HospitalInspections.org

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Based on observation and interview, the critical access hospital failed to ensure that patient care supplies were not available for patient use beyond the manufacturer's expiration date.
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Failure to properly maintain supplies places the patients at risk for infection and delays in treatment.
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Findings:
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1. During the survey, the following observations were made:
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a. On 3/31/2015 at 10:00 AM in the north wing of the acute care unit, Surveyors #1 and #3 found the following: five packages of benzoin tincture with an expiration date of 2/2015; two transparent dressing packages with an expiration date of 6/2014; two occlusive dressing packages with an expiration date of 12/2014 and six tubes used for drawing blood specimens with dates exceeding manufacturer's expiration date. Three of the tubes had an expiration date of 12/2014; two of the tubes had an expiration date of 1/2015 and one with an expiration date of 2/2015.
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b. On 4/1/2015 at 10:00 AM in the emergency room, Surveyors #1 and #3 found five chemistry specimen tubes with an expiration date of 1/2015; three coagulation specimen tubes with an expiration date of 12/2014; and eight packages of sterile gloves size 7.5 with an expiration date of 2/2015.
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c. On 4/1/2015 at 11:00 AM in the procedure room, Surveyor #1 found two unit dose packages of sodium chloride 0.9% for inhalation with an expiration date of 8/2014; one 1000ml bottle of sodium chloride 0.9% for irrigation with an expiration date of 8/2014; and one 500ml bottle of sterile water for irrigation with an expiration date of 2/1/2015.
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d. On 4/1/2015 at 11:30 AM in the central processing area, Surveyor #1 found two bottles of 500ml of sterile water for irrigation with an expiration date of 2/1/2015.
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2. On 4/1/2015 at 11:30 AM, Surveyor #1 interviewed the clinical services director (Staff Member #2) who stated the nursing staff was responsible for checking for outdated or expired patient supplies on a monthly basis. At the time of survey, no hospital policy and procedure could be found describing this process.

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Based on observation the critical access hospital failed to maintain an appropriate air pressure relationship (ventilation) between the laboratory and adjacent spaces.

Failure to maintain appropriate air pressure relationships puts patients, staff and visitors at risk from air-borne contaminates.

Finding:

On 4/1/2015 at 8:55 AM Surveyor #2 used a light weight strip of tissue (flutter strip) to determine if the direction of air flow was into or out of the laboratory. The flutter strip showed that the direction of air flow at the door of the laboratory was out to the corridor not into the laboratory as is required.

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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:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.

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Based on record review the critical access hospital failed to ensure that individuals appointed to the medical staff had their background checked per requirements established by both state regulation and the facility's Medical Staff By-laws. More specifically, the facility failed to perform required criminal background checks and/or obtain necessary disclosure statements.

Failure to perform and/or obtain necessary documentation for criminal history/background inquiries puts children, vulnerable adults and developmentally disabled adults at risk of harm.

References: Medical Staff By-Laws of Odessa Memorial Healthcare Center; and Washington State Hospital Regulations (WAC 246-320-126 Criminal history, disclosure, and background inquiries - Hospital responsibility.

Findings:

1. On 4/2/2015 between the hours of 11:00 AM and 12:00 PM, Surveyor #2 noted that a disclosure statement was not included in the file of 1 of 4 members of the medical staff (Staff Member #4) who had been chosen for review.

2. On 4/2/2015 between the hours of 11:00 AM and 12:00 PM, Surveyor #2 noted a criminal background check was not included in the file of 1 of 4 members of the medical staff (Staff Member #5) who had been chosen for review.

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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure staff members followed its policy for patient identification for 2 of 4 swing bed patients observed (Patients #1, #5).
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Failure to follow policies and procedures for patient identification risks patients receiving medications, treatments, or procedures not prescribed for them.
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Findings:
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1. The hospital's policy and procedure titled "Patient Identification" (Revised 9/2014) read in part: "Acute, observation, certified swing or short term patients: Upon admission, a tamper proof non transferable identification band will be affixed to each patient with their name (first and last), room number and date of birth."
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2. On 3/31/2015 at 10:00 AM in the north wing, acute care unit, Surveyor #1 observed Staff Member #3 administer a pain medication to Patient #1. Surveyor #1 observed Patient #1 was not wearing the required patient identification band as required by hospital policy.
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3. On 3/31/2015 at 11:00 AM in the north wing, acute care unit, Surveyor #3 interviewed Patient #5 and observed the patient was not wearing a patient identification band as required by hospital policy.
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4. On 3/31/2015 at 1:30 PM, Surveyor #1 interviewed the clinical services director (Staff Member #2) who confirmed the hospital policy that all inpatient, observation, or certified swing bed patients required a hospital identification band to include an allergy band if indicated.
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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to assure proper storage and control of medications.
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Failure to ensure medications are secured from unauthorized usage risks patients receiving medications which may have been tampered with or not being available when needed.
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Findings:
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ITEM #1 SECURITY OF MEDICATIONS
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1. The hospital's policy and procedure titled "Emergency Crash Carts - Security and Accountability" (Revised 1/2011) read in part "The emergency crash cart will be secured with a numbered disposable lock at all times when not in use. The seal will be broken only when an emergent situation arises or by Pharmacy/Licensed Nurse (LN) to inventory contents."
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2. On 3/31/2014 at 10:40 AM, during an inspection of the north wing, acute care unit, Surveyor #1 found an unlocked emergency crash cart with the following medications available for use: one intravenous bottle of nitroglycerin 50mg/250 ml in 5% dextrose; one intravenous bag of lidocaine 2gm/500ml in 5% dextrose; and one intravenous bag of heparin 20,000 units in 5% dextrose.
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3. In a subsequent interview immediately following the observation, the clinical services director (Staff Member #2) confirmed the findings and hospital policy that the cart should be locked.
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ITEM #2 ACCOUNTABILITY OF CONTROLLED SUBSTANCES
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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure hospital staff members wasted controlled substances according to its policy.
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Failure to waste controlled substances according to hospital policy risks diversion of narcotics and unsafe healthcare delivery.
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Findings:
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1. The hospital's policy and procedure titled "Controlled Substance Management on Patient Care Units" (Revised 3/2015) read in part: "The controlled substances policies and procedures of the OMHC will be followed in the event of a controlled substance being discarded or wasted (all or part of an issued dose). Generally, the discarded substance is recorded in the ADD (Automated Dispensing Device) computer or a controlled substance administration record."
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2. On 3/31/2015 at 10:00 AM in the north wing, acute care unit, Surveyor #1 observed Staff Member # 3 split an oxycodone 5mg tablet (controlled substance) into two halves. The nurse (Staff Member #3) then tossed one-half tablet into the sharps biohazard container and then administered the remaining half tablet to Patient #1.
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3. In a subsequent interview immediately following the observation, the Staff Member #3 confirmed s/he should have had a second person witness the wastage of the half tablet in the pyxis medication dispensing machine according to hospital policy.

