HospitalInspections.org

Based on observation the facility failed to assure that a sufficient amount of the antidotal drug Dantrium was stocked in the malignant hypothermia cart.

Failure on the part of the facility to have sufficient stocks of a critical drug available during an emergency puts patients at risk of harm and/or death.

Findings include:

1. On 10/23/2012, Surveyor #2 opened the malignant hypothermia cart located in the recovery room of the surgical unit. While screening the contents of the cart the surveyor noted that six (6) of thirty-six (36) viles of Dantrium were past their expiration date of 9/2012. This finding was acknowledged by the pharmacist at the time of the discovery.

Based on record review, the hospital failed to ensure that certain emergency life support equipment (defibrillator) was checked on a daily basis to determine if it was operational.

Failure to ensure that emergency life support equipment is properly checked to see that it will function when needed places patients at risk of harm should the equipment be needed and/or it is not working properly.

Findings include:

1. On 10/23/2012, during a tour of the Emergency Department Surveyor #2 noted that logs of the department's crash cart checks were incomplete. More specifically, checks of the defibrillator were not entered for October 15 and 16, 2012; September 1, 2, 12, and 17, 2012; and August 7, 8, 9, 10, and 12, 2012.

Based on observation and interview the facility failed to ensure the control of potential infections by implementing appropriate nationally recognized standards of prevention related to high level disinfection..

Failure on the part of the facility to implement nationally recognized infection control standards puts patients at risk from nosocomial infection.

References: Centers for Disease Control, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

The following breach of infection control standards was observed during the course of the survey:

Efficacy Testing/Tracking

1. On 10/23/2012, surveyor #2 noted that a bottle of disinfection efficacy test strips (Steris 1E Chemical Indicators) used in the surgical department were expired having an expiration dated of 9/28/2012.

2. On 10/23/2012, surveyor #2 noted that high level disinfection logs kept for Steris 1E scope processing failed to include anything other than the date instruments were processed and the printouts of the Steris 1E cycle data. Information lacking in the log book included but was not limited to the following: The model and serial number of the instrument associated with the cycle data shown on the machine printout; the patient's name and/or patient identifier linked to the scope used; and the name of the individual who processed the instrument and logged the results of efficacy testing.

Subsequent to this finding surveyor #2 was informed by Staff # 8, that nothing in the patient's chart (endoscopic procedure) was provided to show what scope was used during the procedure.

Based on observation 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.

Specific references made in the findings below are found in the Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code.

Findings include:

1. On 10/24/2012, Surveyor #2 observed a member of the kitchen staff (Staff #9) preparing food items while wearing gloves. During the course of the food preparation activity the staff person left the preparation station to retrieve items from a refrigerator located nearby. This was done while wearing the afore mentioned gloves. Upon returning to the preparation station the staff member proceeded to prepare ready to eat items while wearing the same gloves as noted. (see Chapter 3-304.15 (A))

2. On 10/24/2012, Surveyor #2 noted that the kitchen 3 compartment sink was being used for multiple uses (food preparation, chemical sanitizer bucket storage and utility activity) without the benefit of an operation plan that would control how and when the various compartments of the sink would be utilized. (see Chapters 4-301.16 (C) and 4-501.16 (B))

3. On 10/24/2012, Surveyor #2 noted that in the dry goods storage area a sewer line was located over a shelving unit holding food stuffs and other items. The sewer line lacked shielding to intercept potential drips. (see Chapters 3-305.12 (F) and 4-903.11 (2))

Surveyor #1

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:

1. The hospital provided a copy of the annual program evaluation for 2011. The program evaluation document did not include all areas of the total program. Some examples of missing services would include: dietary and nutrition services; out-patient infusions; wound care; respiratory therapy, and pharmacy.

2. The program evaluation document did not contain an evaluation of most of the listed services with the exception of the emergency room countersigning of licensed independent practitioner patient records. The remainder of the document contained a listing of patient numbers and a description of what is being monitored, rather than the results of the monitoring.

The above observations were verified through interviews with Staff #1.

Surveyor #1

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 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:

The hospital provided a copy of the annual program evaluation for 2011. No evidence was presented to show how many open or closed records were reviewed. There was no evidence presented to show what the outcome of the record reviews identified and what was done with this information.

The above was verified by Staff #1 on 10/24/2012.

Surveyor #1

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that health care policies had been reviewed, as a result of annual program evaluation findings.

Failure to document the review of policies that were found to need updating, as a result of the program evaluation, places all 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:

The hospital provided a copy of the annual program evaluation for 2011. The program evaluation document did not identify which policies and procedures were evaluated, reviewed and/or revised as part of the annual program evaluation.

