HospitalInspections.org

A. Consent for Immunization
Based on record review and staff interview, the facility failed to provide documentation that informed consent for an immunization had been obtained from the patient 's guardian for 1 of 2 newborn infants.

Failure to obtain informed consent for treatment creates a risk for provision of care against a patient/guardian's wishes and may be a violation of patient rights


Findings:
Upon on chart review on 8-9-12 of an infant born at the facility, Patient #3, there was not a signed consent for a hepatitis B immunization. The infant did receive the immunization from facility staff according to the record.

This finding was confirmed by Staff Member # 3.


B. Pre-Operative Physician Orders for Nursing Care


Based on record review and staff interview the facility failed to assure that there were pre-operative nursing orders for 4 of 5 patients for having outpatient surgery/invasive procedures.

Failure to do so creates a risk that facility staff perform patient care activities that they are not licensed to perform without an appropriate provider order.

Findings:

1. During medical record review on 8-9-12 the records of 4 (Patient #4-7) of 5 patients were found not to contain orders for routine pre-operative nursing care, including starting intravenous lines and infusing solutions. Patient #4&5 had hernia repairs on 7-10-12 and 7-26-12, respectively and Patient # 6&7 had an endoscopy on 6-7-12 and a colonoscopy on 6-17-12, respectively.
The medical record findings were confirmed by Staff Member #3.

2. On 8-9-12 in interview with the RN Manager of Surgical Services, Staff Member # 4, s/he confirmed that a form signed by the physician was used by the nursing staff to prepare for patient care prior to the date of surgery. It was used as a " worksheet " for planning for surgery. However, the form was not annotated as an order form and did not contain content related to direct nursing care on the day of the surgery/procedure.

.

Based on review of personnel records and clinical documentation, the CAH failed to ensure that all clinical personnel were appropriately licensed by the state for the tasks they were performing, by failing to provide a licensed social worker for discharge planning.

Failure to ensure that the hospital discharge planner was licensed as required by state law risks provision of clinical services by unqualified persons.

Findings include:

During review of personnel records on 08/09/2012, it was found that the critical access hospital discharge planner was not licensed by the state. Review of the job description and chart records of the discharge planner found that s/he was performing clinical assessments (mental status examinations), family and patient counseling, and assisting patients and families in negotiating financial barriers to care. The discharge planner was Staff Member #1.

Based on observation, the critical access hospital failed to provide backflow prevention to protect patients, staff and the public from back-siphonage of contaminated water into the hospital potable water supply.

Failure to provide appropriate backflow prevention risks injury or illness through ingestion of contaminated water.

Findings include:

During a tour of the critical access hospital on 08/07/2012, it was observed that 25 of 25 patient shower rooms had shower wands that were capable of extending to touch the floor of the showers. These wands were not provided with atmospheric vacuum breakers to prevent back-siphonage of contaminated water.

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 include:

Refer to deficiencies written on the

CRITICAL ACCESS HOSPITAL
MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY

dated 08/09/2012.

Based on observation, staff interview and review of policy and procedure, the facility pharmacy failed to assure that injectable medications were properly dated after opening and/or unexpired and secured. The pharmacy also failed to assure that policies and procedures were reviewed/approved by facility administrative staff.

Failure to do so creates a risk for poor quality pharmacy services and potential for poor patient outcomes, including inconsistent and/or unsafe medication practices.

Findings:
A. Opened and undated and/or expired injectable medication
Reference: Drug procurement, distribution and control. (1) General. Pharmaceutical service shall include: (a) Procurement, preparation, storage, distribution and control of all drugs throughout the hospital. (b) A monthly inspection of all nursing care units or other areas of the hospital where medications are dispensed, administered or stored.
1. During a tour of the Emergency Department on 8-7-12 with a registered nurse, Staff Member # 7, the 3 of 7 vials of medication on the laceration cart were found to be opened and undated and/or expired. The injectable medications were as follows:
Bupivicaine-0.5%, 50 millimeters, opened on 7-2-12 (expired on 7-30-12)
Lidocaine-1%, 20 milliliters, opened and not dated
Sodium Bicarbonate 5ml, opened and not dated
During a tour of the acute care unit the same day with a registered nurse, Staff Member #8, the following medication in the intravenous start tray was found to be opened and undated: Lidocaine 1% 2 milliliters.

