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Based on observation, interview, and review of facility policies and procedures, the facility failed to ensure that staff members performed hand hygiene before and after direct patient contact according to acceptable standards of practice for infection control and facility policy for 2 of 6 staff members observed (Staff Members #4, #5).

Failure to follow acceptable standards of practice for infection control risks transmission of communicable diseases to patients and staff members.

Reference: "Guidelines for Hand Hygiene in Health-Care Settings" (MMWR RR-16, October 2002; Centers for Disease Control and Prevention

Findings:

1. The facility's policy and procedure entitled "Infection Control - Hand Hygiene" (Effective March 2005) read as follows: "Indications for handwashing/antisepsis 1. If hands are not visibly soiled, either wash with soap and water or use alcohol based hand rub. 2. Decontaminate: Before direct patient contact... After patient contact... After contact with inanimate objects."

2. The following observations were made by Surveyor #13692 on 1/19/2001:

a. At 12:10 PM, Staff Member #4 did not perform hand hygiene after contact with the patient in room 106 and before contact with the patient in room 108.

b. At 12:15 PM, Staff Member #5 transported a bag of soiled linen to the soiled utility room, then proceeded to room 104 . Staff Member #5 then pushed a vital signs monitor from room 104 without first performing hand hygiene.

3. An interview with the hospital's infection preventionist (Staff Member #6) on 1/21/2011 at 9:45 AM confirmed that these employees did not follow the hospital's handwashing policy and procedure.

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1. Based on record review and review of facility policies, the hospital failed to follow its policy and procedure for monitoring patients while in restraints for 1 of 5 patients reviewed (Patient #10).

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

Findings

a. The hospital's policy and procedure entitled "Restraints - General Guidelines" (Policy #7170-94; Revised April 2009) stated that patients were to be observed every fifteen minutes and that those observations were to be documented on a restraint flow sheet.

b. Review of the records of five patients who had been restrained during their hospitalization revealed the following:

Patient #10 was a 30 year-old patient who had been admitted on 4/27/2010 for treatment of alcohol intoxication and acute alcohol withdrawal. The patient became confused and combative on 4/27/2010 at 12:46 PM and was placed in 4-point restraints.

The restraint flow sheet in the patient's record lacked documentation that the patient was observed every 15 minutes between 1:00 PM and 10:45 PM on 4/27/2010 and between 7:00 AM and 8:45 AM on 4/28/2010.


2. Based on record review and protocol review, the hospital failed to ensure that nursing staff followed physician orders for treatment of alcohol withdrawal for 2 of 3 patients reviewed (Patients #10, 11).

Failure to follow such orders risks patients receiving inadequate or improper treatment, which may result in patient harm.

Findings:

a. The hospital's pre-printed orders included an order set entitled "Alcohol Withdrawal". These orders established how often a patient was to be assessed for symptoms of alcohol withdrawal; how the patient's symptoms were to be scored according to the Clinical Indicators and Withdrawal Assessment Symptom Scale (CIWA); and how medications were to be administered according to CIWA scores.

The order set stated that the patient was to be assessed every 30 minutes for alcohol withdrawal symptoms and assigned a CIWA score. The order set stated the patient was to receive lorazepam 1 mg for a CIWA score of 10-15, lorazepam 2 mg for a CIWA score of 16-20, and lorazepam 3 mg for a CIWA score of 21-25.

Lorazepam was to be given to the patient every 30 minutes as needed until symptoms of withdrawal were controlled. The order set stated that administration of the medication was to be documented on the CIWA flow sheet. The patient was to be reassessed for medication effectiveness using the CIWA scoring system 30 minutes following medication administration.

b. Review of the records of three patients who were treated for alcohol withdrawal during their hospital stay revealed the following:

1) Patient #10 was a 30 year-old patient who had been admitted on 4/27/2010 for treatment of acute alcohol intoxication. The patient showed symptoms of alcohol withdrawal after admission, and the "Alcohol Withdrawal" order set was initiated.

