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Based on review of medical records and policy and procedcure, the facility failed to demonstrate that it ensured the least restrictive approach for use of non-violent (safety) restraints for 1 (Patient #9) of 2 records reviewed.

Failure to do so exposes patients to medically unnecessary restrictions which may have a detrimental effect on health and well-being.

Findings:

1.In review of facility policy titled, "Restraint Policy" (Reviewed 11/01/2015) under the section titled, "Non-Violent, Non-Self Destructive (Safety) Restraints" and under "Monitoring and Documentation" it stated, "Reassessment to ensure the need to continue restraints and if so, the least restrictive, safe restraint is being utilized will be performed and documented by a Registered Nurse every 4 hours."

2. Patient #9 was admitted to the emergency department on 2/13/2016 at 11:27 AM with an acute change in mental and respiratory status. The medical record demonstrated that at 12:00 PM the nurse recorded an assessment for non-violent restraints; 2 point soft wrist restraints and it was noted that the patient was on a ventilator. The nurse recorded over 25 assessment episodes in the medical record between that time and 7:30 PM. However only 1 entry addressed the patient's restraint status. An order for restraints ("NON VIOLENT") was placed at 3:04 PM.

Other chart entries during the care episode indicated that the patient was resting, able to shake her/his head to acknowledge understanding, acknowledge treatment after explanation and communicate via hand squeeze and follow commands. However, there was no indication that the patient was re-assessed for continued use of restraints at least every 4 hours after 12:00 PM during the course of care in the emergency department. The patient transferred to another facility at 7:00 PM.
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Based on review of the human resource record, the facility failed to demonstrate that unit-specific competency was determined for 1 of 1 non-employee nurse (Staff Member #12).

Failure to do so creates risk that patients may receive sub-standard services from a non-employee nurse.

Findings:

In review of the human resource record of a non-employee staff nurse (Staff Member #12) working in the surgical services area, Surveyor #3 determined that there was no documentation that ensured staff clinical competency for her/his unit-specific patient care duties.

This finding was acknowledged at the time by the Director of Human Resources (Staff Member #10).

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#1 - Aseptic Technique
Based on observation and interview, the facility failed to ensure that antiseptic technique was adhered to during the administration of medications according to accepted standards of practice for 3 of 3 patients.

Failure to do so creates risk for transmission of infection during the medication administration process.

Reference: Association for Professionals in Infection Control and Epidemiology (APIC) position paper: "Safe Injection, infusion and medication vial practices in healthcare" (2016) "Aseptic technique: Disinfect the rubber stopper of medication vials and the neck of glass ampuls with sterile 70% alcohol before inserting a needle or breaking the ampul. . . Disinfect catheter hubs, needleless connectors, and injection ports before accessing. Use either an antiseptic containing port protector cap or vigorously apply mechanical friction with chlorhexidine/alcohol, sterile 70% isopropyl alcohol, or other approved disinfectant swab."

Findings:

1. On 2/23/2016 at 1:00 PM during a discussion with the Director of Surgical Services (Staff Member #14) Surveyor #1 confirmed that wiping medication vials after removal of dust covers and wiping the neck of glass ampules is expected practice for medication administration. Staff was unable to locate a facility policy that addressed this expectation.

2. a. On 2/23/2016 at 12:45 PM in Operating Room #4, Surveyor #1 observed an anesthesia provider (Staff Member #15) prepare a medication for administration during anesthesia. The provider broke the neck of a glass ampule without disinfecting the outside of it with an antiseptic product. S/he withdrew the contents into a syringe and injected the medication intravenously into the patient without first cleansing the injection port.

b.On 2/25/2016 at 11:00 AM Surveyor #3 observed a RN (Staff Member #7) place a central line (peripherally inserted central catheter [PICC]) into the bloodstream of Patient #7). The nurse opened a glass ampul of lidocaine and inserted a needle to withdraw the medication and after a needle change, administered the medication into the area of the insertion site. The nurse did not disinfect the outside of the neck of the ampul prior to breaking it open and needle insertion.