2. In review of facility policy and procedure titled, Multi-dose Vials (5-9-12) in the section titled Policy it stated, "Multidose vials of other medication (other than insulin) shall be initialed and dated upon opening and discarded after 30 days. " In the procedure section it stated "Monthly inspections are done to check for dating on open vials as well as checking for outdated stock." The above policy did not explicitly state who was responsible for management of multidose vials throughout the facility.
3. On 8-8-12 during an interview with the Pharmacy Manager, Staff Member #9, s/he reported being unaware of the medication inspection system for medications noted above in the Emergency Room and on the Acute Care unit.

B. Lack of Medication Security
Reference: Pharmacy 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. (a) It is the joint responsibility of the director of pharmacy and the director of nursing to ensure that drug handling, storage, and preparation are carried out in conformance with established policies, procedures, and accepted standards. (b) Locked storage or locked medication carts shall be provided for use on each nursing service area or unit.

1. On 8-8-12 a registered nurse, Staff Member #5, showed how patient care supplies were stored between wound care visits. Patient care supplies included prescribed topical ointments and were stored in the clean supply room next to Recovery Room #2. These items were placed in a clear zip lock plastic bag with patient identifying information and attached to a wall mounted corkboard with a thumbtack. (The clean supply room also contained surgical staff personal lockers.) The medications were not secured from general staff member access.

2. On 8-8-12 the Manager of Infection Control, Staff Member #6, obtained information about the 4 patients whose supplies were posted in zip lock bags in the clean supply room. Two (Patient #3 and #4) of four patients had positive wound cultures on 8-5-12 for methicillin resistant staphylococcus aureus (MRSA). The packaging of the medication was potentially contaminated with a pathogenic organism, MRSA.

3. On 8-8-12 during an interview with the Pharmacy Manager, Staff Member #9, s/he reported being unaware of the medication storage system in the Wound Clinic area.



C. Lack of Facility Approved Pharmacy Policies and Procedures (P&P)
Reference Pharmacy WAC 246-873-080 (4) The director shall establish, annually review and update when necessary comprehensive written policies and procedures governing the responsibilities and functions of the pharmaceutical service. Policies affecting patient care and treatment involving drug use shall be established by the director of pharmacy with the cooperation and input of the medical staff, nursing service and the administration.

1. Based on interview on 8-8-12 when the Pharmacist, Staff Member #9, was asked about current policies and procedures, s/he presented a binder of materials from 2008. Later during the interview, s/he located pharmacy policies and procedures from 5-9-12. S/he stated s/he had worked at the facility for almost 2 years.

2. During the above interview, a document was located in the 2012 Pharmacy P&P Manual titled " Signature Sheet for Pharmacy Policy and Procedure reviewed the year of _____. " On the form there was an attestation statement for review and revision of the documents and section for signatures of the " Hospital Nursing " , Hospital Administration " , " Medical Staff " and " Pharmacy Manager " . The only signature on the form was a signature in the pharmacy manager section. The Pharmacist, Staff Member #9, was unaware of the signature sheet document.

3. On 8-8-12 after the above interview, Staff Member #2 provided the Pharmacy Policy and Procedure Manual to Surveyor #2 which contained a policy titled Pharmacy Policy and Procedure Annual Review. The policy stated that the P&Ps cover sheet would "be signed by the pharmacy manager, administration, and the medical staff." This completed document could not be located by the facility and this was confirmed by Staff Member #2. There was no way to verify whether the Pharmacy P&Ps had been reviewed/approved by other members of the facility staff.

.

Based on observation, staff interview and review of policy and procedure the facility failed to assure that routine hand hygiene precautions were adhered and that used patient care equipment did not contribute to possible cross-contamination in the Wound Clinic.

Failure to do so creates a risk for transmission of pathogenic organisms among patients, staff and visitors to the facility.

