HospitalInspections.org

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Based on interview and record review the Critical Access Hospital (CAH) failed to ensure that all patient care equipment was maintained in a safe operating condition through the implementation of a system of routine planned preventative maintenance.

Failure on the part of the CAH to perform routine planned preventative maintenance puts patients, staff and visitors of the facility at risk from equipment that is unsafe and/or subject to malfunction when needed or being used.

Findings:

1. On 1/8/2015 between 2:00 and 3:00 PM Surveyor #2 interviewed the stationary engineer (Staff Member #11) who indicated that the CAH's life support equipment was being serviced by Sacred Heart Engineering Services and that the equipment under the Sacred Heart Engineering Services maintenance contract was current for required preventative maintenance. Documentation provided at the time of the interview supported this finding.

2. On 1/8/2015 between 2:00 and 3:00 PM Surveyor #2 was advised by the stationary engineer (Staff Member #11) that certain CAH equipment not under a service contract with Sacred Heart Engineering Services or under contract by the vendors of laboratory and imaging services equipment was not current for preventative maintenance. A spreadsheet was presented to the surveyor showing that numerous pieces of equipment had not been serviced on time. Examples include but are not limited to the following types of equipment and last service date: diathermy (6/22/2013), suction pumps (10/3/2013), drainage pumps (10/3/2013), exam lights (5/15/2013), cauterizer (3/19/2013), beds (7/15/2013), transport incubator (5/23/2013), exam tables (2/7/2013), humidifiers (12/2/2013), EKG/BP monitors 3/19/2013), thermometers (10/2/2013), pulse oximeter (12/2/2013) and surgery light (3/19/2013).

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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 on review of policy and procedure and record review, the facility failed to demonstrate that it implemented the least restrictive intervention to protect patient safety during restraint use.

Failure to do so creates risk that patients may be subjected to forms of constraint, not indicated by their condition, and creates a further risk for related injury. It may also create a barrier to restraint removal at the earliest possible time.

Reference: WAC 246-320-226 Patient care services. Hospitals must:(3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address:(f)Use of physical and chemical restraints or seclusion consistent with CFR 42.482

CFR 42.482.13 (e) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal
punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. (3) The type of restraint...used must be the least restrictive intervention that will effective to protect the patient...from harm.

Findings:
1.Upon review of facility document titled, "Restraint" (revised 3/20/13), under section "F. PATIENT MONITORING" and "G.DOCUMENTATION" it did not provide information about ongoing assessment for the use of the least restrictive form of restraints. The section on monitoring focused on assessing for types of injury.

Additionally, the facility documentation form titled, "RESTRAINT ASSESSMENT" did not include a means for staff to indicate that the least restrictive manner of restraint was employed.

A review of the document titled "2014 Patient Restraint Competency" included a competency for "Reassessed need for continued use of restraint." However, it did not include a competency item for assessing for use of the least restrictive form of restraint.

2. The medical record of Patient #1 was reviewed and indicated that the patient was admitted through the emergency room with alcohol related agitation that did not respond to medication on 1/19/2014. The patient was placed in 4 point leather restraints at 2:50 AM. Then at 5:30 AM, the right arm and left leg leather restraints were removed and subsequently at 6:30 AM the left arm and right leg leather restraints were removed. Later that day at 10:00 AM leather restraints were placed on the right leg and right arm and they were both removed at 11:52 AM.

There was documentation at 5:30 AM that the patient was "Resting with eyes closed", at 9:00 AM that the patient was sleeping and at 10:00 AM that the patient was "rousable."

Documentation in the record was not present to indicate the least restrictive form of restraint (soft restraints or other restraint types) was employed in justification of leather restraints.
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Based on observation, interview and review of policy and procedure, the facility failed to demonstrate that it secured medications located in the trauma room from public access.

Failure to do creates risk the quality of emergency patient care items may not be maintained to manufacturer's standard and immediately avaialble for patient care.

Findings:

1.During a tour of the Emergency Department on 1/10/2015 at 9:45 AM it was noted that the trauma room was located outside of the main portion of the Emergency Department and across a public hallway. The main door to the trauma room was unsecured and located next to an unsecured entrance/exit door to the outside of the facility. A crash cart (containing emergency medications among other supplies) was located inside the trauma room with an easily breakable plastic lock on it. In a nearby unsecured cupboard, the stock of sterile intravenous solutions was located.

2. At the above date and time during an interview with the Director of the Pharmacy (Staff Member #4) and the Nursing Director (Staff Member #5 ), they indicated that consideration had not been given to the security of items in the room and acknowledged that the trauma room was occupied infrequently by staff members. They also acknowledged that the trauma room was outside of the regular purview of staff and that staff were not assigned to fully monitor security cameras located in the area.

3. In review of policy and procedure titled, "All Unit Inspection" (revised 10/2012), "Emergency Carts" (reviewed 12/2012) , "Emergency Department Drug Supply" (reviewed 12/12) and "Floor Stock" (reviewed and revised 12/2012) did not address the security of rooms or the environment that contained emergency patient care items.