c. On 2/23/2016 at 12:50 PM, Surveyor #1 observed an anesthesia provider (Staff Member #15) prepare an additional medication for administration during anesthesia. The provider removed the dust cover from the medication vial and, without cleaning the rubber diaphragm of the vial with an antiseptic product, s/he pierced the vial with a needle and withdrew the medication into a syringe and injected the medication intravenously into the patient.

d. On 2/24/2016 at 11:02 AM, in the Endoscopy suite, Surveyor #1 observed a registered nurse, (Staff Member #17) open a medication vial to administer sedation to (Patient #14) who underwent a colonoscopy (a diagnostic procedure that visualizes the colon). S/he did not cleanse the medication vial with an antiseptic product prior to withdrawing the medication into a syringe.

#2 - Safe Medication Practice

Based on observation, interview and review of policy and procedure the facility failed to ensure standards were adhered to for labeling medication in syringes.

Failure to do so creates risk for errors in medication administration and possible harm to patients.

Findings:

1. On 2/23/2016 at 1:00 PM during a discussion with the Director of Surgical Services (Staff Member #14), Surveyor #2 confirmed that facility policy regarding labeling of medication in syringes was to be adhered to in the surgical departments.

2. In review of facility policy titled, "Medications Dispensed to Surgical Field" (Reviewed 12/15/2015) under "Policy. . . 2. All medications in syringes or bowls are to be labeled."

3. a. On 2/23/2016 at 12:55 PM in Operating Room #4, Surveyor #2 observed (Staff Member #15) administer medication intravenously to a patient from a 10cc syringe. There was no labeling on the syringe to identify the medication.

b. On 2/24/2016 at 10:50 AM Surveyor #2 observed a registerd nurse (Staff Member #17) in the Endoscopy Suite administer medication intravenously to (Patient #14) from two different syringes. There was no labeling on either of the syringes to identify what medication they contained.

ITEM #1 - PERSONAL PROTECTIVE EQUIPMENT

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

Failure to follow personal protective equipment per recommended practice puts patients and staff at risk of infection.

Reference: The Centers for Disease Control and Prevention bulletin titled "Example of Safe Donning and Removal of Personal Protective Equipment", dated 3/2010, stated in part: "GOWN: Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back."

Findings:

1. On 2/23/2016 between the hours of 9:00 AM and 9:30 AM Surveyor #2 observed a central reprocessing service technician (Staff Member #1) clean a colonoscopy endoscope. During the cleaning process, the protective gown was not tied at the back allowing the gown to move forward, exposing the back of uniform to potential cross-contamination.

2. On 2/25/2016 at 11:00 AM Surveyor #3 observed a RN (Staff Member #7) place a central line (peripherally inserted central catheter [PICC]) into the bloodstream of Patient #1ls). The nurse donned a sterile gown as part of the procedure to place a catheter into the patient's bloodstream. The gown was secured at the neck and the waist however it was not positioned to fully cover the back of the nurse uniform.

Subsequently, when the nurse turned her/his back to opened sterile tray her/his uniform (not sterile) came in contact with the upper rim of the sterile drape of the procedure tray. Then when the nurse turned to face the sterile tray, the front of her/his gown came in contact with the same area of the rim, thereby potentially cross-contaminating the front of the sterile gown.

ITEM #2 - REPROCESSING OF NON-CRITICAL MEDICAL EQUIPMENT

Based on observation, interview, review of hospital's policy and procedures and manufacturer's instructions for use, the hospital failed to follow manufacturer's instructions for use when disinfecting non-critical medical and hospital equipment.

Failure to follow manufacturer's instruction for use places patients and staff at risk for infections.

Reference: Manufacturer's instructions for use for "Parabath" stated in part 3, "Use paper towels, and a mild non-abrasive, non-chlorine based household cleanser to remove remaining paraffin residue."

