HospitalInspections.org

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Based on interview and document review, the critical access hospital failed to conduct internal reviews and quality monitoring regarding performance of privileges for telemedicine physician contractors.

Failure to conduct internal reviews and quality monitoring regarding telemedicine physician performance of privileges, puts patients at risk of receiving poor quality of care and adverse patient outcomes.

Findings included:

1. Review of the critical access hospital's document titled, "First Amendment to Remote Acute Telemedicine Service Agreement," effective date 12/23/2011, showed that for each physician providing services to the critical access hospital the critical access hospital agreed to conduct an annual internal review regarding the physician's performance of privileges at the hospital including all related adverse events and patient complaints.

2. On 04/20/18 from 8:40 AM to 10:15 AM, Surveyor #5, a medical staff office assistant (Staff #510), and the Chief Quality/Transformation Officer (Staff #503) reviewed the credentialing file for a distant site telemedicine physician credentialed for the critical access hospital's tele-stroke program (Staff #511). Surveyor #5 found no evidence the critical access hospital conducted an internal review or conducted quality monitoring of adverse events or patient complaints for the distant-site tele-stroke physician's performance of privileges.

-At the time of the review, the Chief of Quality/Transformation (Staff #503) confirmed the finding and stated that the information might be located in the tele-stroke program files.

3. On 04/20/18 at 11:30 AM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the critical access hospital's tele-stroke program files. Surveyor #5 found no evidence the critical access hospital conducted internal reviews or conducted quality monitoring of adverse events or patient complaints for the distant-site telemedicine physician's performance of privileges.

-At the time of the review, the Chief Nursing Officer (Staff #501) confirmed the finding and stated that the information might be located on the manager's electronic file but, they did not have access to the files at this time.

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Based on observation and interview, the critical access hospital failed to reprocess and store semi-critical equipment according to acceptable standards of practice in 2 of 2 emergency carts inspected.

Failure to properly reprocess and store semi-critical devices risks contamination with microorganisms and places patients at risk for infection.

Reference: Centers for Disease Control and Prevention. "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008".

Findings included:

1. On 04/17/18 at 10:07 AM, Surveyor #5 inspected 2 carts containing emergency equipment and supplies located on the medical/surgical unit. Surveyor #5 observed:

a. Six laryngoscope blades in the adult emergency cart that were commingled with other supplies and did not have the required protective packaging to ensure protection from sources of contamination.

b. Six laryngoscope blades in the pediatric emergency cart that were commingled with other supplies and did not have the required protective packaging to ensure protection from sources of contamination.

2. At the time of the observation, the Chief Nursing Officer (Staff #501) confirmed that the blades were improperly stored and stated that all emergency carts in the hospital were standardized so the finding would be the same in all emergency carts.

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Based on observation and interview, the critical access hospital failed to maintain smooth, non-absorbent, and easily cleanable interior surfaces and finishes in 2 of 2 operating rooms observed (OR #1, #2).

Failure to provide non-absorbent, cleanable interior surfaces places patients and staff at increased risk of exposure to harmful microorganisms.

Findings included:

1. On 04/18/18 between 10:10 AM and 10:45 AM, Surveyor #6 and the Environmental Services Manager (Staff #605) observed a turnover cleaning of operating room (OR) #1. Surveyor #6 observed that the double doors leading to the sterile core had areas of wear and gouging that exposed bare wood surfaces. Bare wood is absorbent, not smooth or cleanable.

2. On 04/18/18 between 4:40 PM and 6:50 PM, Surveyor #6 and Staff #605 observed a terminal cleaning of OR #2. Surveyor #6 observed penetrations in areas on 3 walls, peeling paint on the walls and around window frames. There were gouges and areas of wear that exposed bare wood surfaces on the double doors. Penetrations in wall surfaces and peeling paint are not cleanable surfaces.

3. On 04/18/18 at 6:50 PM, Surveyor #6 interviewed Staff #605 about the physical environment condition and maintenance of the ORs. Staff #605 acknowledged the finding and stated that since the room is larger, OR#2 gets more use than OR #1 and is therefore more difficult to maintain non-absorbent and easily cleanable surfaces.

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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 included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.


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Based on interview, review of the critical access hospital's quality improvement committee documentation, and review of the governing board meeting minutes, the critical access hospital's governing board failed to ensure annual evaluation and approval of the quality program and safety plan as required.

Failure of the critical access hospital's governing board to approve quality and safety goals and outcomes and perform an annual program evaluation impairs the hospital's ability to determine if utilization of services was appropriate, that established policies were followed, and if any changes to the critical access hospital's program were needed to improve the quality of healthcare it provides to patients.

