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Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 11/30/2010 - 12/2/2010.

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapters 19.2.9 and 7.9.2.2 Emergency Lighting.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 11/30/2010 - 12/2/2010 (Tag K-0045).

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapter 19.3.2.7.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 11/30/2010 - 12/2/2010 (Tag K-0211).

Based on record review, policy and procedure review, and interview, the hospital failed to follow its policy and procedure for monitoring and documenting restraint use in 1 of 2 records reviewed (Patients #1).

Failure to follow established utilization guidelines for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Use of Restraints" (Effective date: 10/2008) stated that restraints would only be used when less restrictive measures have been determined to be ineffective. The policy stated that "the condition of the patient who is in a restraint or in seclusion must be continually assessed, monitored and reevaluated. A minimum check of every fifteen (15) minutes."

According to the policy, documentation for patients in restraints included the following: Level of restraint, type of restraint, level of awareness, activity, circulation and skin color, respiratory status, vital signs every two hours, fluids offered every 2 hours, elimination every 2 hours, position change every 2 hours, and range of motion for at least five (5) minutes during every hour on mechanical restraints.

2. Review of the records of 2 patients who were restrained during their hospital stay revealed the following:

a. Patient #1 was a 25 year-old patient admitted on 3/15/2010 for a court ordered physical exam (Involuntary Treatment Act evaluation) . Review of the patient's medical record revealed that the patient's wrists and ankles were restrained because the patient was determined to be a danger to self or others. There was no documentation of alternative interventions attempted for Patient #1. The patient was in restraints from 6:30PM to 8:00PM. Review of documentation revealed that the patient's level of activity, level of consciousness, location, level of restraint, and circulation were assessed at 6:30PM, 7:00PM, and 7:30PM. The patient was not assessed every 15 minutes as required by policy.

3. The Director of Nursing Services confirmed that staff had not followed hospital policy for care of patients in restraints..

Based on observation and interview, the facility staff failed to ensure medications were secured according to Board of Pharmacy regulations.

Failure to secure medications from unauthorized individuals jeopardizes medication safety related to theft, tampering and/or diversion.

Reference:

WAC 246-873-050 Absence of a pharmacist. (2) Access to the pharmacy. Whenever a drug is required to treat an immediate need and not available from floor stock when the pharmacy is closed, the drug may be obtained from the pharmacy by a designated registered nurse, who shall be accountable for his/her actions. One registered nurse shall be designated in each hospital shift for removing drugs from the pharmacy.

Findings:

An interview with the hospital pharmacist and director of nursing services on 12/2/2010 revealed that the key to the pharmacy was stored in the Omni-cell (electronic medication dispensing system). All RNs had access to the pharmacy key stored in the Omni-cell. There was not one registered nurse designated for removing drugs from the pharmacy when the pharmacist was not on duty.

Based on observation and interview the facility failed to implement policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC). Failure on the part of the facility to comply with the food service codes puts patients of the facility at risk of food borne illness.

References:

Washington State Retail Food Code Working Document; Chapters 2-301.15 Where to Wash; 2-402.11 Effectiveness; 4-301.16 Designated Food Preparation Sinks; and 4-501.16 Warewashing Sinks, Use Limitation .

Findings include:

1. On 12/1/2010 the surveyor observed that members of the kitchen staff were not wearing hair restraints (hats, nets, etc.) so as to prevent the potential for hair contact with food, clean equipment and or other food service articles. At the time of the observation the surveyor was informed by managerial staff that hair was either pulled back and held in place with the use of clips and/or ties or by the application of hair spray.

2. On 12/1/2010 the surveyor noted that a utility sink located at the end of a stainless steel work station was being used for multiple purposes without benefit of being cleaned and sanitized between activities or it was being used inappropriately per code. During the period of observation the sink was used to stage dirty utensils and kitchen ware, hold a container of liquid sanitizer and wiping cloths, food preparation and handwashing.

Based on observation, interview, and record review, the facility failed to meet certain requirements of the Hospital Pharmacy rules, WAC 246-733.

Failure to do so placed patients at risk for harm related to medication errors.

Reference:

WAC 246-873-080 (6) Medication orders. Drugs are to be dispensed and administered only upon orders of authorized practitioner. A pharmacist shall review the original order or direct copy thereof, prior to dispensing any drug, except for emergency use or as authorized in WAC 246-873-050.

WAC 246-873-090 (1) Administration of drugs. Drugs shall be administered only upon the order of a practitioner who has been granted clinical privileges to write such orders. Verbal orders for drugs shall only be issued in emergency or unusual circumstances and shall be accepted only by a licensed nurse, pharmacist, or physician, and shall be immediately recorded and signed by the person receiving the order. Such orders shall be authenticated by the prescribing practitioner within 48 hours.

Findings:

1. Review of the medical records of 6 surgical patients and 6 Emergency Department patients for medication orders revealed the following:

Five of 6 surgical patients had a pre-printed order form entitled "Recovery Room Orders" that were signed by the registered nurses (RN) but were not signed by the ordering physicians (Patient #2, #3, #4, #5, #6).

One of 6 surgical patients had a pre-printed order entitled "Perioperative Physician's Order" that was not signed by the ordering physician (Patient #4).

The Emergency Department used a form entitled "Emergency/Miscellaneous Outpatient Record" that contained documentation of physician orders and nursing assessments, interventions, and medication administration. The form served as the physician's order and was supposed to be signed by the ordering physician as well as the RN. Review of 6 medical records for physician's signature on the "Emergency/Miscellaneous Outpatient Record" found that 2 of 6 forms were not signed by the ordering physician (Patient #7, #8).

Patient #3 was a 7 year-old patient admitted on 10/6/2010 for surgical removal of tonsils and adenoids. In the recovery room the patient was given Fentanyl 1 ml. at 10:55AM. There was no physician ' s order for the medication.

2. The above findings were reviewed with the director of nursing services (DNS) on 12/2/2010. The DNS stated that the physicians and staff had not followed hospital policy for medication ordering and administration.

Based on observation and interview, the hospital failed to maintain confidentiality of health information for patients enrolled in the Physical therapy "Fit for Life program."

Failure to secure patient care files places patients at risk for portability/loss, destruction or unauthorized use by the general public and/or breach of patient confidentiality.

Findings:

On 11/30/2010 during a tour of the hospital's physical therapy area, surveyor #17188 observed patient care information in files hanging in a public hallway. According to the director of nursing services, the files belonged to former physical therapy patients who were participating in the hospital's Fit for Life program. Some of the files contained confidential patient information. An interview with the director of nursing services revealed that the files were placed in the hallway for access by patients participating in the program. The director of nursing services had all patient personal health information removed from the files following discovery of the information in the Fit for Life program files.