HospitalInspections.org

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Based on observation and interview, the critical access hospital failed to develop and implement policies and procedures that ensured surgical supplies were within expiration date and ready for use.

Failure to develop and implement policies that ensure safe, usable supplies puts patients at risk of exposure to microorganisms and inadequate or unsafe equipment during an emergency procedure.

Findings:

1. On 3/31/2015 at 8:00 AM, Surveyor #2 observed a surgical procedure in operating room (OR) #3. In OR #3, a surgical suture cabinet contained wrapped boxes of sterile sutures. During a quick inventory, two boxes of Plain cut suture 6-0 and 5-0 expired January 2015. The manager for surgical services (Staff Member #5) immediately removed the boxes of expired suture.

2. On 3/31/2015 at 10:25 AM, Surveyor #2 interviewed Staff Member #5, who confirmed there was no formal procedure for checking sterile material expiration dates in accordance with accepted standards of practice.

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Based on interview and observation the critical access hospital failed to demonstrate a system to assure a maximum capacity of 25 inpatient beds, excluding rooms for patients on observation status.

Failure to identify designated rooms for inpatients creates a risk that the facility will exceed its eligibility capacity for patient care which may result in poor patient outcomes due to inadequate care or poor resource allocation.

Findings:

1. On 3/30/15 at 4:00 PM, Surveyor #1 accompanied by the chief operating officer (Staff Member #2), completed a bed count for the number of inpatient and observation beds available in the hospital. The total number of beds set up for patient use was 32, which exceeded the 25 maximum beds allowed under regulation for a Critical Access Hospital.

2. On 4/1/2015, at 4:45 PM, during a re-check of the medical-surgical department, Surveyor #1 observed placards on individual patient-occupied rooms indicating if the patient was in "observation" or "inpatient" status. However, patient rooms without patients lacked an identifying placard. Under this system, the surveyor was unable to determine the number of beds the hospital designated for inpatients and the number of beds the hospital designated for patients in observation status.

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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to develop and implement a current comprehensive emergency preparedness plan to ensure the safety and well-being of patients during emergency situations and/or events.

Failure to develop and implement a current emergency preparedness plan places the safety of patients, staff, and visitors of the facility at risk during non-medical emergencies.

Findings:

On 3/31/2015 at 2:38 PM, Surveyors #1 and #3 reviewed the hospital's emergency preparedness plan for the year 2013. The plan was not current, was not comprehensive, and it did not contain an assessment of the most likely non-medical emergency events facing the facility and/or immediate area. The plan did not include guidance on how the facility would respond to emergency situations and events identified as the most likely to occur. During concurrent interview with the plant services manager (Staff Member #7), s/he confirmed that the hospital's emergency preparedness plan was not current and did not contain all required information. S/he further indicated that the plan was reviewed in 2013 and is currently being revised.

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Based on observation and interview, the critcal 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 interview, review of documents, deficiencies cited during the current survey and review of previous survey findings, the critical access hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure. The Governing Body failed to ensure that the hospital had an effective Periodic Evaluation and Quality Assurance program , and failed to ensure ongoing compliance with previously cited deficiencies.

Failure to ensure that the hospital meets established organizational structure requirements impairs the hospital's ability to provide quality care in a safe environment.


Cross Reference: Tags C330; C276

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Based on record review and review of Medical Staff Bylaws, the critical access hospital failed to follow its credentialing procedure for medical staff appointments.

Failure to adhere to criteria for medical staff appointments put patients at risk from inadequate or unsafe care.

1. The hospital's Medical Staff Credentialing policy Section C "Verification of Information" read in part: "Representatives of MSS (Medical Staff Services) (Working with the Credentials Committee Chairperson), shall organize and coordinate the collection and verification of information from the following sources:..j. Washington State Patrol...2. Verification shall include: a. Sending a copy of the list of clinical privileges requested by the Applicant to relevant residency and fellowship training programs and to at least his most recent affiliations and request for specific information regarding his training and competence in exercising each of the privileges requested:"


2. On 4/2/2015 at 9:05 AM, Surveyors #1 and #3 reviewed a sample of Medical Staff credentialing files with the manager of medical staff services (Staff Member #6). three of six files were missing the Washington State Patrol background check documentation as required by the hospital policy/procedure for the credentialing process and 2 of 2 practitioners with conscious sedation privileges had no evidence of competency for conscious sedation in the file, as required by the hospital's credentialing policy.

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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.


Failure to assure medication storage areas are void of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, or stability.

