HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that all personnel having unsupervised access to vulnerable adults had completed a Washington state patrol background inquiry.

Failure to ensure that required background inquiries are completed on all relevent personnel risks exposure of vulnerable hospital patients to potentially dangerous persons.

Findings include:

During review of human resource records on 02/03/11, it was found that:

a) The records of 2 of 2 emergency department personnel whose records were reviewed did not contain evidence of a Washington state patrol background inquiry

b) There was no evidence of a Washington state patrol background check for the registered dietician, who had unsupervised access to pateints.

c) Interview with the interim director of the human resource department on the same date found that the hospital was using a contracted service to perform background inquirires. There was no evidence on the background inquiries that were reviewed that showed the inquiries included the Washington state patrol database.

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 02/03/11.

Based on observation, interview, and record review, the facility failed to develop, implement, and/or maintain policies and procedures for specific infection prevention issues.

Failure to do so places patients, staff, and visitors at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.

Findings:

The following breaches of infection control standards, policies and procedures were observed during the three days of the survey:

? On 2/1/11 approximately 10:00AM the surveyor observed an open, damp (used) bedpan on the floor of the shower stall in a patient room, calling into question facility-specified storage methods and the potential for cross-contamination if the bedpan were used for a patient, or if a patient used the shower. Interview with staff #2 approximately 3:00PM on 2/1/11 resulted in the staff member being unable to speculate how the situation arose. S/he stated that bedpans were to be stored in a plastic bag on a shelf in the patient care area.
? On 2/1/11 approximately 10:15AM the surveyor observed staff #3 licking fingers to turn document pages, raising the risk of contaminating the documents and/or being exposed to any potential pathogen on the document.
? On 2/2/11 the surveyor observed several breaches of infection control standards during medication passes to two patients, beginning approximately 9:30AM. During the first medication pass, staff #4 dropped a medication in its package on the floor. Rather than discard it and obtain an uncontaminated package, staff #4 administered this medication to the patient along with his/her other drugs. No hand hygiene was performed after staff #4 retrieved the medication from the (contaminated) floor.
? During the second medication pass, staff #4 dropped a patient label on the floor, picked it up and placed it back on the bin where clean medications were stored. Staff #4 did not perform hand hygiene after retrieving the label from the floor.
? Staff #4 administered medications via a feeding tube, then changed gloves without performing hand hygiene before donning the new gloves. S/he then picked up soiled linen from the floor, did not perform hand hygiene and change gloves before setting up a respiratory medication (nebulizer) treatment. Staff #4 then reached into a pocket located underneath his/her protective isolation gown to retrieve an alcohol swab, wearing the same contaminated gloves. S/he also used a hand to open the trash can lid, rather than the foot pedal designed to protect hands from contamination.
? On 2/1/11 approximately 10:00AM the surveyor observed an uncovered cup of coffee in a patient unit hallway cabinet (the cabinet is used for storing patient records and care supplies). This cabinet was directly outside the room of a patient who was in isolation. Page 45 of the Employee Handbook reads that " beverages in containers with lids may be utilized at work stations " .


The above observations were witnessed and/or described to administrative staff #1, 5, and 6, who confirmed that such actions were not in keeping with facility infection control policy.



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Based on observation and record review, the hospital failed to ensure that the dietitian planned and implemented patient care to meet the nutritional needs of patients, which includes evaluating, recommending, prescribing, or modifying therapeutic diets as needed to meet the nutritional needs of the patients.


Failure to do so places patients at risk for complications of care from inadequate nutritional status, including new, sustained, or worsening infection, open wounds, progression of chronic illness and debilitation .


Findings:


1. Per hospital policy titled " Dietary and Nutritional Services " , item #3 states " the Registered Dietitian will recommend a diet appropriate for the patient ' s medical condition " . In the weekly conference notes the dietitian did not identify the patient ' s diet and its ' . The notes did not demonstrate that the dietitian planned or implemented patient care to meet the nutritional needs of patients, including evaluating, recommending, prescribing, or modifying therapeutic diets, including diabetic management, as needed to meet the nutritional needs of the patients.


Four of five patients noted below had significant decubiti and 5 of 5 were at moderate to high nutritional risk with usually moderate to severe protein deficiency. Two of five patients experienced weight loss. In a review of 46 dietary chart notes, there was a total of 3 individualized dietary recommendations/interventions in the medical records of Patient #10, 16, 19-21.


A. Patient #19 was a 46 year old male at moderate nutritional risk with mild protein depletion who was an insulin dependent diabetic receiving antibiotic therapy for a closed MRSA infection. He had elevated blood sugars frequently in the 300 range and was receiving sliding scale insulin. There were no dietary recommendations/interventions in the medical record, except for Vitamin C.


B. Patient #20 was a 72 year old male who had been an inpatient for nearly 4.5 months. At his initial consult he was determined to be at moderate nutritional risk with a stage 4 decubitus and multiple chronic wounds, MRSA infection and anemia. During the course of his stay his weight was normal however there were no dietary recommendations/interventions in the medical record per an initial consult note stating it was " doubtful further supplements would be beneficial since this condition is long-standing. " Further dietary analysis during the 4.5 month stay would have been warranted based on his physical condition as baseline was already determined to be at moderate nutritional risk.


