HospitalInspections.org

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Based on observation and interview, the critical access hospital failed to lock a medication cart.
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Failure to lock medication carts could lead to drug diversion and possible harm to patients.
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Findings included:
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1. On 12/06/17 at 8:35 AM, Surveyor #1 entered the operating room and checked a cart containing medications. The top drawer was unlocked. The observation showed that the drawer contained a controlled substance, propofol (medication used to sedate patients during surgery).

2. The Director of Surgery (Staff #3) stated that the cart was to be locked when anesthesia staff were not in the room.

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Based on observation and interview, the critical access hospital failed to maintain operating room walls in a condition that is cleanable and sanitary.

Failure to maintain cleanable walls in patient care areas puts patients at increased risk of infection.

Findings included:

1. On 12/06/17 at 11:25 AM, Surveyor #2 observed a penetration through the wall of the Operating Room (OR) that exposed the wall cavity, a broken cement surface, and broken porcelain tile.

2. The surveyor interviewed the Director of Quality Improvement/Risk Management (Staff #2) and the Director of Surgery/Trauma (Staff #3) about the penetration. Staff #3 stated she was aware of the penetration and has requested that it be repaired.

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Based on observation and interview, the critical access hospital failed to maintain a complete inventory of patient care equipment.

Failure to maintain a complete inventory of patient care equipment puts patients at risk from inoperable or unmaintained equipment.

Findings included:

1. On 12/05/17 at 2:15 PM, Surveyor #2 observed 3 patient care devices that did not have inventory/asset tags: a Dopplex D900 (a Doppler ultrasound instrument); a Dopplex D920; and a GlideScope video laryngoscope. Each of the devices was located in the Overflow Emergency Room.

2. On 12/07/17 at 8:20 AM, Surveyor #2 and the Facilities Manager (Staff #1) reviewed the hospital's biomedical program and equipment inventory. The review showed that the three patient care devices were not listed in the equipment inventory.

3. At the time of the review, Staff #1 stated that those items were not part of the inventory list and that he had not been aware of them.

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ITEM #1 - Patient Care Equipment

Based on observation, interview and review of the critical access hospital policy and procedure, the hospital failed to clean patient care items after use.

Failure to clean patient care items between patients could lead to the spread of microorganisms to other patients and staff.

Findings included:

1. The hospital's Infection Control Plan for Patient-Care Equipment, Instruments, and Devices, approved on 03/01/17 showed that all patient-care equipment should be cleaned between uses.

2. On 12/05/17 at 12:00 PM, Surveyor #1 observed a respiratory therapist (RT) (Staff #4), as he prepared to give a patient a nebulizer treatment (a breathing treatment/medication used to treat breathing problems). Prior to and after treatment, the RT listened to the patients lungs with his stethoscope. Upon leaving the room, the RT did not clean or disinfect the stethoscope.

3. At the time of the observation, the Director of Nursing (Staff #10) confirmed this observation at the time and acknowleged it did not meet hospital policy.

ITEM #2 - Environmental Cleaning

Based on observation, document review, and interview, the critical access hospital failed to implement effective infection control techniques when cleaning patient procedure/treatment rooms.

Failure to effectively clean procedure/treatment rooms places patients and staff at risk of infection from cross-contamination.

Findings included:

1. Document review of the hospital's policy titled, "Surgical/OR Cleaning," Policy #10037, dated 06/08/17, showed that hospital staff are to move the procedure table/bed away from the center of the room prior to disinfecting the lights and rails.

2. On 12/05/17 at 2:15 PM, the Director of Quality Improvement/Risk Management (Staff #2) and Surveyor #2 observed a housekeeper (Staff #4), conduct a discharge cleaning of the Overflow Emergency Room (ER). After emptying a dustpan containing floor debris, Staff #4 retrieved clean bed linens from the linen supply room without performing hand hygiene. The surveyor directed Staff #4 to discard the linens, wash her hands, and collect clean linens to complete the discharge cleaning process. Staff #4 stated that she knew she should have performed hand hygiene prior to handling clean linens.

3. On 12/06/17 at 11:35 AM the Director of Quality Improvement/Risk Management (Staff #2) and Surveyor #2 observed a housekeeper (Staff #5), perform a post-procedure cleaning of the Operating Room (OR). After disinfecting the procedure table, Staff #5 dusted and disinfected the ceiling mounted procedure lights directly over the previously disinfected table.

