from patient's room.

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Based on observation and review of hospital policies and procedures, the facility failed to ensure that staff followed procedure and appropriately identified patients when distributing oral medication to patients.
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Failure to appropriately identify patients prior to administration of medications places patients at risk for harm and adverse outcomes due to medication errors.
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1. The hospital ' s policy and procedure titled, "Administering Oral Medications" (Effective 5/20/07, Revised 3/22/2014) " . . . Check the patient ' s Identification band, Allergy band, ask the patient his/her name, and ask if patient has any allergies."
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2. On 3/08/16 at 10 AM Surveyor #2 observed a licensed practical nurse (Staff Member #4) administer oral medication to Patient #5. The patient's arm band and allergy band with his/her name and allergies was on the bedside table. Surveyor #2 asked (Staff Member #4) and the Director of Nursing (Staff Member #3) if this was normal process for identifying patients and Staff Member #4 noted that patients were normally identified using their name band or by looking at patient's photo on the medication administration sheet. S/he noted that s/he knew the patient.

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Based on observation, record review and review of Medical Staff Bylaws, the hospital failed to ensure that pre-procedure history and physical was dated when completed for 1 of 2 patient records reviewed.

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Failure to date patient histories and physicals puts patients at risk of not having up to date information regarding their condition available to staff and could lead to inappropriate treatment.
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Based on hospital rules and regulation (Revised 11/05/14, Final 11/2014), "6. A medical history and physical exam will be completed and documented preoperative/pre-procedure by the medical provider no more than 14 days prior to the procedure or surgery."
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2. On 3/10/2016 at 9:00 AM Surveyor #2 reviewed the medical record for (Patient #6) undergoing a esophagogastroduodenoscopy (EGD), a test to examine the lining of the esophagus, stomach and first part of the small intestine, it revealed that the provider (Staff Member #5) had not dated the hand-written pre-procedure history and physical. During a subsequent discussion with the interim Chief Executive Officer (Staff Member #6) on 3/10/2016 at 12:45 PM Surveyor #2 confirmed that dating of history and physicals was an expectation.
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Based on record review and interview, the Critical Access Hospital failed to ensure that there were qualified staff members who were responsible for the activities program for swing bed patients.
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Failure to have qualified staff to develop an activities program and activity plans of care for swing bed patients risks impairment of physical, mental, and psychosocial well-being.
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Findings:
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1. During record review on 3/10/2016 at 2:30 PM Surveyor #2 found no documentation to indicate the assessment, development, or implementation of an activity plan for swing bed patients as follows:
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(Patient #1) admitted on 12/12/15 for skin infection and infected wound, (Patient #2) admitted 4/15/15 with pneumonia and HTN and (Patient #3) admitted on 9/11/15 with excess fluid retention.
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2. On 3/10/2016 at 3:15 PM Surveyor #2 interviewed the Long Term Care Coordinator (Staff #1). S/he confirmed that there were no activity plans documented for Patients #1, #2 or #3. Additionally, s/he stated that there were no qualified staff currently employed who were responsible for developing individualized plans and responsible for monitoring the delivery of activities to swing bed patients.