Findings:

1.a. In review of Hospital's policy and procedure titled, "IC 11- Cleaning, Low Level Disinfection, High Level Disinfection and Sterilization" and using the Centers for Disease Control "Infection Control in Health Care Facilities", page 11-12, section IV, part 2. stated, "Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly)."

1.b. On 2/25/2016 between the hours of 11:00 and 11:30 AM in the physical therapy unit, Surveyor #2 interviewed a physical therapist aide (Staff Member #2) on the process of disinfecting the paraffin bath equipment. The physical therapist aide stated in part, after removing the wax from the unit s/he would wipe it down with a paper towel and then refill the tank with paraffin wax.

2. On 2/23/2016 between the hours of 2:30 PM and 3:30 PM, Surveyor #2 interviewed a housekeeper (Staff Member #3) on the disinfection process of the bathtub in the birthing center. The housekeeper (Staff Member #3) stated, in part, that she had written down instructions from a previous housekeeper on a sticky note on how to disinfect the bathtub; these instructions did not match the drafted policy and procedure that was attached to the wall next to the bathtub. The drafted policy and procedures did not specify how much of the 2.8 quart of bleach should be used in the bathtub.

ITEM #3 REPROCESSING OF CRITICAL EQUIPMENT

Based on observation, interview, and document review, the hospital failed to ensure that staff members documented results of the hydrogen peroxide sterilization process in the sterile processing department.

Failure to follow manufacturer's instructions for use places patients and staff at risk for infection.

Findings:

On 2/23/2015 at 9:30 AM, Surveyor #2 reviewed the documentation (logbook) for biological indicators used in the facility's hydrogen peroxide sterilizers. The logbook indicated that staff members recorded the date for the incubation of biological indicators, the staff members' initials, and the biological indicator results (pass/fail) for the sterilization process. The surveyor found during an interview with lead sterile technician (Staff Member #4) that the form created by the facility was missing key elements to identify incubation start and end times. The surveyor was unable to verify that the facility followed manufacturer's instructions for use. The biological indicator (6 - Well Verify Steam/VHP Incubators) used in the facility required a 24 hour incubation time prior to reading the result.

ITEM #4 HAND HYGIENE

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

Failure to perform effective hand hygiene puts patients at risk for infections.

Findings:

1. In review of facility policy and procedure titled "IC 03 - Hand Hygiene" on page 03-2 under IV Procedures part A. Indications for handwashing and hand disinfection - "Wash hands with either a non-antimicrobial soap or antimicrobial soap and water: (4) Before eating and after using a restroom."

Additionally on page 03-3, section B. item 8 stated, "After removing gloves", item 4 stated "After contact with intact skin",item 7 stated "After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient" and item 9 stated "Entering and exiting patient rooms."

2. a. On 2/23/2016 at 11:00 AM and on 2/24/2016 at 11:30 AM, Surveyor #2 observed the same anesthesiologist (Staff Member #5) eating and drinking food in the operating room semi-restricted area; s/he discarded the food and entered into an operating room suite #3 without doing hand hygiene.

b. On 2/25/2016 at 11:00 AM Surveyor #3 observed a RN (Staff Member #7) place a central line (peripherally inserted central catheter [PICC]) into the bloodstream of Patient #1). The nurse wore a pair of gloves at the beginning of the procedure and then adjusted the height of the bed and placed a tourniquet on the patient's arm. Then, s/he discarded the gloves and did not perform hand hygiene. Subsequent to glove removal, s/he put her/his hands in uniform pockets and then proceeded to perform an antiseptic skin scrub.

c. On 2/24/2016 at 9:50 AM in the Intensive Care Unit, Surveyor #1 observed a respiratory therapist (Staff Member #19) enter Room 105 to care for (Patient #11). S/he did not perform hand hygiene prior to donning personal protective equipment or entering the patient's room.


d. On 2/24/2016 at 11:09 AM in the Endoscopy suite, Surveyor #1 observed a registered nurse (Staff Member #17) drop the plastic cap of a medication vial on the floor and retrieve it without changing his/her gloves or performing HH prior to returning to patient care activities.

