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Based on medical record review and administrative staff interview, the hospital failed to follow the requirements of State law RCW 70.41.350 to ensure that victims of sexual assault were provided medically and factually accurate and unbiased oral information about emergency contraception for 4 of 4 records reviewed (S1-S4).

Failure to ensure that documentation exists that patient's receive required information places these patients at risk of harm related to healthcare decisions that could be made without adequate information.

Findings:

1. Per review of Patient S1's medical record, the patient was seen in the Emergency Department (ED) on 5/1/2010 with a complaint of being sexually assaulted. Per review of ED documentation, no evidence was found that hospital staff had provided the information, per requirements of the WAC.

2. Per review of Patient S2's medical record, the patient was seen in the ED on 5/20/2010 with a complaint of being sexually assaulted. Per review of ED documentation, no evidence was found that hospital staff had provided oral information, per requirements of the WAC.

Based on observation, interview, and record review, the facility failed to implement their policy to provide malignant hyperthermia (MH) services and supplies in the peri-operative area, where triggering agents are used.

Failure to do so places patients at risk of inadequate care in the event of a MH crisis, potentially resulting in permanent disability or death.

Findings:

MH is a rare but life-threatening emergency reaction to general anesthesia. According to the Malignant Hyperthermia Association of the United States (MHAUS) the syndrome must be identified and treated early in its course in order for there to be a successful outcome. MHAUS also specifies that a patient who had undergone a MH crisis should be monitored in a critical care unit for 36 hours following the event, since the symptoms may recur.

During tour of the peri-operative areas on 8/11/10, staff #VS13 identified 5 different triggering agents which were used to anesthetize patients in those areas. The policy "Malignant Hyperthermia" effective date 8/5/05 specified that 36 vials of the medication used to treat a MH crisis (dantrolene) were to be present in the area. Staff #VS14 provided an undated document "MH CART CONTENTS", which confirmed that 36 vials were to be present in the cart. This document also specified that 2 vials of regular insulin were to be present.

Upon opening the cart and examining the contents, it was found that 30, rather than 36 vials of dantrolene were present. One, rather than 2 vials of regular insulin was present. This was confirmed by staff #VS13, who speculated that the drug had become outdated and not yet been replaced.

Further review of the MH policy showed that it specified the patient be monitored in critical care for 24 hours in the post-acute phase, rather than the 36 hours outlined by MHAUS. This observation was confirmed by staff #VS11.

Based on interview the facility failed to have a system in place that would assure the safety of patients, staff and visitors of the facility during non-medical emergencies. More specifically, the facility failed to have a plan in place that would protect vital supplies of emergency fuel and water.

Findings include:

1. On 8/9/2010 and 8/12/2010 during discussions with the Director of Plant Services the surveyor was informed that a needs assessment for fuel and water had not been performed and that no written plan was available specifying how those resources would be prioritized and protected in time of need until adequate supplies of both were available. It was indicated that informal agreements had been made with suppliers but no written agreements had been entered into.

2. On 8/9/2010 the surveyor was informed that a disaster response on the part of the facility would be directed via methodologies of the National Incident Management System (NIMS). As explained NIMS protocols would direct facility activities during an emergency and would be a coordinated effort of various entities both public and private on a regional scale. Because of this it is unknown what priority level the facility would be given in regards to meeting its particular needs for fuel and water.

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 8/9/2010 - 8/12/2010.

Based on interview and record review, the facility failed to accurately implement its policy and procedure for administration of blood and blood products.

Failure to do so places patients at risk for lack of informed consent, and transfusion complications, resulting in discomfort, debility, and potential for death.

Findings:

The surveyor reviewed closed records on 8/11/10 for three former inpatients who had received blood during their admission (patients #P12-P14). Assessment data and other documentation discrepancies from policy were found in all three records.

Staff #VS16 provided the policy and procedure "Blood Products Transfusion" review date 6/11/10 and confirmed that this was the current policy. The policy reads in part:

" [A licensed independent practitioner] or registered nurse will explain to the patient the procedure and obtain a signed Informed Consent for Transfusion of Blood or Blood Products before being placed in the patient ' s chart. "

"Vital signs will be recorded as follows on the Blood Transfusion Record:
A. Baseline vital signs within 5 minutes of the start of the transfusion
B. Repeat vital signs at the first 15 minute interval after the transfusion begins
C. Immediate Post infusion
D. Any other time during the transfusion if signs or symptoms of potential transfusion reaction exist "

" The completed Transfusion Record will be placed in the patient ' s chart under the Laboratory section. "

Review of patient #P13's record revealed no evidence that consent for the transfusion had been obtained. This was confirmed by staff #S16.

Review of patient #P12 ' s record showed that s/he received 7 units of blood. For 2 units, no vital signs were recorded. For another unit, the 15 minute vital signs were not recorded. This patient's transfusion records were otherwise incomplete. The staff verifying the patient identity and blood unit matching data failed to document the transfusion start date once, and failed to document the transfusion start time 3 times. For 1 unit the person ending the transfusion failed to document the time, amount transfused, and his/her signature.