Surveyor #1

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that utilization of services were appropriate, established policies were followed, and any changes were needed.

Failure to document the review of comprehensive evaluation for services used and any identified changes to policies, procedures or facility practices places all 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:

The hospital provided a copy of the annual program evaluation for 2011. The program evaluation document did not provide evidence that the utilization of services were appropriate, established policies were followed, and any changes were needed.

Surveyor #1

I. Based on observations, review of the quality assurance plan and minutes, and administrative staff interview, the hospital failed to ensure that the quality plan included the provision to collect, measure and assess data related to monitoring of patient care supplies.

Failure to include data related to all patient care services that affect patients places patients at risk of harm related to potential care and treatment issues not being identified and corrected.

Findings:

1. During observational rounds on 10/24/2012 the following was noted in the surgical services operating room anesthesia cart: a) two (2) one liter intravenous fluid bags were found that had a manufacturer's expiration date of May 2012.

2. During observational rounds on 10/24/2012 the following was noted in the surgical services post-anesthesia area: a) a spinal kit with an expiration date of July 2012; b) multiple packages of povidone-iodine swabs with expiration dates of April 2012, September 2009, July 2009 and December 2008; c) two (2) vials of .9% sodium chloride injectable solution with an expiration date of 1 August 2012; d) one intravenous bag of fluid (100ml) of .9% sodium chloride with an expiration date of September 2012; and e) one bag of Intralipid fat emulsion intravenous solution (20%) with an expiration date of April 2012.

3. Multiple electrocardiograph (ECG) electrodes were found in emergency carts located in the Medical-Surgical, Emergency, and the Sanctuary units. These electrodes had been removed from their over-wrap. The over-wrap contained the expiration date. Thus, the expiration date of individual electrodes could not be ascertained.

No documentation was found that the quality plan included a way to collect, measure and assess data related to expiration dates on patient care services related products. Per interview with Staff #1 on 10/25/2012 the hospital could not provide documentation that the quality program was adequately monitoring for expired patient care supplies.

II. Based on observations and administrative staff interview, the infection control program failed to ensure that policies and procedures were followed regarding the consumption of food in the operating room suites.

Failure to monitor for potential infection control practices places patients at risk of harm related to the potential cross-contamination provided by having food items consumed in a surgical operating suite.

Findings:

During observation rounds in the operating room suites on 10/24/2012, an unlocked anesthesia cart was opened. Inside there was an unopened package of candy and a nutritional snack bar. This cart was in a suite that was imminently expecting a patient for surgery. The observation was verified by Staff #1, who was present at the time.

Surveyor #1

Based on review of the quality assurance plan and minutes, and administrative staff interview, the hospital failed to ensure that the quality plan included the provision to collect, measure and assess data related to evaluating the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists, and physician assistants.

Failure to include, as a part of their quality assurance program, an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment provided by each licensed independent practitioner providing services to hospital patients places patients at risk of harm related to potential care and treatment issues not being identified and corrected.

Findings:

Per review of hospital quality program documentation, no evidence was found that care and services provided by licensed independent practitioners were evaluated for quality and appropriateness of the diagnoses and treatments being furnished to patients. Per interview with Staff #1 on 10/25/2012 the hospital could not provide documentation of the required evaluations.

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: "The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition".

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did not contain the required language identifying the right, as identified above.
The form did include a proviso that this patient right could potentially not be given to the patient if there was a "medical contraindication".

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: (1) Resident rights (?483.10(b)(5) & (6)): "(?483.10(b) (5) The facility must- (i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section."; and "(?483.10(b )(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate."

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did not contain the required language identifying the right, as identified above.

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: "The resident has the right to be fully informed in advance about...any changes in that care or treatment that may affect the resident's well-being.

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did not contain the required language identifying the right, as identified above.

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: The resident has the right to privacy in written communications, including the right to a) Send and promptly receive mail that is unopened; and b) Have access to stationery, postage, and writing implements at the resident's own expense.

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did not contain the required language identifying the right, as identified above.
The form did include a proviso that this patient right could potentially not be given to the patient if there was a "medical contraindication".

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: a) The resident has the right and the facility must provide immediate access to any resident by the following which is subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and b) 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 ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did not contain the required language identifying the right, as identified above.

Surveyor #1

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: "The resident has the 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 ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of medical record documentation provided to patients admitted to the Swing Bed program, the form titled "Patient Rights/Swing Bed" was reviewed. The form did contain the required language identifying the right, as identified above.
The form included a proviso that this patient right could potentially not be given to the patient if there was a "medical contraindication".