ITEM #5 PATIENT ROOM CLEANING

Based on review of policy and procedure and observation, the hospital failed to ensure housekeeping staff members used effective infection control techniques.

Failure to ensure standard cleaning practices places patients at risk for increase infection/illness.

Findings:

1. a. In review of hospital's policy, "Nursery/Labor and Delivery" step 18 in the cleaning procedure stated in part, "With a clean microfiber mop. . . damp mop floor beginning in the far corner. Be sure to move furniture, clean under the bed moving toward the bathroom and the door".

b. On 2/23/2016 at 2:40 PM Surveyor #2 observed the discharge cleaning of a patient's room in the birthing center by a housekeeper (Staff Member #3). After the cleaning was completed the surveyor noticed blood splatter on the floor in the bathroom near the toilet that was missed. The housekeeper went back in and disinfected the area.

2.a. In review of hospital's policy, "Surgical Area- Operating Room" Under key recommendations, it stated, in between cases. . . "Floor mopped in a 3-4 foot area around the operating room table or farther if needed."

b. On 2/24/2016 at 12:00 PM Surveyor #2 observed an in between case cleaning of an operating room suite #3. After the cleaning was completed, the surveyor noticed a piece of biological tissue approximately a centimeter in length on the floor next to the operating table. Upon notification by the surveyor, the housekeeper (Staff Member #6) went back in, and removed the tissue and disinfected the area.

Item # 6 Use of an Antiseptic Solution

Based on observation and review of policy and procedure, the facility failed to ensure that an antiseptic products was used correctly.

Failure to do so creates risk that patients may acquire exposure to infectious agents that may result in a clinical infection.

Findings:

1. On 2/25/2016 at 10:50 AM Surveyor #3 observed a RN (Staff Member #7) place a central line (peripherally inserted central catheter [PICC]) into the bloodstream of Patient #1. The nurse used a 3 milliliter applicator of a solution called ChloraPrep to cleanse the skin. The solution was applied over the catheter insertion site for 15 seconds prior to skin piercing. The applicator was provided inside the sterile tray without it's package instructions.

2. Subsequent to the observation in review of the manufacturer's instructions, Surveyor #3 noted that the applicator skin contact time required 30 seconds of gentle repeated back and forth strokes over dry sites.

3. In review of facility policy titled, "Peripherally Inserted Central Catheter (PICC) Insertion Procedure" item 8 stated, "Prep the skin. . .Chloraprep using up and down and back and forth motion for 30 seconds..."


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Item #7 - Urinary Catheterization

Based on observation, interview and review of hospital policy and procedure, the hospital failed to ensure that staff used appropriate technique during urinary catheterization (placing a tube into the bladder for drainage of urine) to avoid potential introduction of harmful bacteria into the patient's bladder.

Failure to do so may result in development of bladder and/or systemic infections.

Findings:

1. On 2/23/2016 at 4:00 PM, Surveyor #1 discussed hospital policy and procedure regarding urinary catheterization (placing a tube in the bladder to drain urine) with the Director of Quality and Risk Management (Staff Member #13) and confirmed that it was an expectation that staff would follow hospital policy outlining the cleansing of skin prior to catheterization.

2. In review of facility policy titled, "Catheterization: Urinary Procedure" (Reviewed 12/10/2013) . . . "15. Female Patients: . . . e. Cleanse meatal area. [opening into the bladder] f. Use each cotton ball for only one wipe and then discard in garbage area. g. wipe from front to back of perineum. . . Moving from cleaner area to dirtier area . . . "

3. On 2/23/2016 at 1:05 PM, Surveyor #1 observed Staff Member #18 prepare to insert a urinary catheter into a female patient. When cleansing the skin, s/he used a back and forth motion with an antiseptic solution soaked cotton ball rather than wiping in one direction on the skin and discarding the cotton ball after one wipe.

Item #8- Contact Isolation Precautions

Based on observation and review of policy and procedures the facility failed to ensure that standards were followed to avoid cross contamination.

