HospitalInspections.org

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Based on interview and review of personnel records and documents, the Critical Access Hospital failed to ensure that the social worker responsible for discharge planning and case management was appropriately licensed by the State of Washington (Staff #704).

Failure to ensure that a hospital social worker is licensed as required by State law risks provision of clinical services by an unqualified person.

References:

Chapter 18.19 RCW - Agency Affiliated Counselors.
RCW 18.19.020. "Definitions. The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Agency" means (a) an agency or facility operated, licensed, or certified by the state of Washington; (b) a federally recognized Indian tribe located within the state; or (c) a county.
(2) "Agency affiliated counselor" means a person registered under this chapter who is engaged in counseling and employed by an agency...
(6) "Counseling" means employing any therapeutic techniques, including but not limited to social work, mental health counseling, marriage and family therapy, and hypnotherapy, for a fee that offer, assist or attempt to assist an individual or individuals in the amelioration or adjustment of mental, emotional, or behavioral problems, and includes therapeutic techniques to achieve sensitivity and awareness of self and others and the development of human potential ..."

Chapter 18.225 RCW Mental Health Counselors, Marriage and Family Therapists, Social Workers.
RCW 18.225.010 "Definitions. The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Advanced social work" means the application of social work theory and methods, including:
(c) Case management;"
(d) Consultation;
(e) Advocacy;

Findings included:

1. On 03/21/18 at 9:00 AM during an interview with Surveyor #7, the hospital's Director of Social Services (Staff #704) stated he had a master's degree in social work but was not licensed as a social worker or an Agency Affiliated Counselor (AAC). The social worker stated he was responsible for discharge planning for hospital patients.

2. On 03/22/18 at 9:00 AM, Surveyor #1 interviewed the hospital's Human Resources manager (Staff #103) and reviewed Staff #704's personnel records. The review confirmed the staff member was not licensed as a social worker or an AAC.

3. On 03/22/18 at 12:00 PM, review of the social worker's job description titled "Director, Social Services", Job Code S100 dated 01/18, under "Job Summary", showed the social worker was responsible for providing and performing "casework and discharge planning activities". The job description under "Performance Expectations" showed that the social worker was to "Perform comprehensive psychosocial assessments on cases identified using case find and social service consultation methods". The job description showed under "Associations and Credentialing" that the social worker was to "Attend to continuing education requirements for advanced degrees and certification in social work".

4. On 03/11/18 at 12:55 PM during a second interview with Surveyor #7, the hospital's Director of Social Services stated he did not perform case management activities but supervised a hospital staff member who did so.
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Based on observation, interview, and document review, the Critical Access Hospital failed to develop and implement a system to assure that the hospital identified beds to be used for inpatients and observation patients (not to exceed 25 beds); and beds to be used exclusively for observation patients and obstetric patients in labor or recovery after delivery of newborn infants.

Failure to identify beds to be used for inpatients creates the risk that the facility will exceed its capacity for patient care, which may result in poor patient outcomes due to inadequate care or poor resource allocation.

Findings included:

1. On 03/20/18 at 10:00 AM, Surveyor #7, accompanied by the hospital's quality program director (Staff Member #701), completed a bed count for the number of inpatient, observation, and labor, delivery, and recovery beds available in the hospital. The hospital had 34 beds set up for patient use: 17 in the medical-surgical unit, 7 in the intensive care unit, and 10 in the obstetrical/nursery unit. Each room in the medical-surgical unit and intensive care unit had a removable placard outside the door that identified the bed as for "inpatient" or "observation" patients. Each room in the obstetrical/nursery unit had a removable placard outside the door that identified the bed as for "inpatient", "LDR" (labor, delivery, recovery) or "observation" patients.

2. On 03/20/18 at 10:10 AM, Surveyor #7 interviewed the nurse manager for the medical/surgical and intensive care units (Staff #702). During the interview, the manager stated that hospital staff members changed the placards outside each patient's room according to the patient's admission status.

3. On 03/20/18 at 1:05 PM, record review of the hospital's policy titled "Bed Count/Census Management", no policy number, dated 05/08/15, showed that bed status designation would be depicted by a placard at the door of a patient's room, either "Inpatient", "LDR" (labor, delivery, recovery", or "Observation. The location of available inpatient beds would vary based on patient need. The hospital did not have a process for designating which 25 beds were to be used for inpatient and observations services, and which beds were to be used exclusively for observation and labor/delivery/recovery services.
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Based on observation and interview, the Critical Access Hospital failed to maintain walls in a condition that is cleanable and sanitary, and that prevents access by pests.