C. Patient #10 was a 63 year old male who was been an inpatient for 3 weeks. He was determined to be at high nutritional risk with mild protein depletion with a decubitus (although the dietary note stated his skin was intact). There was 1 dietary recommendation/intervention to discontinue a protein supplement. No other dietary recommendations/interventions were provided in the medical record however the fact that the patient had a decubitus was not included in the initial assessment.


D. Patient #21 was a 58 year old male who was an inpatient for 10 weeks with a stage 4 decubitus and other co-morbidities including diabetes. It was determined that the patient was at high nutritional risk with severe protein depletion. The patient ' s blood sugars were out of control on a weekly basis with high blood sugars ranging from 250-350 over 8 weeks. The patient lost weight during the hospital stay. There were no dietary recommendations/interventions in the medical record during his prolonged stay.


E. Patient #16 was a 80 year old female who was an inpatient for 3 weeks with a hip fracture and with a decubitus. The patient was determined to be at moderate nutritional risk with mild protein deficiency. The patient lost 2.5 pounds over 3 weeks which is a 10% weight loss and is considered severe weight loss per CAH guidelines The patient ' s albumin level was 2.8 on admission which is significantly low however she was identified as having mild protein deficiency. There was only one dietary recommendation/intervention which was about managing free water.


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Based on observation, interview, and record review, the facility failed ensure that patient needs were met for four of four outpatient records reviewed for this issue (Patients #1 - 3, 18). The facility ' s policy did not include developing and documenting care in an interdisciplinary manner as required by state law.
Failure to develop care plans with interventions appropriate for patients ' needs risks neglect and a failure to meet those needs.
Findings include:
Reference: WAC 246-320-226 Patient care services. Hospitals must: (4) Have a system to plan and document care in an interdisciplinary manner including: (a) Development of an individualized patient plan of care, based on an initial assessment ...
The surveyor requested a list of patients who had received outpatient services within a specific time frame in December, 2010, and chose a cross-section of those records to review. Services rendered these patients (#1 - 3) included intravenous infusions and intra-muscular injections. Review of the patient records failed to demonstrate a care planning process for these patients. The VPMA (staff #1) stated that the facility did not develop care plans for patients receiving outpatient services.

On 2/2/11 surveyor 29784 observed foot wound care delivered to a diabetic patient (#18). (Diabetic persons are at high risk of developing significant, deteriorating wounds on the feet due to circulatory impairment, and this patient was receiving a course of intravenous antibiotics for his/her wounds). The nurse performing the wound care (staff #7) applied tincture of benzoin to the patient ' s toes, though record review revealed no order to do so. The surveyor learned that the wound care expert (staff #8) had used benzoin for another purpose on another area of the patient ' s feet. Record review demonstrated no care plan which would have outlined the approaches which the wound care expert determined to be appropriate for this patient. Interview with staff #8 confirmed that benzoin was not ordered for application to the toes, and that no care plan was developed for this or other outpatients who receive ongoing care in the hospital setting.



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REFERENCE:

?483.10 Resident Rights
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights:
?483.10(a) Exercise of Rights
(1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.
(3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident ' s behalf.
(4) In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident ' s rights to the extent provided by State law.

?483.10(b) Notice of Rights and Services
(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident ' s stay. Receipt of such information, and any amendments to it, must be acknowledged in writing.
(2) The resident or his or her legal representative has the right--
(i) Upon an oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays); and
(ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility.
(3) 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.



Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of certain patient ' s rights outlined in this regulation.

Failure to do so impedes the patient ' s ability to be aware of and exercise these rights.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s rights to:
? exercise rights as a citizen of the United States
? be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights
? access his/her records and photocopies thereof within the defined time frames

This finding was confirmed by the VPMA (staff #1).

Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the availability of and charges for patient services as outlined in this regulation.

Failure to do so impedes the patient ' s ability to be aware of availability of services and their costs.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the available patient services both included in, and excluded from inclusion in daily charges, as well as the charges for excluded services.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights outlined in this regulation.

Failure to do so impedes the patient ' s ability to be aware of and exercise these rights.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s right to work for the facility or refuse to do so, with the attendant details outlined above.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights outlined in this regulation.

Failure to do so impedes the patient ' s ability to be aware of and exercise these rights.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s right to mail privacy and access to supplies.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights regarding visitation.

Failure to do so impedes the patient ' s ability to be aware of and exercise these rights.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s right to visit and receive visitors as outlined in the regulation.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights regarding personal possessions.

Failure to do so impedes the patient ' s ability to be aware of and exercise this right.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s right to use of personal possessions.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights outlined in the regulation.

Failure to do so impedes the patient ' s ability to be aware of and exercise this right.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the right of married couples to share a room if both so desire.

This finding was confirmed by the VPMA (staff #1).



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Based on interview and record review, the facility failed to inform swing bed patients and family or surrogate decision makers of the patient ' s rights outlined in the regulation.

Failure to do so impedes the patient ' s ability to be aware of and exercise these rights.

Findings include:

The surveyor requested the document given to swing bed patients which outlines their rights. The brochure supplied, entitled " Patient Rights & Responsibilities " did not address the patient ' s right to remain in the facility as outlined above.

This finding was confirmed by the VPMA (S #1).



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