Findings:

1 The hospital's policy and procedure entitled, "Multiple Dose Vials" (Effective 02/08/2010, Reviewed 5/2014) read in part as follows: "D. The multi-dose vial will be dated upon initial use and discarded after 28 days if stored under appropriate conditions unless otherwise specified by the manufacturer."

2. On 3/30/2015 at 1:30 PM, during an inspection of the emergency department's automatic medication dispensing machine, Surveyor #2 found an opened multidose vial of Humulin Regular insulin. The used vial had no opened date or expired date marked.

3. An interview on 4/1/2015 at 9:00 AM with Surveyor #2 and the hospital's Director of Pharmacy Services, (Staff Member #4) confirmed that the multi-dose vial should have been marked with the open and expiration date.


THIS IS A REPEAT VIOLATION - PREVIOUSLY CITED UNDER TAG C203, 11/03/2011

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Item #1- Infection Control Program
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Based on interview and document review, the critical access hospital failed to implement a system for reporting, investigating and controlling infections in patients and personnel.

Failure to implement procedures for infectious disease surveillance in patients and staff puts patients, staff and visitors at risk for communicable diseases.

Findings:

1. On 4/1/2015 between 9:00 and 11:00 AM, Surveyors #1 and #3 conducted a review of the hospital's overall infection control program with the manager for quality services and risk management (Staff Member #3). During the course of the program review, the staff member was unable to provide evidence of data collection and analysis consistent with the hospital's 2014 infection control risk assessment plan.

2. On 4/1/2015, between 9:00 and 11:00 AM, Surveyor #1 requested evidence that infection control staff tracked occurences of infectious disease in the patient population. Staff Member #3 was unable to provide information on the number and types of infections present in the inpatient population at the hospital.

Item #2- Employee Health Records

Reference: Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17): 29.

On 4/2/2015, at 10:00 AM, Surveyors #1 and #3 reviewed employee health records for 4 hospital employees including one contracted employee. Information in the contracted employee's health record contained only a single Mantoux tuberculin skin test (TST), and no indication the employee had a previously documented TST within the previous 12 months.




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Item #3 - Disinfection and Sterilization of Medical Equipment

Based on observation, interview, and document review, the critical access hospital failed to implement policies and procedures designed to prevent exposure to infectious agents during the processing of medical equipment.

Failure to adhere to the manufacturer's guidelines for processing medical equipment puts patients at risk from infection caused by improper disinfection and sterilization.

Findings:

1. On 3/31/2015 at 10:40 AM, Surveyors #1 and #3 interviewed a central sterile technician (Staff Member #9) about the pre-cleaning and disinfection of surgical instruments. The staff member explained that the instruments are cleaned using the manufacturer's directions of one ounce of enzymatic cleaner to one gallon of water. The staff member indicated that s/he did not measure the proper amount of water to ensure the correct mixture ratio.

2. On 3/31/2015 at 12:15 PM, Surveyors #1 and #3 observed a surgical technician (Staff Member #10) cleaning and disinfecting an endoscope. The staff member explained that the scopes are cleaned using the manufacturer's directions of one pump of enzymatic cleaner to three gallons of water. The staff member indicated that s/he did not measure the proper amount of water to ensure the correct mixture ratio.

3. On 3/31/2015 at 12:28 PM, Surveyors #1 and #3 observed the following:

a. The instructions printed on the "Rapicide Glutaraldehyde Test Strips" bottle, under the sub-heading "Important Precautions" read in part: "...do not use test strips 90 days after opening the bottle...do not use the test strips after the expiration date (opened or unopened)." There is a space on the outside of the bottle for staff members to mark the "open date".

b. A surgical technician (Staff Member #10) used a rapicide test strip to determine the efficacy of the glutaraldehyde disinfectant used in the automated endoscope reprocessor. The surveyors observed that the open date of the bottle of test strips was not marked in the designated space on the outside of the bottle. During concurrent interview with the staff member, s/he indicated they were unaware of the manufacturer's directions that the test strips could only be used for 90 days once opened.

Item #4 - Hand Hygiene

Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure that staff members performed hand hygiene according to hospital policy and accepted standards of care.

Failure to perform proper hand hygiene puts patients at risk from infection and/or disease.

Findings:

1. The hospital's policy and procedure titled "Hand Washing and Glove Policy and Glove Changing" (Effective Date: 12/09/2014) read in part: "Hands must be washed: 1. Upon entering the Dept. from the hall or from the cafeteria. 2. After changing torn or damaged gloves. 3. After handling unsanitary items i.e.: garbage, patient trays, door handles, freight, raw meat, handling money, chemicals, stocking the Café etc. 4. After 2 glove changes."