Findings included:

1. Review of the critical access hospital's document titled, "Bylaws of Whidbey Island Public Hospital District Island County Washington," revised 10/12/15, showed that the critical access hospital's quality and patient safety plans goals and outcomes are to be approved by the Board of Commissioners, and that the director of quality will present to the governing board, at least annually, the operations and the outcomes of the plan.

-Review of the critical access hospital's document titled, "Plan for Provision of Patient Care and Scope of Services," effective date 07/25/14, showed that outcomes of quality improvement activities and safety initiatives from each patient care department are reported to the chief nurse executive and director of quality who summarize the information in a report to the quality improvement committee, the administrative team, and to the Board of Commissioners.

2. On 04/20/18 at 10:15 AM, Surveyor #5 reviewed the critical access hospital's Board of Commissioners meeting minutes for 2017 and 2018 year to date. The review showed:

-No evidence the critical access hospital's Board of Commissioners approved the quality and patient safety plan goals for 2017 or 2018.

-No evidence the critical access hospital's Board of Commissioners approved the quality and patient safety plan outcomes for 2016 or 2017.

-No evidence the quality improvement director presented an annual review including operations and outcomes of the critical access hospital's quality and patient safety plan to the Board of Commissioners for 2016 or 2017.

3. At the time of the review, The Chief Quality Officer (Staff #503) and the Chief Nursing Officer (Staff #501) acknowledged the finding and were unable to locate documentation in the Board of Commissioners minutes that showed approval of the critical access hospital's quality and safety plans for 2017 or 2018, or an annual review of the quality and safety plans operations and outcomes for 2016 or 2017.


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Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that medications were stored in accordance with the manufacturer's directions for use for 2 of 2 medications observed.

Failure to store medications in accordance with the manufacturer's directions for use risks administration of medications that are ineffective and harmful to patients.

Reference:

Quelicin (Trademark): Food and Drug Administration (FDA) Package Insert and Label Information by Hospira, Inc., revised 04/18. Quelicin (Trademark) (Succinylcholine Chloride Injection, USP): Store in refrigerator 2° to 8°C (36° to 46°F). The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency.

Findings included:

1. On 04/18/18 at 8:50 AM, Surveyor #5 inspected an anesthesia cart located in operating room #1. The anesthesia cart contained two unrefrigerated vials of Succinylcholine. One vial was dated 04/17/18 and the other vial was dated 05/16/18.

2. At the time of the observation, the Certified Registered Nurse Anesthetist (CRNA) (Staff #504) stated that the boxes containing anesthesia medications were picked up and returned to pharmacy each day and that pharmacy was responsible for stocking the medications in the anesthesia boxes. She stated that the Succinylcholine was good for 30 days at room temperature.

3. On 04/18/18 at 1:20 PM, Surveyor #5 interviewed a pharmacist (Staff #505) and a pharmacy technician (Staff #506) about the finding above. Staff #506 stated that the Succinylcholine was good for 30 days at room temperature and that the pharmacy dated the room temperature bottles with a 30 day expiration date. Staff #505 agreed with these statements and verified the pharmacy's process. At this time Surveyor #5, Staff #505, and Staff #506 reviewed the package insert for the medication. Staff #505, and Staff #506 verified the vials had not been stored in accordance with the manufacturer's directions for use. The Chief Nursing Officer (Staff #501) confirmed the vials had not been stored in accordance with the manufacturer's directions for use and directed the pharmacy technician to store the Succinylcholine under refrigeration.


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ITEM #1 CROSS CONTAMINATION DURING CLEANING PROCEDURES

Based on observation, document review, and interview, the Critical Access Hospital failed to ensure that staff used effective procedures to prevent transfer of contamination in 3 of 3 cleaning procedures observed.

Failure to prevent cross contamination places patients, staff, and visitors at increased risk of exposure to harmful microorganisms.

Findings included:

1. Document review of the hospital's undated policies titled, "Operating Room Turnover Cleaning" and "Operating Room Terminal Cleaning," showed that Environmental Services and Surgical Services staff are to change disinfectant cleaning cloths (microfiber towels) frequently throughout the cleaning procedure and whenever the cloth touches the floor.