Similar issues were noted with documentation of blood transfusion data for patients #P13 and #P14. These failures were confirmed by staff #VS16.

Based on observation, interview, and document review, the facility failed to store and administer medications in accordance with accepted professional principles and facility policy.

Failure to do so resulted in specific risks. One failed practice placed patients at risk of receiving intravenous (IV) fluids which had degraded, contained bacterial overgrowth, or fluids potentially hot enough to burn. Another failed practice placed patients at risk of medication errors.

Findings:

Part I

Reference from WA State Hospital Pharmacy Rules:
WAC 246-873-070 Physical requirements. (4) Drug storage areas. Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.
During tour of the peri-operative areas on 8/11/10 the surveyor examined a warming cabinet in which IV fluids were stored. The temperature display varied between 106-107 degrees Fahrenheit (F). The policy and procedure posted on the cabinet, "Fluid Warmer-Solution Monitoring" revised 4-10-09 read that IV solutions were not to exceed 104 degrees F. The policy also directed staff to monitor temperature of specific areas daily using a separate thermometer.

The temperature log was reviewed for the current and 7 previous. Temperatures had been documented for the upper part of the warming chamber, plus specific areas on the IV fluid containers. For all of these areas, on only one day was a temperature (the chamber) documented as being 104 degrees F. The fluid container temperatures on that day were documented as 107, 110, and 111 degrees F. Temperatures during this 8 day period were documented as high as 113 degrees F.

Staff #VS14 stated that s/he and the other staff thought there was a +/- 10 degree F. variance allowed in temperature for the fluids; however this was not in policy and there was no documentation found to support this.

On 8/10/10 Surveyor #08982 found fluid warming issues in the C-section area of the Mother-Baby Unit. The surveyor observed a warmer for storing intravenous fluids. The form used by staff to record the internal temperature showed that no temperature reading was conducted on 7/25/10 in the AM and none on 7/28/10 in the PM. Further review of temperature documentation forms from February through June, 2010 showed the following:
? For February, no temperatures were recorded for 15 of 35 opportunities
? For March 21 of 62 opportunities, no temperatures were recorded; also two temperatures recorded were above the manufacturer's identified maximum temperature
? For April 8 of 60 opportunities, no temperatures were recorded; one temperature recorded was above the manufacturer's identified maximum temperature
? For May 13 of 62 opportunities, no temperatures were recorded; one temperature recorded was above the manufacturer's identified maximum temperature
? For June 6 of 60 opportunities, no temperatures were recorded

For both locations in the above situations in which temperatures were documented as being in excess of manufacturer's identified maximum temperature there was no evidence that corrective actions had been taken.

Part II

Reference from WA State Hospital Pharmacy rules:
WAC 246-873-090 Administration of drugs. (2) Administration. Drugs shall be administered only by appropriately licensed personnel in accordance with state and federal laws and regulations governing such acts and in accordance with medical staff approved hospital policy.
On 8/9/10 during survey of the acute care unit, patient #P6 informed the surveyor that when giving medications the staff did not always check his/her armband, nor did they ask the patient's name and another identifier such as birth date, to ensure they had the correct patient.

Staff #VS2 was interviewed on 8/9/10 regarding the medication administration process. When describing patient identification, s/he acknowledged that s/he did not do a complete identification process every time s/he gave a medication, if s/he "knew" the patient. Staff #VS2 stated that if it was a patient new to him/her, s/he would perform a complete identification one time at the beginning of the shift.

On 8/10/10 during tour of the Critical Care Unit the surveyor observed a medication administration episode. Staff #VS8 greeted the patient by his/her first name, rather than querying the patient's name and another identifier. Staff #VS8 did not compare the patient's identifying armband to the medication record, but proceeded to administer the medication to the patient.

The Policy and Procedure "Medication Administration" was presented to the surveyor by staff #VS12 on 8/10/10. It was marked "Draft" with a review date of 3/24/10. On 8/11/10 staff #VS11 confirmed that this policy was in effect house-wide, and that two identifiers were required for every medication administration episode. The policy reads that staff are to "verify medication selected for administration is correct based on ... patient identifiers (patient name, patient ' s date of birth, medical record number, or visit identification number)."

Based on observation and interview, the facility failed to develop, implement, and maintain policies and procedures for specific infection prevention issues.

Failure to do so places patients, staff, and visitors at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.

Findings:

Part I
On 8/9/10 the surveyor interviewed staff #VS4 about the medication administration process. S/he stated that staff brought the patient's medication administration record (MAR) in a plastic binder into the room when giving medications. The purpose was to do a final double-check that the correct medication and dose were being given at the correct time. However, when queried staff #VS4 indicated that s/he hadn't given thought to where the binder was placed in the room, the potential for contamination, and a process for cleaning/sanitizing the binder when removing it from the room.