Failure to maintain secure and cleanable walls in patient care areas risks access by rodents and other pests, and puts patients at increased risk of infection.

Findings included:

1. On 03/21/18 between 11:50 AM and 12:40 PM, Surveyor #6 toured the Health Center on Summitview Avenue in Yakima with the Chief Nursing Officer (Staff #609), the Infection Preventionist (Staff #610), and the Clinic Coordinator (Staff #611). At 12:30 PM, Surveyor #6 inspected the X-Ray Room and observed an opening in the wall behind an electrical box. The opening was approximately 18-inches wide by 9-inches long. There was a pile of shredded insulation material on the floor at the opening.

2. At the time of the observation, Surveyor #6 interviewed Staff #611 and a Radiation Technologist (Staff #612) about the condition of the wall, and the shredded material. Staff #611 and #612 stated that they had not been aware of the opening in the wall or the shredded material on the floor.
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Based on observation and interview, the Critical Access Hospital failed to provide for secure storage of E-cylinder oxygen tanks.

Failure to safely store pressurized medical gas tanks places patients, staff, and visitors at risk of injury due to fire or explosion.

Findings included:

1. On 03/20/18 between 2:00 PM and 4:00 PM, Surveyor #6 toured the Specialty Center Surgery Group clinic on 11th Street in Sunnyside with the Interim Human Resources Director (Staff #601), the Clinic Coordinator (Staff #607), and a Medical Assistant (Staff #608). At 2:20 PM, Surveyor #6 inspected the Point of Care Room and observed that one of three compressed oxygen E-cylinder tanks was unsecured.

2. At the time of the observation, Surveyor #6 interviewed Staff #607 and #608 about the unsecured cylinder. Staff #608 stated that the cylinders were recently refilled but she wasn't aware that one of the tanks was unsecured.
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Based on observation the Critical Access Hospital failed to maintain appropriate air pressure relationships in the main campus central sterile clean supply room.

Failure to maintain proper air pressure relationships puts patients at risk from supplies contaminated by airborne pathogens.

References: ASHRAE/ASHE Standard 170-2008: Ventilation of Health Care Facilities, Table 7-1 Design Standards; and American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities 2006 ed., Table 2.1-2, Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities.

Findings included:

1. On 03/20/18 at 10:05 AM, Surveyor #6 used a lightweight string to determine the direction of air flow between the hospitals' Central Sterile Clean Storage Room and the corridor. The string was drawn into the Clean Storage Room indicating the room was under negative pressure with respect to the corridor, contrary to federal requirements.

2. During an interview with Surveyor #6 at the time of the observation, the Interim Human Resources Director (Staff #601) confirmed that the string was drawn into the room.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet all applicable provisions of the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement policies and procedures for safe preparation of intravenous (IV) medications and fluids.

Failure to comply with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.

Reference: United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016)

Findings included:

1. Record review of the hospital's policy titled "IV [intravenous] Admixtures Policy", Policy #6398 dated 06/09/17, showed that intravenous admixtures would be prepared in the hospital pharmacy using sterile technique under an IV preparation hood.

2. On 03/20/18 at 2:45 PM, Surveyor #7 inspected a medication storage cabinet located at the nurses' station in the hospital's intensive care unit (ICU). During the inspection, the surveyor found a multi-dose vial of 1% lidocaine (a local anesthetic) dated as opened on 03/16/18.

3. At the time of the inspection, Surveyor #7 interviewed the ICU nurse manager (Staff #702). The manager stated that when patients receiving intravenous fluids containing potassium experienced pain at the infusion insertion site, physicians occasionally ordered lidocaine to be added to the intravenous fluid. The manager stated nurses prepared the admixture in the ICU.

