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Based on observation, record review and staff interviews, the Critical Access Hospital failed to provide a safe environment for the provision of patient care.

Failure to maintain an effective fire suppression system risked serious injury and death during a fire for patients, staff, and visitors in the hospital.

Findings included:

Cross Reference: C0231 and attached Fire/Life Safety Report
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to implement procedures for identification of newborn infants prior to discharge for 1 of 5 newborn records reviewed (Patient #1).

Failure to systematically identify newborns risks discharging infants to the wrong family.

Findings included:

1.The hospital's policy titled "Identification of Infants" (Reference #8008; Reviewed January 2017) stated that labor and delivery nursing staff would establish the legal identity of each baby born at the hospital by documenting identifying information on a "Newborn Identification Sheet". Information on the identification would include the mother's name, baby's name, sex and date of birth, the infant's footprints, and the number printed on the baby's identification band. The "Newborn Identification Sheet" included a section that read: "I hereby certify that on being discharged I examined my baby and determined that it was mine. On checking the bracelet units sealed onto the baby and myself, I found that they were identically numbered [space for entering the identification number] and contained correct identifying information." The form included spaces for the mother to sign and date and a space for the signature of a witness.

2. On 07/13/17, Surveyor #1 reviewed the medical records of five babies born at the hospital during the month of June 2017. The review revealed that the "Newborn Identification Sheet" for Patient #1 had not been signed by the patient's mother and a witness when discharged on 06/10/17.

3. During an interview with Surveyor #1 on 07/13/17 at 2:25 PM, the Director of Nursing Services (Staff Member #1) confirmed the findings above.
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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), 2012 edition.

Failure to meet the Life Safety Code of the National Fire Protection Association risks patients, staff, and visitor safety.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports
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Based on interview, record review, and review of medical staff bylaws, the Critical Access Hospital failed to review medical staff privileges within the required timeframe as directed by the hospital's medical staff bylaws (Staff Members #1, #10, #11, #12, #13).

Failure to review medical staff privileges within the required timeframe put patients at risk from inadequate or unsafe care.

Findings included:

1. The hospital's medical staff bylaws under Section 3, "Condition of Duration of Appointment" stated: "Appointment and Reappointments to other categories of the Medical Staff shall be for a period of not more than two years ... Appointment to the Medical Staff confers on the appointee only such Clinical Privileges as have been granted by Governing Body, in accordance with these Bylaws."

2. On 07/12/2017 at 2:00 PM, Surveyor #2 reviewed a sample of medical staff credentialing files with the manager of medical staff services (Staff Member #5). The surveyor found five of seven provider privileges were not reviewed during the re-appointment process.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital (CAH) failed to develop a policy for annual review of CAH policies and procedures.

Failure to review and update hospital policies risk medical errors and patient harm.

Reference:

§485.635(a)(3) The policies include the following: (i) A description of the services the CAH furnishes directly and those furnished through agreement or arrangement.

§485.635(a)(3)(ii) Policies and procedures for emergency medical services.

§485.635(a)(3)(iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.

§485.635(a)(3)(iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

§485.635(a)(3)(v) Procedures for reporting adverse drug reactions and errors in the administration of drugs.

§485.635(a)(3)(vi) A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

§485.635(a)(3)(vii) If the CAH furnishes inpatient services, procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of §483.25(i) is met with respect to inpatients receiving post CAH SNF care.

Findings included:

1. Review of the hospital's policies and procedures revealed that department supervisors annually reviewed departmental policies and procedures for acute care, obstetrics, surgery, anesthesia, laboratory, and infection control. The policies and procedures for rehabilitation services, the post-anesthesia recovery unit, and the swing bed program had not been reviewed annually.

2. On 07/12/17 at 9:00 AM during an interview with Surveyor #1, the hospital's Director of Nursing Services (Staff Member #1) stated the hospital did not have a policy identifying which CAH policies and procedures would be reviewed annually by a professional group, including a physician.
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ITEM #1 - OUTDATED MEDICATIONS

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that all drug storage areas were inspected monthly to prevent administration of outdated medications, as directed by hospital policy.

Failure to inspect medication storage areas and to remove and discard medications that have exceeded their manufacture's expiration date risks administration of medications that are no longer effective, which can result in patient harm.

Findings:

1. The hospital's policy and procedure entitled "Outdated Drug Control" (Reference #7071; Reviewed June 2017) stated that all locations where drugs were stored would be checked monthly for outdated items and immediately restocked.

2. On 07/11/2017 at 1:15 PM, Surveyor #1 inspected the emergency medication and supply storage cart in the acute care unit. The cart contained the following:

Adenocard (adenosine) 3 syringes - 6 mg/2 ml - Manufacturer's expiration date 7/1/2017

Calcium chloride 10% 1 syringe - 1 gm/100 ml - Manufacturer's expiration date 5/1/2017

Epinephrine 1:1000 1 mg/ml - 1 vial - Manufacturer's expiration date 7/1/2017

3. During an interview with Surveyor #1 at the time of the observation, the hospital's Director of Nursing (Staff Member #1) confirmed the findings above.


ITEM #2 - MULTI-DOSE MEDICATION VIALS

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement policies and procedures for labeling and storing multi-dose vials of medication.

Failure to date and discard multi-dose vials after 28 days of opening risks contamination of the contents of the vials and transmission of infectious diseases to patients during medication administration.