2. On 04/17/18 and 04/18/18, Surveyor #6 and the Environmental Services Manager (Staff #605) observed a patient room discharge cleaning, an operating room (OR) turnover cleaning, and an OR terminal cleaning by staff from environmental services and surgical services. Surveyor #6 made the following observations:

a. On 04/17/18 between 4:25 PM and 5:20 PM, environmental services staff (Staff #603 and Staff # 604) performed a discharge cleaning of patient room #2307. During the cleaning process, the staff members used cleaning cloths to disinfect equipment and furniture (IV poles, workstation on wheels, over-bed table, chairs, etc.) wiping the bases, legs, and wheels. Staff #603 and #604 allowed their cloths to touch the floor and used the now contaminated cloths to re-wipe the bases of the equipment and furniture.

b. On 04/18/18 between 10:10 AM and 10:45 AM, an operating room assistant (Staff #606) performed a turnover cleaning of operating room (OR) #1. During the cleaning process, Staff #606 used cleaning cloths to disinfect patient care and procedure equipment (IV poles, workstation on wheels, instrument tray stands, rolling tables, etc.), wiping the bases, legs, and wheels. Staff #606 allowed the cloths to touch the floor and then used the now contaminated cloths to re-wipe the bases of the patient care and procedure equipment.

c. On 04/18/18 between 4:40 PM and 6:50 PM, an environmental services technician (Staff #607) performed a terminal cleaning of OR #2. During the cleaning process, Staff #607 used cleaning cloths to disinfect patient care and procedure equipment (IV poles, workstation on wheels, instrument tray stands, rolling tables, etc.), wiping the bases, legs, and wheels. Staff #607 allowed the cloths to touch the floor and then used the now contaminated cloths to re-wipe the bases of the patient care and procedure equipment.

3. On 4/18/18 at 6:50 PM, Surveyor #6 interviewed the Environmental Services Manager (Staff #605) about the hospital's cleaning procedures. Staff #605 stated that the floor is always contaminated and that staff are expected to change their disinfectant cloth if it touches the floor.

ITEM #2 - FLEXIBLE ENDOSCOPE REPROCESSING PROCEDURES

Based on observation, document review, and interview, the critical access hospital failed to ensure that flexible endoscopes are immersed in high-level disinfectant during manual cleaning as directed by hospital policy and manufacturer's guidance.

Failure to adhere to accepted endoscope reprocessing procedures places patients and staff at risk from infections caused by improper high-level disinfection of endoscopes.

References: CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (last update 02/15/17); "C. Recommendations, 7. High-Level Disinfection of Endoscopes, s. Completely immerse the endoscope in the high-level disinfectant, and ensure all channels are perfused. ..."

Findings included:

1. Document review of the hospital's undated policy titled, "Flexible Endoscope - High Level Disinfection," showed that staff who reprocess flexible endoscopes are to "Completely submerge the endoscope in the cleaning solution during the cleaning process (Manual Cleaning Step #8)."

Document review of the endoscope manufacturer's instructions, "PENTAX Medical Optimized Manual Cleaning instructions (posted above the endoscope reprocessing station) showed Step 2. Endoscope Cleaning, c. While still immersed in detergent solution, wash the entire surface of the endoscope..."

2. On 04/18/18 between 8:35 AM and 9:10 AM, Surveyor #6 and the Perioperative Supervisor (Staff #610) observed a surgical tech (Staff #608) reprocess a flexible endoscope (PENTAX model EG29-i10). After initially immersing the endoscope in Endozime solution (a high-level disinfectant) during the manual cleaning process, Staff #608 held the endoscope above the level of the cleaning solution to wipe the exterior surface, and then pass a cleaning brush through the interior channels.

3. On 04/18/18 at 9:10 AM, Surveyor #6 interviewed the Surgical Tech (Staff #608), the Chief Nursing Officer (Staff #609), and the Perioperative Supervisor (Staff #610) about the endoscope reprocessing procedures. Staff #608 stated that it was difficult to keep the scope submerged because the sink basin wasn't very deep.


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Based on interview and document review, the critical access hospital failed to routinely inspect patient protective shielding (lead aprons) in all areas of diagnostic imaging services.

Failure to routinely inspect and maintain protective shielding risks insufficient radiation protection and puts patients at increased risk from exposure to harmful levels of ionizing radiation.

Findings included:

1. On 04/17/18 at 11:20 AM, Surveyor #6 interviewed a radiology technologist (Staff #601) about preventive maintenance of radiologic equipment, including lead shields, at the Goldie Street clinic. Staff #601 stated the lead shields at the clinic were included in the main hospital's inventory and audited annually at the hospital. She stated that the maintenance records were kept at the main hospital.