4. On 03/21/18 at 9:35 AM, Surveyor #7 interviewed the hospital's pharmacy director (Staff #703) regarding nurses preparing IV admixtures in the ICU. During the interview, the director stated that there was no written policy or procedure for adding lidocaine to an IV to ensure preparation met USP 797 sterile compounding standards.
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ITEM #1 - SAFE INJECTION PRACTICES

Based on observation and interview, the Critical Access Hospital failed to ensure health care providers wore surgical masks when performing spinal injection procedures according guidelines from the Centers for Disease Prevention and Control.

Failure to wear a mask during spinal injection procedures risks contamination of the injection site, which could lead to a spinal cord infection.

Reference: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee) "Part IV: Recommendations - V.H. Safe Injection Practices. The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems: ...IV.I. Infection control practices for special lumbar puncture procedures. Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia)."

Findings included:

1. On 03/21/18 at 11:30 AM at Yakima Imaging, Surveyor #8 observed a surgeon (Staff #813) inject a steroid (a medication to relieve chronic pain and numbness) into Patient #812's spine. The surgeon did not wear a surgical mask during the injection procedure.

2. During an interview with Surveyor #8 immediately following the procedure, the imaging technician who assisted the surgeon (Staff #803) stated that health care providers at that clinic did not wear surgical masks when performing spinal injection procedures.

3. On 03/22/18 at 1:00 PM, Surveyors #1, #7, and #8 interviewed the hospital's Infection Preventionist (IP) (Staff #610) regarding the findings above. During the interview, the IP confirmed that health care providers should wear surgical masks when performing spinal injection procedures.


ITEM #2 - FOOD SAFETY

Based on interview, observation, and document review, the Critical Access Hospital failed to implement policies and procedures to ensure compliance with the Washington State Retail Food Code (Chapter 246-215 WAC).

Failure to comply with food service regulations puts patients, staff, and visitors at risk from food borne illness.

Findings included:

1. On 03/20/18 between 11:00 AM and 12:10 PM, Surveyor #6 toured the Food and Nutrition Services Department with the Interim Human Resources Director (Staff #601), the Food Service Supervisor (Staff #602), and the Nutrition Director (Staff #603). While inspecting the produce refrigerator, the surveyor observed a tightly covered 2-quart container of cubed chicken that had an accumulation of condensation on the inside (evidence of improper cooling). Using a thin-stemmed thermometer, the surveyor assessed the temperature of the chicken at 51 degrees Fahrenheit.

2. On 03/20/18 at 11:10 AM, Surveyor #6 interviewed a Cook Assistant (Staff #604) about the chicken. Staff #604 stated that she did not document time or temperature information, and described the process of cooking and cooling the chicken:

a. On 03/20/18 at an undetermined time, ten (10) chicken breasts were cooked in the oven from a frozen state. Staff #604 used a digital food thermometer to assess the temperature of the chicken breasts at 175 degrees Fahrenheit before taking them out of the oven.

b. About 9:45 AM, Staff #604 moved the cooked chicken breasts to 2-inch pans and placed them on the top shelf of the meat refrigerator for cooling.

c. About 10:15 AM, the chicken breasts were cubed, placed in a 2-quart container, covered with a tight fitting lid, and placed in the produce refrigerator.

3. On 03/20/18 at 11:20 AM, Surveyor #6 interviewed the Food Service Supervisor (Staff #602) about the hospital's procedures for cooling Potentially Hazardous Food (PHF). Staff #602 stated that Food and Nutrition Services staff are to document time and temperature information on daily logs; and that no refrigerated PHF should be covered unless its internal temperature is at or below 41 degrees Fahrenheit.

Reference: Washington State Retail Food Code WAC 246-215-03515 (2009 FDA Food Code 3-501.14)


ITEM #3 - CROSS CONTAMINATION

Based on observation and interview, the Critical Access Hospital failed to ensure that staff used effective procedures to prevent cross contamination.

Failure to prevent cross contamination places patients, staff, and visitors at risk of exposure to harmful pathogens.

Findings included:

1. On 03/21/18 between 12:00 AM and 12:55 AM, Surveyor #6 and the Environmental Services Manager (Staff #605) observed as a housekeeper (Staff #606) performed terminal cleaning of the procedure room at the Specialty Center Surgical Group clinic on 11th Street in Sunnyside. After disinfecting the patient pillow, Staff #606 placed it on a supply cabinet that had not been disinfected. She disinfected the mattress and patient examination table and then returned the now contaminated pillow to the table without disinfecting it.