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Based on observation, document review and interview, the facility failed to implement reporting of a patient care incident that may have, but did not, result in harm.

Failure to do so creates risk that potentially unsafe events will not be fully addressed that may impact the quality of services delivered .

Findings:

1. In review of facility policy titled, "Safe Medication Practices" (revised 11/16/2011) under the section "Right Medication" it stated, "Read label in good light and make sure it matches the medication order. Read the label again before measuring."

2.On 1/6/2015 at 4:00 PM, Surveyor #1 observed a RN (Staff Member #7) attempt to administer medication to Patient #4. The patient required intravenous antibiotic treatment for a kidney infection. When the RN scanned the medication and the patient's identification arm band, s/he received a warning error message.

Then she proceeded to the pharmacy and discussed the situation with the Director of Pharmacy (Staff Member #4). At that point, it was identified that the product dispensed by pharmacy staff that the RN attempted to administer was prescribed for a different patient (already discharged) and was a different type of intravenous antibiotic.

3. On the following day at 4:30 PM the Director of Nursing (Staff Member #5) was asked if an unusual incident report was completed about the incident that had occurred the prior day. S/he stated that one had not been completed.

4. On 1/8/2014 at 1:30 PM the Quality Coordinator (Staff Member # 6) verified that there was not a facility policy and procedure to direct staff about identifying and reporting an unusual incident (whether or not the patient was harmed.) However, a policy was under development.

The "Employee Manual" (revised 05/2014) contained information about completing incident reports. Under section F. it stated, "Each employee will: 1. Report all incidents and/or injuries to a supervisor immediately and complete the WSHA Employee report of Incident form or the QA memo form as appropriate."

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Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure the control of potential infections by implementing recognized standards and practices of prevention.

Failure on the part of the CAH to implement recognized infection control standards and practices puts patients at risk for nosocomial infection.

References:

Flash sterilization-Steam sterilization of patient care items for immediate use, ANSI/AAMI ST37:1996;
Okanogan Douglas District Hospital policy titled: Flash Sterilization, Effective Date: 5/1/2004

Findings:

Item #1- Sterilization of Instruments - Non-Emergent Immediate Use Sterilization

1. On 1/7/2015 and 1/8/2015 Surveyor #2 reviewed sterilization logs (Autoclave Control Record) that are kept for sterilization procedures performed by staff of the surgical team. During the course of the review the surveyor noted the following issues:


a. Incomplete log entries were noted in the "Autoclave Control Record". As examples "Patient Label" (identifier) entries were missing in the Autoclave Control Record on 12/28/2014. And, a "Content (instrument description)" entry was missing on 12/12/2014.

b. A review of the "Autoclave Control Record" showed that surgical hand-sets were subjected to immediate use sterilization on more than one occasion on 10/23/2014. According to Staff Member #12 this was because the Critical Access Hospital has too few of the hand-sets available.

c. A review of the "Autoclave Control Record" showed that "Arthro" sets were subjected to immediate use sterilization on more than one occasion on 10/31/2014.

Item #2 - Environmental Infection Controls
Reference:CDC Guidelines for Environmental Infection Control in Health Care Facilities, June 6, 2003.

Findings:

1. On 1/7/2015 at 10:30 AM Surveyor #2 observed that a junction box in the wall of the Central Sterile clean area was exposed creating the potential for dust and debris from the interior wall spaces to infiltrate the clean area.


2. On 1/7/2015 at 12:45 PM Surveyor #2 observed the turnover (environmental cleaning) of an operating room in which a surgical case had just been completed. At that time it was noted that the mattress pad on the operating table had a long tear on its bottom surface rendering it uncleanable and a potential harbinger for pathogens. It is the recommendation of the CDC that torn mattress covers be replaced.

3. On 1/7/2015 at 12:50 PM Surveyor #2 observed Staff Member #1 performing an operating room turnover. At the time of the observation the staff member was using a disinfectant soaked rag to wipe down environmental surfaces. During this act the rag being used was dropped on the floor, picked up and then used to wipe down another environmental surface of the operating room (a step stool).


4. On 1/7/2015 at 1:00 PM Surveyor #2 noted that the double sink being used to mix ZolvStat an enzymatic cleaner was not graduated so as to allow for an accurate/proper mixed cleanser to water ratio meeting the manufacturer's directions for use (DFU). It was also noted that the only means of determining the amount of cleaner being used was to approximate the amount of cleaner being dispensed with each depression of the pump provided on the product container. A graduated measuring vessel was not readily available for accurately determining the amount of cleaner being used.

At the time of this finding it was noted by the surveyor that a second enzymatic cleaner (Klenzymes) was available for use. The DFU's for both ZolvStat and Klenzymes have similar but not identical mixing directions which if not followed could affect the effectiveness of the respective product being employed for the cleaning of surgical instruments.