On 8/10/10 the surveyor observed a medication administration episode by staff #VS8. Staff #VS8 first placed the binder with the MAR on the patient's bed, then moved it to the counter immediately adjacent to the hand sink, which was moist and potentially contaminated. S/he did not clean or sanitize the binder upon removal from the room.

Part II

During a tour of the combined peri-operative and medical outpatient areas on 8/11/10 staff #VS15 described the use of the work stations (computers) on wheels (WOWs). S/he indicated that staff would be making more use of the WOWs in the future, since more of their paper charts were going to be electronic. Since the WOWs would be moving from room to room more often, they were revising the policy for cleaning and sanitizing them. The surveyor noted that staff on that unit commonly carried hand-held electronic devices, such as phones, which were handed off to other staff regularly. Staff #VS15 and #VS14 acknowledged that these items had not been considered for a similar policy.

Part III

During the same tour in Part II above staff #VS14 was observed repeatedly licking his/her finger to turn pages of documents. On 8/11/10 staff VS#1 expressed dismay at the practice, indicating that the facility had done much work directed at this practice, including stocking all areas with rubber page turning devices.

Based on observation and staff 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, staff and visitors of the facility at risk of food borne illness.

References:

Washington State Retail Food Code Working Document; et al

Findings include:

1. On 8/11/2010 the surveyor observed members of the kitchen staff who were not wearing hair restraints so as to prevent the potential for hair contact with food, clean equipment and or other food service articles. Hair was noted to be less than shoulder length for most but not necessarily all kitchen staff members. Kitchen managerial staff indicated to the surveyor that a State Code Clarification from the Department (DOH) indicates that not all hair requires restraint. The facility's policy is reflective of the code clarification document permitting those who have short hair not to wear hair restraints. Based on this fact the surveyor indicated he/she would contact staff in the program that had formulated the code clarification to get an opinion on whether restraints are required.

Subsequent to the survey exit the surveyor consulted with two DOH food program staff who indicated that short hair of the type worn by the kitchen staff would need to be restrained so as to meet the intent of the Food Code Working Document.

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information showing an evaluation of its total program.

Failure to document an evaluation of the total program places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation identified program services being offered to patients, such as: Hospitalist's; Surgical Services; Obstetrical Services; Urgent Care Services; Physical Rehabilitation Services; and Respiratory Care Services. However, the document did not contain an evaluation of any of these services. Per interview with Staff #VS11 on 8/9/2010, it was stated that the program evaluation process had become a one-person responsibility and hospital oversight had been lost.

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information from a representative sample of open and closed patient records.

Failure to document the inclusion of open and closed records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify whether records reviewed were from open of closed patient charts. Per interview with Staff #VS11 on 8/9/2010, it was stated that the record review process was set-up to only have closed records sent to the reviewer. Thus, open records were never reviewed as part of the audit process.

Based on review of hospital provided documents, the hospital failed to take appropriate remedial action to address hand hygiene deficiencies found through the quality assurance program.

Failure to address deficiencies found through the quality assurance program places all patients at risk of harm related to the potential negative outcome associated with uncorrected deficiencies.

Findings:

1. Per review of Infection Control Program documentation, it was noted that the program documented not achieving a "Hand Hygiene" goal for several patient care units over the past 18 months of data collection. The documentation indicated that "Improvement required" and referred to an "action plan". The only "action plan" found was dated July 1, 2009 and indicated that a task force was generated with the resulting corrective action to be re-education and rounding for accountability. The hospital could not provide evidence of a written plan of correction, nor evidence of data collected through "rounding for accountability".
The statistics for the first two quarters of 2010 showed that the hospital was still not meeting its performance goal for hand hygiene. The plan included placing education posters and continuing patient rounds. The last annotation about this issue stated that data collection was continuing. There was no evidence that the hospital's plan had corrected the problem and that actions other than observation and education had been implemented.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents, upon admission and periodically thereafter, about their right to be informed about Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged...

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to personal privacy and confidentiality for his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for a resident.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to refuse to perform services for the facility or perform services for the facility, if he or she chooses, when the facility has documented the need or desire for work in the plan of care.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to privacy in written communications, including the right to send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the resident's own expense.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to and the facility must provide immediate access to any resident by any representative of the Secretary; subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other residents.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.

Based on administrative staff interview and review of medical records, the hospital failed to provide information to residents about their right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

Failure to adequately inform patients of their rights places them at risk of harm related to decisions being made that the patient may not have a clear, and complete understanding of that determine their future health status.

Findings:

Per review of medical records, Patients S1 and S2 were transferred to Swing Bed status on 6/2/2009 and 1/21/2009 respectively. Their records did not contain any evidence that the hospital had provided them with the Federally required patient rights upon admission. Per interview with Staff #VS11 on 8/13/2010, the hospital did not have a process in place to provide a separate set of Resident Rights when patients were transferred to a Swing Bed status.