Failure to do so created the risk that patients may be exposed to infections and develop infections.

Findings:

1. In review of hospital policy, "Precautions: Standard, Contact, Droplet + Respirator, Airborne + Respirator, Protective" (Policy IC 06) (Dated June 2011) stated in part, ". . . IV. Precaution Notes . . . B. Personal Protective Equipment (PPE) Note: 1. Specialized protective equipment or clothing is available to protect against contact with potentially hazardous materials . . . 3. Standard Precautions: Prevent contamination of clothing. . . C. Gloves: . . . 5. Remove gloves after contact with patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination."

2. a. On 2/24/2016 at 9:50 AM in the Intensive Care Unit, Surveyor #1 observed a registered nurse (Staff Member #20) caring for (Patient #11) in contact isolation. After touching the patient, s/he reached under their protective gown and into their uniform pocket with a soiled glove to retrieve patient care items contaminating their uniform.

b. Additionally on 2/24/2016 at 10:10 AM, Surveyor #1 observed the same staff member (#20) caring for (Patient #11) pick up a garbage receptacle with gloved hands to move it closer to the patient's bedside. S/he then proceeded to assist with changing tracheostomy dressings without removing gloves or performing hand hygiene.

Item #9- Order of Donning and Doffing Personal Protective Equipment

Based on review of policy and procedure the facility failed to assure that staff adhered to standards for doffing personal protective equipment.

Failure to do so creates risk that infection may be transmitted between patients being cared for by staff.

1. In review of hospital policy regarding Contact Precautions, staff is to follow Washington State Hospital Association Placard (Revised 4/16/2009) for instructions regarding the order to remove personal protective equipment. The placard stated in part . . . "Take OFF & dispose in this order: 1. Gloves 2. Eye cover (if used) 3.Gown 4. Mask (if used) 5. Wash or gel hands (even if gloves used)"

2. On 2/25/2016 at 10:25 AM in the Intensive Care Unit, Surveyor #1 observed a respiratory therapist (Staff Member #19) caring for Patient #11 remove PPE in the following order, gown, mask, and then gloves. Additionally, prior to removing their gloves s/he wiped patient care items with disinfectant but did not remove contaminated gloves.

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Based on review of policy and procedure and staff interview, the facility failed to ensure that patient assessments identified the criteria for at-risk patients.

Failure to do so creates risk for patients to receive services that are inadequate or not targeted to their needs.

Findings:

1. In review of facility job description titled, "UR [utilization review]/Case Manager, Care Management (URCCMCM)", (Reviewed 12/29/2014) it described the purpose of the role. Duties included, but were not limited to, "identified patients at risk for encountering problems post-hospitalization. . . Performs needs assessment. . ."

In review of the policy titled, "Care Management Patient Assessment" (reviewed 12/30/2014) it stated that the "purpose of the care management assessment is to screen patients" for factors that might impact a safe discharge after hospitalization. In the "Procedure" section it stated "Care Management assessments will be completed for patients identified as 'at risk' by" various team members.

However, patient screening criteria for determining which patients were at risk were not identified and information about when subsequent care management assessments were to be completed was not provided.

Additionally, another policy and procedure titled, "Documentation" (Revised 8/7/2015) applied to nursing staff documentation requirements on the acute care and intensive care unit. It did not mention completion of screening or assessment for patient discharge planning needs. Similarly, a policy titled "Assessment/Reassessment of the Patient" (revised 12/17/2014) did not address assessing patient discharge planning needs.

2. On 2/22/2016 at 2:45 PM, a case manager-social worker (Staff Member #8) was interviewed about her/his role. S/he stated that all patients were reviewed by case management within 24 hours of hospitalization. When asked if there were standard patient assessment and/or patient screening tools, s/he stated that there were not. Additionally, the staff member stated that s/he was not aware of a departmental discharge planning policy and procedure.