2. During the terminal cleaning procedure, Staff #606 used a mop to clean the floor and swept plastic debris and two pens from under a supply cabinet. Staff #606 picked up the items; discarded the plastic debris, and added the two dirty pens to a container of pens on the cabinet. She did not disinfect the pens after picking them up off the floor.

3. Surveyor #6 interviewed Staff #605 and #606 at the time of the observation. Staff #605 stated that staff should take steps to prevent cross-contamination.


ITEM #4 - HAND HYGIENE

Based on observation, document review, and interview, the Critical Access Hospital failed to ensure that hospital staff members performed hand hygiene as directed by hospital policy during 3 of 6 hand hygiene observations.

Failure to follow effective hand hygiene practices puts patients and staff at risk of infection.

Findings included:

1. Record review of the hospital's policy titled, "Hand Hygiene Policy and Procedure," Policy #337, Version 7, dated 02/10/18, showed that all staff are to perform hand hygiene before donning gloves, and after removing gloves.

2. On 03/21/18, Surveyor #6 made the following observations of staff removing and donning gloves without performing hand hygiene:

a. At 12:45 AM, at the Specialty Center Surgical Group on 11th Street in Sunnyside, during a terminal cleaning of the procedure room, a member of the housekeeping staff (Staff #606) donned gloves after using a hand sanitizer. When she removed her gloves, she did not perform hand hygiene prior to donning clean gloves.

b. At 12:00 PM, at the Health Center on Summitview Avenue in Yakima, a medical assistant (Staff #613) cleaned Exam Room #6 following a patient procedure. Staff #613 used hand sanitizer before donning gloves, but removed them without performing hand hygiene.

c. At 12:15 PM, at the Health Center on Summitview Avenue in Yakima, a Magnetic Resonance Imaging (MRI) Technologist (Staff #614) cleaned Procedure Room #2 following a patient procedure. Staff #614 used hand sanitizer before donning gloves but did not perform hand hygiene after removing the gloves.

3. At 12:30 PM, Surveyor #6 interviewed the Clinic Coordinator for the Health Center on Summitview Avenue (Staff #611) about the hospital's hand hygiene policy for staff who clean patient care areas. Staff #611 stated that all staff are expected to perform hand hygiene before donning and after removing gloves.


ITEM #5 - HEMODIALYSIS CIRCUIT DRAINAGE

Based on observation, interview and document review, the Critical Access Hospital failed to ensure that staff members maintained proper backflow prevention when preparing equipment for inpatient hemodialysis.

Failure to provide a backflow prevention device places patients at risk of infection from water contamination.

Reference: Centers for Medicare and Medicaid Services web-based training - Water Treatment for Hemodialysis" (Nephrology Nursing Journal September-October 2013 Vol. 40, No. 5 page 386): "Discharge of spent water and dialysate in the acute care setting should be into an appropriate floor drain or standpipe connection. If these are not available, a sink may be used as long as there is an air gap to prevent contaminated effluent from back-flowing into the dialysis machine, and the sink is not used for any other purpose during the treatment."

Findings included:

1. In review of the contracted services (Davita) policies and procedures Titled, "Infection Control in the Hospital Dialysis Setting" (Reviewed Oct 2017) stated on page 4 part 21, "Sinks should be easily accessible and readily available in the treatment area and in other appropriate areas. Dedicated hand washing sinks should be for hand washing purposes and remain clean. Avoid placing, cleaning or draining used items in dedicated hand washing sinks."

2. On 03/21/18 at 9:30 AM, Surveyor #1 observed a dialysis nurse (Staff #101) set up the hospital's portable reverse osmosis (RO) water system in advance of beginning hemodialysis for the patient in room #126. The staff member placed the RO's drain line from the unit directly into the hand sink. The surveyor asked the dialysis nurse if she had a way to provide an air gap for the dialysis machine drain line. She stated that she did not.

3. On 03/22/18 at 9:30 AM Surveyor #1 interviewed the Director of Maintenance (Staff #102) regarding air gaps for dialysis machines. The Director of Maintenance stated that there were air gaps underneath the hand washing sinks. During a tour of the hospital, the Director of Maintenance showed the surveyor that patient room #126 had an air gap underneath the hand washing sink. The Director of Maintenance stated that it was installed for the contracted services to use.