4. During the post-procedure cleaning of the OR, Staff #5 dropped the head section of the procedure table onto the floor as she moved it to the side of the room. Staff #5 picked up the section and placed it on the previously disinfected center section of the table. After reconnecting the head section, Staff #5 completed cleaning the room and did not disinfect the now contaminated procedure table. Surveyor #2 directed Staff #5 to re-disinfect the procedure table before completing the post procedure cleaning.

5. Surveyor #2 interviewed Staff #2 about Infection Control training for housekeeping staff. Staff #2 stated that all housekeepers receive annual training in prevention of cross contamination during cleaning processes.

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Based on interview and observation, the critical access hospital failed to implement policies and procedures to ensure compliance with the Washington State Retail Food Code (Chapter 246-215 WAC) and the 2009 FDA Food Code.

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

Findings included:

1. On 12/06/17 at 9:30 AM, during a tour of the dietary department with the Director of Quality Improvement/Risk Management (Staff #2), Surveyor #2 observed a food worker (Staff #6) don food service gloves without washing her hands as required.

Surveyor #2 interviewed Staff #6 about handwashing and the use of food service gloves. Staff #6 stated that she was aware that handwashing is required before donning food service gloves.

Reference: Washington State Retail Food Code, WAC 246-215-02310(4); (2009 FDA Food Code 2-301.14)

2. On 12/06/17 at 9:40 AM, during a tour of the dietary department, Surveyor #2 observed evidence of improper cooling methods in a freezer unit. A one-gallon zip closure plastic bag of sausage links and patties had an accumulation of condensation on the inside of the bag. Using a thin-stemmed thermometer, the surveyor assessed the temperature of sausage links at 82.6; 76.3; and 75.6 degrees Fahrenheit, and sausage patties at 100; 93.8; and 65 degrees Fahrenheit.

Surveyor #2 interviewed the Dietary Manager (Staff #7) about the sausages. He stated that the sausages had been removed from the breakfast service hot food line about 40 minutes earlier and that he intended to reheat them for use in sausage gravy at a later time. Staff #7 stated that there was no cooling log or other documentation of the cooling process as required by the food code.

Staff #7 removed the sausages from the bag, placed them on a sheet pan, and put them in the walk-in refrigerator. He directed staff to begin a cooling log to monitor the temperature of the sausages in order to determine that the temperature was below 70 degrees Fahrenheit by 11:00 AM; and below 41 degrees Fahrenheit by 3:00 PM.

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

3. On 12/06/17 at 12:40 PM, Surveyor #2 observed that the kitchen ice maker's drain line did not have an air gap (backflow prevention) as required.

The surveyor interviewed the Facilities Manager (Staff #1) about the requirement for backflow prevention. Staff #1 stated he knew of the requirement and that he would immediately repair the drain line to provide a 1-inch air gap.

Reference: Washington State Retail Food Code WAC 246-215-05410; (2009 FDA Food Code 5-402.11)

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Based on record review, review of policy and procedure, and interview, the critical access hospital failed to ensure that a pre-operative nursing assessment contained all elements required for pediatric assessment.
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Failure to complete a pediatric pre-operative assessment could lead to patient harm.
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Findings included:
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1. The hospital's policy and procedure titled, "Care of Pediatric Patients," revised 08/14/17, showed that all pediatric patients should have their immunization status recorded.
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2. On 12/06/17 at 1:00 PM, Surveyor #1 reviewed the record of Patient #1, a nine-year-old female undergoing a minor procedure. Review of the pre-operative assessment showed that there was record of the patient's immunization status as required by hospital policy.

3. The Director of Surgery (Staff #3) and the Director of Nurses (Staff #10) acknowledged there was no section on the pre-operative record to note a pediatric patient's immunization status.

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Based on observation and policy review, the critical access hospital failed to ensure that staff followed hospital guidelines for surgical attire.
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Failure to follow hospital policy regarding surgical attire could lead to contamination of sterile fields resulting in an infection of the surgical site.
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Findings included:
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1. The hospital policy titled, "Surgical Attire," reviewed 01/17/17, stated that all hair should be contained within the cap or hat.
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2. On 12/06/07 at 9:10 AM Surveyor #1 observed two registered nurses (Staff #3 and Staff #8); and a surgical technician (Staff #9) in the operating room. These staff members did not have all hair tucked into their caps.

3. The Director of Surgery (Staff #2) acknowledged the observation.