Review of the patient's CIWA flow sheet for 4/27/2010 indicated that the patient's CIWA scores were 18 at 4:45 PM, 5:15 PM, 5:45 PM, and 6:15 PM; 14 at 6:45; 10 at 7:15 PM; 14 at 7:45 PM; "thrashing" at 8:15 PM; 18 at 8:45 PM; not scored at 9:15 PM; 18 at 9:45 PM; 18 at 10:15 PM; 22 at 10:45 PM; 22 at 11:10 PM; not scored at 11:45 PM, 12:15 PM or 12:45 PM; 17 at 1:00 AM; and 17 at 1:30 AM.

The patient's CIWA flow sheet indicated the patient was given lorazepam 2 mg at 4:45 PM, 5:45 PM, 8:45 PM, 10:15 PM, 10:45 PM, 11:10 PM, and 1:00 AM.

The patient was not assessed and medicated according to the Alcohol Withdrawal protocol, and his withdrawal symptoms were not controlled.

2) Patient #11 was a 50 year-old patient who had been admitted on 1/27/2011 for treatment of acute alcohol intoxication The patient showed symptoms of alcohol withdrawal after admission, and the "Alcohol Withdrawal" order set was initiated.

Review of the patient's CIWA flow sheet for 1/18/2011 indicated that the patient was given lorazepam 7 times between 2:30 AM and 12:44 PM. The patient was not reassessed using the CIWA scoring system to determine the medication's effectiveness 30 minutes after each dose of medication as directed by the Alcohol Withdrawal protocol.

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Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that physician orders were signed, dated and timed in accordance with hospital policy and current state hospital regulations in 9 of 15 records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9).

Failure to ensure that physician entries are authenticated by signature, date and time puts patients at risk for medical errors.

Reference: WAC 240-360-166(4)(e): "Hospitals must create medical records that have accurately written, signed, dated, and timed entries."

Findings:

1. The hospital's policy and procedure entitled "Physician Orders-Written, Verbal Telephone" (Policy 7170-82, Revised 2/2007) read as follows:

"Written Orders: Orders may be accepted that are legible, dated, timed, and signed by an active member of the medical staff."

"Verbal Orders ...The responsible practitioner will countersign, date and time verbal orders within 48 hours. The medical practitioner must countersign orders for hypnotics, narcotics, anticoagulants, antibiotics and blood transfusions within 24 hours."

2. Review of 15 medical records on 1/19/2011 and 1/20/2011 revealed the following:

a. The records of Patients #4, #5, #6, and #8 included 8 written orders that were missing the date and/or time that the order was signed by the physician.

b. The records of Patients #1, #2, #3, #7, and #9 included 17 verbal orders that were missing a physician's countersignature or the date and time of the countersignature.

3. An interview with the hospital's Chief Operating Officer (Staff Member #3) on 1/21/2011 at 12:00 PM confirmed that the orders above had not been written according to hospital policy.

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Based on review of medical staff appointment records and interview with hospital staff, the hospital failed to implement bylaws, rules and regulations for granting delineated clinical privileges to 1 of 6 physicians reviewed (Physician #1).

Failure to implement these bylaws, rules and regulations for granting delineated clinical privileges allows unauthorized providers to perform procedures which potentially placing patients at risk

Findings:

During a tour of the Surgery Department on 1/19/11, the department manager (Staff Member #9) was unable to verify that Physician #1, who was scheduled to perform an esophagogastroduodenscopy (EGD) on 1/20/2011, was authorized to do so.

Surveyor #29784 observed Physician 1 performing an EGD on 1/20/11.

No evidence was found in the hospital medical staff records for Physician #1 that the privilege for performing EGD was found.

The Credentialing Coordinator (Staff Member #10) confirmed during an interview on 1/21/11 that the privilege for performing EGD was not granted from Physician #1.

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