Later that day at 3:15 PM during an interview with the Case Management supervisor (Staff Member #9), s/he stated that not all patients were seen by case management and that patients were screened for case management services. Additionally, s/he stated there were not established patient screening criteria.

3. In review of 5 of 5 patient (Patients #4-8 ) medical records, the facility could not demonstrate implementation of the hospital's criteria and screening process for discharge planning evaluation. Two of the 5 patients were greater than 95 to 99 years old, admitted from nursing homes and were determined upon admission by nursing to not require case management services for discharge planning.

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Based on review of job description the facility failed to ensure that a staff member (Staff Member #5) was qualified to perform case management services for hospital patients.

Failure to do so creates risk that patients may receive services from staff members that are under-qualified to perform those services which may negatively impact the quality of the services delivered.

Findings:

1.In review of the job description titled, "Care Manager", under "Qualifications/Requirements"and under "License/Certification" it stated "Current Washington State RN or LPN licensure and or bachelors in a related field (social services)." The job description was signed by a Care Manager (Staff Member #5) in 2008.

2.On 2/25/2016 at 9:15 AM, Surveyor #3 interviewed the Director of Human Resources (Staff Member #10), s/he stated that employees sign their job descriptions every 3 years and that this practice was implemented at the end of 2015. Additionally s/he stated the case manager job descriptions has not been updated yet. The most recent signed job description for the case manager was dated 2008.

When asked if Staff Member #11, who had a bachelor's degree in an education field, met the license/certification requirements for the current job description, s/he stated that those qualifications were likely not met.

Based on observation, interview and review of hospital policy, the hospital failed to follow recommended practice for protecting patients from infection by containing all hair and facial hair during surgical procedures.

Failure to follow recommended practice for containing hair and facial hair poses a risk of contamination of the sterile field and possible infection for patients.

Reference: Association of Perioperative Registered Nurses (AORN) "Guideline for Surgical Attire, 2015" Recommendation: III a. "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp, skin, sideburns and nape of neck should be worn."

Findings:

1. On 02/23/2016 at 11:30 PM Surveyor #1 interviewed the Director of Surgical Services (Staff Member #JW1). S/he stated that the facility followed AORN guidelines in the formulation of their policies and procedures.

2. The hospital's policy and procedure titled, "Dress Code" (Reviewed 9/22/2015) read as follows: . . . "Surgical Services: OPERATING ROOM (OR) . . . All possible head and facial hair, including sideburns and neckline, is covered with a disposable bouffant hat, or hood/beard cover while in the semi-restricted and restricted areas of the surgical suite."

3. On 2/23/2016 at 12:40 PM Surveyor #1 observed the following in Operating Room #4 during a spinal surgery (surgery on the back).

a. At 12:45 PM Surveyor #1 observed an anesthesiologist (Staff Member #15) wearing a disposable bouffant type head cover that did not completely contain hair at the sides and back of the head.

b. At 1:30 PM Surveyor #1 observed a surgeon (Staff Member #16) wearing a disposable bouffant type head cover that did not cover their sideburns.

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Based on review of job description the facility failed to ensure that a staff member (Staff Member #5) was qualified to perform case management services for hospital patients.

Failure to do so creates risk that patients may receive services from staff members that are under-qualified to perform those services which may negatively impact the quality of the services delivered.

Findings:

1.In review of the job description titled, "Care Manager", under "Qualifications/Requirements"and under "License/Certification" it stated "Current Washington State RN or LPN licensure and or bachelors in a related field (social services)." The job description was signed by a Care Manager (Staff Member #5) in 2008.

2.On 2/25/2016 at 9:15 AM, Surveyor #3 interviewed the Director of Human Resources (Staff Member #10), s/he stated that employees sign their job descriptions every 3 years and that this practice was implemented at the end of 2015. Additionally s/he stated the case manager job descriptions has not been updated yet. The most recent signed job description for the case manager was dated 2008.

When asked if Staff Member #11, who had a bachelor's degree in an education field, met the license/certification requirements for the current job description, s/he stated that those qualifications were likely not met.