Findings:
A. Hand Hygiene
1. During observation of care on 8-8-12 for Patient #2, it was noted that were several missed opportunities for hand hygiene. The patient had a post-surgical wound infection wound vac in place for about 1 week and was being seen for her second visit in the Wound Clinic. The wound was an abdominal wound and measured approximately 7.6 x 3.5 x 1.5 centimeters The missed opportunities for hand hygiene were as follows:
a. After removing gloves and before proceeding to touch furniture (a stool).
b. After glove removal used for bandage/drain removal and before opening new bandage packages.
c. Before proceeding to put gloves on to use forceps to remove a gauze sponge placed inside the wound.
d. After removing gloves and prior to proceeding to cut new sponge and place it in the wound reservoir.
e. After removing gloves that came in contact with the wound during tailoring the sponge to the wound perimeter with scissors and before donning another pair of gloves.
f. After disconnecting and re-connecting wound vac tubing and prior to cell phone use to call a physician.

2. In an interview on 8-8-12 with the Wound Care nurse following the dressing change, Staff Member #5, s/he stated that s/he does not wash hands between gloves changes in the midst of patient care. S/he stated that gloves changes were mostly related to " opening supplies " . The nurse did not mention glove changes when going from a "dirty "(managing the old dressing) to "clean" (managing the inside of the wound, applying a new dressing) patient care activities. S/he stated that there was no sink available in the treatment room for hand cleaning. S/he neglected to comment on use of the facility supplied foam hand sanitizer as an acceptable method for hand hygiene after gloves removal when hands are not visibly soiled.

3. Upon review of facility policy and procedure titled, Hand Hygiene item 1. stated to wash hands "Before and after using gloves." Alcohol based hand products were listed as an "adjunct" to hand washing in the policy and it stated that hand washing was "recommended after 10 applications" of hand sanitizer or when hands become visibly soiled."
According to this facility policy, the staff member failed to adhere to it.



B. Used Patient Care Equipment

1. During observation of care on 8-8-12 for Patient #2, it was noted that a pair of scissors was used to trim a foam sponge that was placed inside the wound of the above patient and then the sponge was subsequently removed from inside the wound and to further trim it. After the scissors had come in contact with the surface of the sponge that had contact inside the wound, the scissors were placed on a facility sheet of paper that was subsequently used outside of the treatment room. This sheet of paper was potentially contaminated with any wound organisms.

2. On 8-8-12 a registered nurse, Staff Member #5, showed how patient care supplies were stored between wound care visits. Patient care supplies included items such as scissors, prescribed topical ointments and forceps and were stored in the clean supply room next to Recovery Room #2. These items were placed in a clear zip lock plastic bag with patient identifying information and attached to a wall mounted corkboard with a thumbtack. (The clean supply room also contained surgical staff personal lockers.)
On 8-8-12 the Manager of Infection Control, Staff Member #6, obtained information about the 4 patients whose supplies were posted in zip lock bags in the clean supply room. Two (Patient #3 and 4) of four patients had positive wound cultures on 8-5-12 for methicillin resistant staphylococcus aureus (MRSA).
The patient care equipment was potentially contaminated with a pathogenic organism, MRSA, and could present a risk for contamination to other room content.

.

Based on interview and review of performance improvement documentation, the critical access hospital failed to systematically include the hospital pharmacy service in the assessment of medication errors for patterns and trends.

Failure to include the hospital pharmacy service in the assessment of medication errors limits the hospital's ability to prevent future errors and reduce risk of patient harm.

Findings include:

During review of performance improvement data and an interview on 08/09/2012, it was found that the critical access hospital medication error reporting system did not include a means of systematically including the hospital pharmacist in the review and assessment of medication errors. Review of pharmacist involvement in medication errors found that the pharmacist was included in reviewing 2 of the previous 28 reported errors.

Based on staff interview and review of a facility document, the facility failed to have written policies and procedures regarding the visitation rights of patients.

Failure to develop policies and procedures as above creates a risk that patients' visitation rights may be violated by staff not aware and/or not prepared to implement the standards.

Reference: from subsection of 485.635(f)
(1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, in advance of furnishing patient care whenever possible.
(2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.


Findings:

1. Per interview with Staff Member #2 on 8-7-12, the facility did not have a policy and procedure to assure the visitation rights of critical access hospital patients, including information related to clinical restriction and types of visitors. Types of visitors would include, but would not be not limited to, spouse, domestic partner (including same sex domestic partner), another family member, or a friend.


.