5. On 1/8/2015 at 3:42 PM Surveyor #2 noted that pill cups staged on the medication carts in the hall across from the nurses ' station were subject to cross contamination. More specifically, the cups on medication cart #2 were not being stored inverted and they were in close proximity to a sharps disposal container affixed to the back of the medication cart. The pill cups being staged on medication cart #1 also were not inverted subjecting them to cross contamination.

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Based on observation the Critical Access Hospital failed to implement policies and procedures to ensure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC).

Failure on the part of the CAH to comply with the food service codes puts patients, staff and visitors of the facility at risk of food borne illness.

References:

Washington State Retail Food Code Working Document; Part 3: Food; Subpart E- Limitation of Growth of Organisms of Public Health Concern; 03525 (1)(b) Temperature and time control - Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16) etal

Findings:

1. On 1/8/2015 at 11:50 AM, Surveyor #2 used a thin stem digital thermometer to check the cold holding temperature of a sandwich being made available for service. The sandwich was one of two being kept under refrigeration in a serving pan on the self service line. The internal temperature of the sandwich was recorded as being 46 degrees F.
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Based on interview, the facility failed to implement a process to evaluate all services provided through arrangement or agreement.

Failure to do so creates risk that substandard contract services may be provided to patients.

Findings:

On 1/5/2015 at 9:00 AM, Surveyor #1 interviewed the Chief Operating Officer (Staff Member #6) about the process for service contract evaluation. S/he stated that there was not a current system in place. In the past the facility utilized a form titled, "Contract Services Evaluation" but that form had ceased to be operational for over 1 year.

Additionally, there was not a system to evaluate contract services provided by the clincal dietician (Staff Member #10) annually.

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Based on review of policy and procedure and record review, the facility failed to ensure staff adherance to clincial standards during blood product administration.

Failure to do so creates a risk that a patient may have adverse health outcomes as result of substandard care.

Findings:

1.Upon review of policy and procedure titled, "Blood and Blood Components, Administration of" (revised 07/30/12) on page 2 and under item E. it stated "a full set of vital signs ...shall be taken prior to infusion, 15 minutes after infusion [initiated] and q [every] 1 hour until transfusion is done "

2. Review of Patient #2's medical record indicated that the patient required blood transfusions following a spontaneous vaginal delivery. The blood was started at 10:50 AM on 7/8/2014. Subsequently, another intravenous line (in the hand) was started and the blood transfusion resumed at 11:55 am after administration at the first site.

A set of vital signs was obtained at 12:10 PM and one hour vital signs were obtained at 1:07 PM. The record indicated that the infusion was stopped at 3:00 PM and a set of post-transfusion vital signs were obtained at that time. A set of vital signs was not recorded in the medical record between 1:00 and 3:00 PM while the patient received blood products.

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Based on document review and review of policy and procedure, the facility failed to ensure that health care policies were reviewed and revised (as needed) on an annual basis.

Failure to do so creates risk that staff will not be able to reference up-to-date information to administer patient care and patients may receive care that is not up to current standards.

Findings:

1.On 1/8/2014 at 10:30 AM during a discussion with the Quality Coordinator (Staff Member #3) and Surveyor #2, the staff member indicated that there was no active process for reviewing health care policies on an annual basis and that a process had not been in place for at least one year.

2. During document review the following policies were last reviewed by the facility on the dates indicated:
Infection Control for Central Service-6/14/2004; Flash Sterilzation-6/14/2004; Steam Sterilization-6/10/2004; Blood & Blood Components Administration-7/30/12.
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Based on review of policy and procedure, record review and interview, the facility failed to demonstrate that it notified residents and patients in writing of the plan for discharge or transfer for 2 of 2 residents.

Failure to do so may result in residents and patients being discharged from the facility without sufficient information to exercise their rights including, but not limited to, contesting the plan.

Findings:

1. Upon review of facility policy titled, "Swingbed" (revised 05/06/2013) on page 3, under item 13.b. it stated, "The hospital must notify patient and a family member, legal representative of transfer or discharge and reason for move, written in a language patient understands."

2. During record review the following residents' records were found not to contain a written patient notice of discharge/transfer:

Patient #5 was 85 years old and admitted to a swing bed after open surgery on 7/8/2014 for a fractured right arm and right leg. There was a discharge planner note in the record indicating that the resident was being transferred to a swing bed at another facility. However, there was no documentation that the patient or a representative had received written notification of the plan prior to discharge.

Patient #6 was 71 year old and had open surgery to repair a right hip fracture on 3/28/2014 after a fall from a ladder. On 4/4/2014 there was a discharge planner note in the record indicating that the resident would be receiving care at a community nursing home upon discharge. However, there was no documentation that the patient or a representative had received written notification of the plan prior to discharge.

3. On 1/08/2015 during an interview between Surveyor #1 and the Discharge Planner (Staff Member #8), the staff member stated that s/he was not aware of the need to provide patients with written notice of the discharge or transfer plan. S/he acknowledged that written notification had not been occurring within designated time frames (within 30 days or as soon as practicable before transfer or discharge), especially for patients that were discharged to locations other than home.

THIS IS A REPEAT CITATION FROM 2011.