Findings:

1. The hospital's policy and procedure entitled "Opening/Dating Sterile Vials" (Reference #7071; Reviewed June 2017) stated that multi-dose vials of medication would be discarded 28 days after opening. When opened, the date of expiration would be written on the vial.

2. On 07/11/17 at 12:55 PM, Surveyor #1 inspected four vials of insulin in refrigerator section of the acute care unit's automated drug dispensing device. Pre-printed labels had been placed on the vials that read "Date Vial Expires" with a space for hospital staff to write the expiration date. Two of the vials had been labeled with an expiration date of 07/09/17. Two of the vials did not have an expiration date on the label.

3. During an interview with Surveyor #1 at the time of the observation, the acute care nurse manager (Staff Member #2) confirmed the findings above and discarded the vials.


ITEM #3 - COMPOUNDED INTRAVENOUS FLUIDS

Based on interview and review of hospital contracts, the Critical Access Hospital failed to ensure that contracts with pharmacies that compounded and distributed intravenous fluids were compliant with USP 797 standards for preparation of sterile products.

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. On 07/11/17 at 11:00 AM, Surveyor #1 interviewed the hospital's Director of Pharmacy (Staff Member #3) and a registered nurse who assisted with pharmacy procedures (Staff Member #4). During the interview, the staff members stated that the hospital had a contract with a compounding pharmacy to obtain intravenous fluids for parenteral nutrition when needed.

2. Review of the hospital's contract with this pharmacy revealed the contract did not include language to ensure that the pharmacy complied with USP 797 when preparing compounded intravenous fluids; and that the CAH had access to quality assurance date to verify adherence to USP 797.
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ITEM #1 EQUIPMENT CLEANING

Based on observation, interview, and document review, the Critical Access Hospital failed to clean the hospital's ice machines as specified in manufacturer's manuals; and to clean the microwave in the acute care unit as specified in Washington State Administrative Code for Food Service (246-215 WAC).

Failure to clean hospital equipment places patients, staff and visitors at risk of infection and illness.

Reference: Follett Ice machine 400 Series Manual states, "the frequency in cleaning and sanitizing ice machine according to the schedule below:"

Drain Line - weekly
Drain Pan/Drip Pan -weekly
Exterior - as needed
Condenser - Monthly (air-cooled only)
Ice Machine - semi-annually
Transport Tube - semi- annually

Findings included:

1. On 07/11/2017 between 10:00 AM and 11:00 AM, Surveyor #2 observed algae growth in the drip pans and drain lines of the Folett ice machines in the nourishment rooms in the acute care unit and emergency department. During an interview at the time of the observations, a facilities support staff member (Staff Member #6) stated that the ice machines were cleaned quarterly. This involved sanitizing the interior and exterior of the machines, and descaling and cleaning the condensers. Hospital staff members were not cleaning and sanitizing the drain lines and drip pans weekly. The ice machines were not being cleaned as directed by the manufacturer's directions for use.

2. On 07/12/2017 at 10:00 AM, Surveyor #2 observed that the microwave in the acute care nourishment room had food debris build up in the interior ceiling of the unit. During an interview at the time of the observation, the housekeeping manager (Staff Member #7) and dietary manager (Staff Member #8) stated that the responsibility for ensuring the cleaning frequency of the microwave had not been determined. The microwave was not being cleaned every 24 hours as directed by the Washington State food code.

Reference: Washington State Retail Food Code (2009 FDA Food Code 4-602.12): The cavities and door seals of microwave ovens must be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure.


ITEM #2 WATER MANAGEMENT PROGRAM

Based on interview and document review, the hospital failed to develop water management policies and procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the hospital water systems.

Failure to develop and implement a water management program places patients, staff, and visitors at risk for illness.

Findings included:

On 07/13/2017 between 8:00 AM and 9:00 AM, Surveyor #2 interviewed the Director of Primary and Ancillary Care (Staff Member #9) regarding the hospital's water system management program. During the interview, Surveyor #2 reviewed documentation of the facility's water system risk assessment and found that facility had not developed control measures or testing protocols to minimize waterborne pathogens.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that dietary staff members conducted a comprehensive nutritional assessment as directed by hospital policy and the patient's admitting physician for 2 of 5 long-term care ("swing bed") patients reviewed (Patients #2, #3).

Failure to ensure that patients at nutritional risk receive adequate nutrition can result in impaired healing and comorbidities.

Findings included:

1. The hospital's policy and procedure entitled "Swing Bed Dietary/Nutritional Services" (No Reference Number; Effective March 2006) stated that upon admission the "dietary staff" would complete and document a comprehensive nutritional assessment. A plan of care based on the assessment would be implemented and continuously reviewed and revised throughout the patient's hospital stay.

2. On 07/12/17, Surveyor #1 reviewed of the medical records of five "swing bed" patients currently receiving care in the hospital's inpatient unit. Each of the records included a pre-printed swing bed order set that included an order for a dietary consult. Review of the records for Patient #2, a patient with generalized weakness related to uncontrolled diabetes mellitus; and Patient #3, a patient with Parkinson's Disease, anemia, and renal failure, revealed that a comprehensive nutritional assessment had not been performed as ordered.

3. On 07/12/17 at 3:00 PM during an interview with Surveyor #1, the hospital's acute care nurse manager (Staff Member #2) confirmed the findings above.
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