2. On 04/18/18 at 3:30 PM, Surveyor #6 interviewed the Diagnostic Imaging Manager (Staff #602), about preventive maintenance of radiologic equipment, including lead shields at all hospital imaging locations. Staff #602 stated that the lead shields at the main hospital campus were audited annually but that he was not certain whether the inventory included the lead shields at the Goldie Street clinic.

3. On 04/19/18, Staff #602 provided a memo to Surveyor #6 confirming that the hospital's lead shield inventory did not include those used at the Goldie Street clinic and therefore they had not been audited/reviewed as part of the hospital process.

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Based on interview, record review, and review of the critical access hospital's policy and procedure, the critical access hospital failed to adequately monitor 1 of 1 patient's identified at risk for suicide (Patient #506).

Failure to adequately monitor patients identified at risk for suicide risks serious injury or death of patients.

Findings included:

1. Document review of the critical access hospital's policy and procedure titled, "Suicide Precautions-Implementation," no policy number effective date 02/12/18, showed that patients assessed at risk for suicide require 1:1 bedside observation with documentation of safety every 15 minutes, that potentially harmful objects be removed from the room, that a sign be placed on the door for visitors to check in with the nurse, and development of an individualized plan to keep the patient safe.

2. On 04/18/18 at 11:30 AM, Surveyor #5 and a registered nurse (Staff #509) reviewed the medical record of Patient #506, who was admitted to the emergency department on 04/17/18 at 5:20 PM for the treatment of chest pain. The medical record review showed:

-On 04/17/18 at 6:45 PM, the emergency department physician (Staff #512) reassessed the patient for discharge. At this time, the patient stated she was suicidal and if she was discharged, she would attempt suicide at home by cutting her wrists. Further assessment showed that the patient had a history of suicide attempts, self-mutilation, and was currently experiencing significant emotional distress. At the time of the review, the patient was waiting for assessment by a mental health professional. Surveyor #5 found no evidence the patient was placed on suicide precautions and no evidence suicide ideation or risk of self-harm had been added to the patient's plan of care.

3. At the time of the review, the registered nurse (Staff #512) verified that the patient had not been placed on suicide precautions and stated that the patient should have been placed on suicide precautions and the plan of care updated.

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ITEM #1 PAIN REASSESSMENT

Based on record review, interview, and review of policy and procedure, the critical access hospital failed to ensure staff members completed and documented pain reassessments after each pain management intervention for 3 of 3 patient records reviewed (Patient #501, #502, #503).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain.

Findings included:

1. Review of the critical access hospital's policy and procedure titled, "Whidbey Health Lippincott Procedures- Pain Management," no policy number, revised 11/16/17, showed that nursing staff must reassess and respond to a patient's pain by evaluating the response to treatment and progress toward pain management goals.

Review of the critical access hospital's policy and procedure titled, "Whidbey Health Lippincott Procedures- Safe Medication Administration Practices-General," no policy number, revised 11/16/17, showed that nursing staff must monitor and document the effectiveness of all medications.

2. On 04/17/18 at 10:49 AM, Surveyor #5 and a registered nurse (Staff #507) reviewed the medical record of Patient #501 who was admitted for the treatment of urinary tract infection, altered mental status and possible stroke. The record review showed:

-The patient was administered intravenous (IV) Morphine (a pain medication) for severe pain on 04/14/18 at 1:21 AM, on 04/14/18 at 7:17 PM, and on 04/16/18 at 5:44 AM. Surveyor #5 found no documentation in the medical record that the patient's pain had been reassessed after the medication administrations.

-At the time of the observation, the registered nurse (Staff #507) confirmed the finding and stated that the patient's pain should have been reassessed after the medication administrations.

3. On 04/17/18 at 2:43 PM, Surveyor #5 and a registered nurse (Staff #508) reviewed the medical record of Patient #502 who was admitted for the treatment of bronchitis, severe cough, and dehydration. The patient was administered Oxycodone 5mg (a pain medication) by mouth for severe pain on 04/17/18 at 5:03 AM. Surveyor #5 found no documentation in the medical record that the patient's pain had been reassessed after the medication administration.

-At the time of the observation, the registered nurse (Staff #508) confirmed the finding and stated that the effectiveness of the pain medication should have been reassessed.

4. On 04/18/18 at 11:09 AM, Surveyor #5 and a registered nurse (Staff #509) reviewed the medical record of Patient #503 who was admitted to the Emergency Department following a fall from a roof. The patient was administered intravenous (IV) Acetaminophen 1,000 mg for moderate pain on 04/18/18 at 9:17 AM. Surveyor #5 found no documentation in the medical record that the patient's pain had been reassessed after the medication administration.