2. On 3/31/2015 at 9:30 AM, Surveyors #1 and #3 observed dietary staff perform multiple tasks and more than two glove changes without performing hand hygiene.

3. On 3/31/2015 at 3:16 PM, Surveyors #1 and #3 observed a terminal cleaning of operating room (OR) #1. During the cleaning process, the surveyors observed a CRNA (Staff Member #11) walk in and out of OR #1 three times while touching the clean operating table, clean anesthesia equipment, and placing supplies in the anesthesia cart without wearing gloves or performing hand hygiene.

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Based on observation and interview, the critical access hospital failed to implement policies and procedures to assure compliance with the Washington State Retail Food Code (246-215 WAC).

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

Findings:

On 3/31/2015 at 9:35 AM, Surveyor #3 used a thin-stem thermometer to assess the temperature of a container of yogurt from a refrigerated display case. The yogurt was 48.5 degrees Fahrenheit and exceeded the maximum allowable temperature of 41 degrees Fahrenheit for cold-holding of potentially hazardous foods. The dietary manager (Staff Member #8) confirmed this finding and discarded all potentially hazardous foods in the display case.

Reference: Washington State Retail Food Code, WAC 246-215-03525 (1) (b)

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Based on interview, review of quality documents and review of deficiencies cited during the current survey, the critical access hospital failed to complete an annual review and update of patient care policies, failed to develop a systematic process for tracking and evaluating action plans to improve hospital performance and failed to implement actions to address deficiencies identified through the quality assurance program. The cumulative effect of these systemic problems resulted in the critical access hospital's failure to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.


Failure to develop and implement an effective quality assurance program impairs the facility's ability to provide quality care in a safe environment.


Cross Reference: Tags C334; C336; C342

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Based on interview and Medicare Conditions of Participation (CoP) the critical access hospital failed to ensure patient care policies were reviewed and updated annually as required.

Failure to review and update patient care policies can result in unsafe and inappropriate care to patients.

Findings:

1. On 3/31/2015 at 10:00 AM, Surveyor #2 reviewed eighteen surgical services and twelve patient care policies. The policies' review or effective dates ranged from 5/2008 to 3/2015. Of the thirty patient care polices, ten surgical polices and eight nursing care policies had exceeded at least one year since their last review date.

2. On 4/2/2015 at 3:30 PM, an interview with the hospital's chief nursing officer (Staff Member #1) and surveyor #2, confirmed the patient care policies are overdue for review.

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Based on interview and review of the hospital's quality program, the critical access hospital failed to develop a systematic process for tracking and evaluating action plans to improve hospital performance.

Failure to collect and analyze performance data on quality indicators puts patients at risk from unsafe or inappropriate care.


Findings:

1. The hospital's document "Organization-Wide Performance Improvement Program Sunnyside Community Hospital", approved by the Board of Trustees on 2/20/2014, established performance improvement projects at both an organizational and departmental level. The document included multiple indicators drawn from both Federal and State quality intiatives.

2. On 4/2/2015 between 2:00 and 3:30 PM, Surveyors #1 and #3 reviewed the hospital's quality program with the manager for quality services and risk management (Staff Member #3), the chief nursing officer (Staff Member #1), and the manager for surgical services (Staff Member #5). Hospital staff were unable to provide evidence of data collection, and analysis consistent with goals outlined in the hospital's 2014 "Organization-Wide Performance Improvement Program". Some of the data had been collected individually as line lists in each department, but there was no evidence of data collected in aggregate for assessing compliance with quality measures identified in the 2014 plan.

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Based on interview and document review, the critical access hospital failed to implement actions to address deficiencies identified through the quality assurance program.


Failure to take appropriate remedial actions to address identified deficiencies in patient care practice puts patients at risk of unsafe care.

Findings:

1. The hospital's document "Organization-Wide Performance Improvement Program Sunnyside Community Hospital", approved by the Board of Trustees on 2/20/14, stated under section "B. Clinical Support Services Performance Improvement Activities: The department manager of each clinical support service shall ensure an ongoing and systematic process for monitoring and evaluating the appropriateness of the processes provided, in conformance with the FOCUS/PDCA model for monitoring and evaluation."

2. On 4/2/2015 between 2:00 and 3:30 PM, Surveyors #1 and #3 reviewed the hospital's quality program with manager for quality services and risk management (Staff Member #3), the Chief Nursing Officer (Staff Member #1), and the Manager for Surgical Services (Staff Member #5). Hospital staff members were unable to provide evidence that department managers had completed ongoing monitoring of performance improvement projects and initiated corrective actions based on the results of their evaluation.