ITEM #6 - ICE MACHINE DRAINAGE

Based on observation, and document review, the Critical Access Hospital failed to properly install ice machine drain lines.

Failure to properly install ice machine drain lines could result in potential contamination of the water and ice supply.

Reference: Design, construction and installation-Backflow prevention, air gap (2009 FDA Food Code 5-202.13).

Findings included:

On 03/22/18 between the hours of 11:00 AM and 12:00 PM, Surveyor #1 observed that the ice machine drain lines in the emergency department and the acute care unit were not installed with an approved air gap (1 inch air space between the bottom of the drain line and top floor drain or hub drain). This risks contamination of the ice by waste water.


ITEM #7 - WATER MANAGEMENT PLAN

Based on observation, interview, and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a) Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system;

b) Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;

c) Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained."

Findings included:

1. Document review of the hospital's "Water Management Plan," policy #7145, dated 03/05/18, showed that there should be one plan per facility (campus).

2. On 03/22/18 between 11:00 AM and 12:00 PM, Surveyor #6 reviewed the Water Management Plan with the Biomed Manager (Staff #615), the Chief Operations Officer (Staff #616), the Infection Preventionist (Staff#610), the Director of Maintenance (Staff #617), and the lead maintenance worker (Staff #618). The surveyor asked whether the hospital's 5 off-site campuses had been considered in the plan or whether there were individual plans for each campus. Staff #616 and #617 agreed that the plan did not address off-site campuses and that they were not aware of individual plans for those campuses.

3. On 03/22/18 between the hours of 1:30 PM and 2: 30 PM, during an interview with the Director of Maintenance (Staff #102) Surveyor #1 asked to see if the hospitals facilities equipment and medical equipment were incorporated into the water management risk assessment. In review of the water management risk assessment, the surveyor identified that medical equipment (hydrotherapy tubs, CPAP (Continuous Positive Air Pressure) machines, dialysis machines and ventilators) that poses a risk for legionella growth were not included into the water management risk assessment.
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Based on interview and document review, the Critical Access Hospital failed to provide evidence of compliance with the Condition for Participation at 42 CFR 485.645: "Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds")".

Failure to provide services for swing-bed patients for a prolonged period of time risks decline in staff competency and patient care delivery systems, which can result in adverse patient outcomes related to substandard care

Findings included:

1. On 03/20/18 at 9:00 AM during the survey entrance conference, the hospital's Chief Nursing Officer (Staff #703) stated that the hospital had not had a "swing-bed" patient for three years.

2. On 03/21/18 at 10:00 AM, the hospital's quality program director presented documentation that showed that the last swing-bed patient had been admitted to the hospital on 08/19/15.

3. The hospital did not provide current evidence at the time of the recertification survey that it was in compliance with all of the requirements under 42 CFR 485.645.
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Based on interview and document review, the Critical Access Hospital failed to provide written policies and procedures for the provision of subsistence needs.

Failure to provide written policies for provision of subsistence needs places patients, staff, and visitors at risk of injury and/or death during emergencies.

Findings included:

1. On 03/20/18 between the hours of 1030 and 1230, Deputy Fire Marshal #1 reviewed the hospital's emergency plan. Review of the plan showed that it did not include policies and procedures to ensure adequate alternate energy sources necessary to maintain temperatures to protect patient health and safety, or the safe and sanitary storage of provisions.

2. The deputy fire marshal's review of the emergency plan further revealed that it did not include policies and procedures to provide for sewage and waste disposal.

3. At the time of document review, the deputy fire marshal interviewed the maintenance staff about the emergency plan. The staff acknowledged that written policies were not available.
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Based on interview and document review, the Critical Access Hospital failed to ensure that its emergency power supply meets the requirements of the emergency plan.

Failure to ensure adequate power supply from emergency and standby power systems risks endangering patients, staff, and visitors during an emergency or power outage.

Findings included:

1. On 03/20/18 between the hours of 1030 and 1230, Deputy Fire Marshal #1 reviewed the hospital's emergency plan. Review of the plan showed that the hospital could not verify that the standby power system could maintain the hospital's cooling system during an emergency.

2. At the time of document review, the deputy fire marshal interviewed the maintenance staff about the plan. The maintenance staff acknowledged the finding.
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