-At the time of the observation, the registered nurse (Staff #509) confirmed the finding and stated that the patient's pain level should have been reassessed.


ITEM #2 SUICIDE RISK ASSESSMENT
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Based on interview, record review, and review of policy and procedure and the critical access hospital failed to ensure that patients received a suicide risk assessment as directed by hospital policy and procedure for 8 of 8 medical records reviewed (Patients #501, #502, #503, # 504, #505, #506, #507, #508).

Failure to perform a suicide risk assessment risks patients not receiving medical treatment appropriate to their care needs.

Findings included:

1. Review of the critical access hospital's policy and procedure titled, "Suicide Precautions-Implementation," no policy number, effective date 02/12/18, showed that patients located in the intensive care unit, medical/surgical unit, Whidbey family birth place, emergency department and surgical services department must be assessed for suicide lethality using the "Suicide Risk Assessment" and an order must be obtained from the provider for suicide precautions for patients who are considered at high or moderate risk for suicide.

2. On 04/17/18 at 10:49 AM, Surveyor #5 and a registered nurse (Staff #507) reviewed the medical record of Patient #501 who was admitted for the treatment of urinary tract infection, altered mental status and possible stroke. Surveyor #5 found no evidence the patient was assessed for suicide risk. Surveyor #5 found no evidence in the patient's assessment that the "suicide safety check" had been completed. Further review of the "suicide safety check" showed that it only listed suicide precaution interventions and was not a risk assessment.

3. At the time of the review a registered nurse (Staff #507) and the Chief Nursing Officer (Staff #501) confirmed the finding and verified that a suicide risk assessment had not been completed and that the "suicide safety check" listed interventions only. At this same time, Staff #507 and Staff #501 identified that there was no "suicide risk assessment" built into the hospital's electronic medical record documentation system. Staff #501 stated that this was an oversight and she would work with the information technology department to have a risk assessment added.

4. On 04/18/18 at 11:30 AM, Surveyor #5 and a registered nurse (Staff #509) reviewed the medical record of Patient #506, who was admitted to the emergency department on 04/17/18 at 5:20 PM for the treatment of chest pain. The medical record review showed:

-On 04/17/18 at 5:20 PM, a triage assessment was completed at 5:57 PM, the emergency department past medical history assessment was completed. Surveyor #5 found no evidence the patient was assessed for suicide risk during either assessment.

-On 04/17/18 at 6:45 PM, the emergency department physician (Staff #512) reassessed the patient for discharge. At this time, the patient stated she was suicidal and if she was discharged, she would attempt suicide at home by cutting her wrists. Further assessment showed that the patient had a history of suicide attempts, self-mutilation, and was currently experiencing emotional distress. Surveyor #5 found no evidence a suicide risk assessment was completed at this time.

5. At the time of the review, the registered nurse (Staff #512) and the Chief Nursing Officer (Staff #501) verified that a suicide risk assessment had not been completed and identified that a suicide risk assessment was not an assessment option in the hospital's emergency department electronic medical record system.

6. Review of the medical records for patients #502, #503, #504, #505, #507, and #508 showed similar findings.


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Based on interview, record review, and review of policy and procedures, the critical access hospital failed to properly obtain informed consent as directed by the critical access hospital's policy and procedure for 1 of 1 outpatients receiving infusion therapy (Patient #509) in the medical ambulatory care unit.

Failure to properly obtain informed consent risks patients not being fully informed of potential risks.

Findings included:

1. Review of the critical access hospital's policy and procedure titled, "MAC Patient Consents Policy," no policy number, effective date 03/06/17, showed that consent for treatment will be obtained yearly for patients receiving care in the critical access hospital's medical ambulatory care (MAC) unit.

2. On 04/18/18 at 2:25 PM, Surveyor #5 and an advanced registered nurse practitioner (ARNP) (Staff #513) reviewed the medical record for Patient #509 who was receiving an intravenous infusion treatment for Myelodysplastic syndrome (MDS) (a group of cancers in which immature blood cells in the bone marrow do not mature). The record review showed that the patient's consent for treatment was obtained on 06/16/16.

3. At the time of the finding, Staff #513 stated that consents for treatment in the medical ambulatory care (MAC) unit were obtained once at the beginning of treatment and any time the treatment changed.

4. On 04/18/18 at 3:30 PM, Surveyor #5 and the Chief Nursing Officer (Staff #501) reviewed the critical access hospital's consent policy. At that time, Staff #501 confirmed the finding and stated a new consent should have been gotten yearly per the policy.

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