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Based on observation and interview the critical access hospital failed to ensure the control of potential infections by implementing appropriate nationally recognized standards of prevention. More specifically, standards related to steam sterilization.

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

Reference: Association for the Advancement of Medical Instrumentation (AAMI) ANSI/AAMI ST46:2002, Steam sterilization and sterility assurance in health care facilities; Chapter 7.4.2.3 Using chemical indicators, b) Internal chemical indicators, 1) Placement and frequency of use, which states in part: "An internal CI should be used within each package to be sterilized".

Findings:

1. On 4/1/2015 at 3:00 PM Surveyors #2 and #3 noted that instruments such as scissors, forceps, etc. stored in the emergency department had been sterilized in peel pouches without benefit of chemical indicators being placed within them.

2. On 4/2/2015 between the hours of 9:30 AM and 11:00 AM Staff Member #6 gave Surveyor #2 an overview of both disinfection and sterilization processes employed at the facility. During the course of the discussion, Staff Member #6 informed Surveyor #2 that s/he was not aware that chemical indicators needed to be placed within the peel pouches used for the sterilization of instruments.

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Based on review of personnel files and interview, the critical access hospital failed to ensure temporary agency nurses assigned to provide care to patients were oriented to hospital policies and procedures for 1 of 1 temporary agency nurse personnel file reviewed.
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Failure to orient all patient care staff to hospital policies and procedures prior to assigning them patient care duties risks patient health and safety.
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Findings:
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1. On 4/2/2015 at 9:00 AM, Surveyors #1 and #3 reviewed Staff Member #3's personnel file. His/Her orientation checklist did not include training on usage of restraints unlike other permanent hospital employees.
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2. On 4/2/2015 at 11:00 AM, Surveyor #1 interviewed Staff Member #2 who stated temporary agency nursing personnel should receive restraint training as part of their orientation and that the hospital corresponding staff orientation checklist needed to be updated.

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Based on record review, review of hospital policy and procedures, and interview, the critical access hospital failed to ensure hospital staff members completed and documented pain reassessments after each pain management intervention for 3 of 5 swing bed patients reviewed (Patient #1, #3, #4).
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Failure to reassess for pain places patients at risk for inconsistent, inadequate, or delayed relief of pain.
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Findings:
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1. The hospital's policy and procedure titled "Pain Management" (Revised 12/2014) read in part: "Re-assess pain intensity after each pain management intervention (pharmacological or non-pharmacological) once sufficient time has elapsed for the treatment to reach peak effect."
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2. Review of five swing bed patient records revealed the following:
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a. Patient #1 was a 79 year-old patient who was admitted to swing bed status on 3/29/2014 for rehabilitation following surgery for rectal prolapse. The patient was medicated for pain with oxycodone (narcotic) on several occasions with no evidence of a reassessment for pain following medication administration.
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b. Similar findings were found in the records of Patients #3 and #4.
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3. On 4/1/2015 at 4:00 PM, Surveyor #1 interviewed the clinical services director (Staff Member #2) who confirmed that reassessments of the patient's pain following medication administration had not been documented in the patient's record as directed by hospital policy.

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Based on record review, review of hospital policies and procedures, and interview, the critical access hospital failed to ensure that hospital staff completed swing bed admission activity assessments for 2 of 5 patients reviewed (Patients #1, #2).

Failure to develop and implement an activity plan for long-term care patients puts patients at risk of physical, mental, and psychosocial impairment.

Findings:

1. The hospital's policy and procedure titled "Activity Assessment" (Revised 12/2014) read in part: "The initial assessment should be completed within 24-72 hours of admit either by paper or on Meditech."


2. On 3/31/2015 at 2:45 PM, Surveyor #1 interviewed the hospital's activity program director (Staff Member #1). Staff Member #1 confirmed that it was facility policy to assess swing bed patients for activity interests and have their assessment completed within 72 hours. S/he acknowledged that Patient #1 did not have an activity assessment completed.

3. On 4/1/2015 at 1:00 PM, a review of the medical records of five swing bed patients revealed two of five records with no documentation of a comprehensive activities assessment completed within the required timeframe.
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