HospitalInspections.org

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Item #1 - Aseptic Technique

Based on observation and review of policy and procedure, the facility failed to ensure that antiseptic technique during the administration of medications was adhered to.

Failure to do so created risk for transmission of infection during the medication administration process for 3 of 3 patients..

Findings:

1. The Risk Management/Process Improvement Director (Staff Member #8) stated that the facility used "Mosby's Clinical Skills for Medication Administration" as the policy for intravenous (IV) medication administration.

2. In review of "Mosby's Clinical Skills Medication Administration: Injection Preparation from Ampules and Vials, Extended Text" (2006-2015) used by the facility, under "Preparing a Vial Containing a Solution" it stated, ". . . Firmly and briskly wipe surface of rubber seal with alcohol swab; being sure to apply friction and allow it to dry . . . Not all drug manufacturers guarantee that rubber seals of unused vials are sterile. . ."

3. "Mosby's Clinical Skills" also stated, "Medication Administration: Intravenous Bolus. . ." e. Intravenous Push (Existing Line). . . 2. Using friction, clean the access port or hub with an antiseptic swab and then allow the port to air dry completely. "

4. a. On 11/3/2015 at 12:00 PM Surveyor #2 observed a nurse (Staff Member #1) obtain medications for administration to Patient #1. One of the medications was a steroid to be administered intravenously. The nurse removed the dust cover from the medication vial and, without cleaning the rubber diaphragm of the vial with an antiseptic product, s/he pierced the vial with a needle, withdrew the medication into a syringe and injected the medication intravenously into the patient.

b. On 11/3/2015 at 1:53 PM, in the Endoscopy suite, Surveyor #1 observed a registered nurse (RN) (Staff Member #9) administer intravenous (IV) medication for sedation to (Patient #6) who underwent an esophagogastroduodenoscopy (EGD), a diagnostic procedure that visualizes the upper part of the gastrointestinal tract. S/he did not disinfect the hub connection site on the IV with an antiseptic wipe two out of four times during medication administration.

c. On 11/3/2015 at 2:25 PM, in the Interventional Radiology suite, Surveyor #1 observed an RN (Staff Member #10) administer intravenous (IV) medication for sedation to (Patient #3 who underwent a procedure to place a venous access device placement in the chest area. S/he did not disinfect the IV port site prior to administering medication 2 out of 2 times.


Item #2 - Double Verification of Medication

Based on review of policy and procedure and record review, the facility failed to ensure that standards were adhered to for administration of medications in 2 of 2 pediatric patients.

Failure to do so creates risk for errors in medication administration and possible harm to patients.

Findings:

1. In review of facility policy titled, "High Alert Medication (Double Check) Policy" (Dept/Committee Approval 3/25/15) under item 3 "Special Populations", it stated, "All medications are double checked in pediatric patients 17 years or younger. 4. Double checking is required when a. the medication is started . . ."

2. The following chart reviews showed that there was no documentation of double verification of medication prior to administration:

a. In review of the record of a 17 year old pediatric patient (Patient #4) initially seen in the emergency department on 6/28/2015 and discharged 7/1/2015, s/he received several doses of medications during care for a ruptured appendix, including surgery for drainage of an abscess and placement of a drain. The medication types included oral and/or intravenous anti-nausea medication, opioids, sedation medication and antibiotics.

b. Another pediatric patient (Patient #5) seen in the emergency department for a flare-up of allergies on 9/10/2015 received a nebulizer treatment of 2 medications to the lungs from a respiratory therapist and steroid medication.







36018

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ITEM #1 - FOOD SERVICES - COMPLIANCE WITH WASHINGTON STATE RETAIL FOOD CODE

Based on observation, the hospital failed to provide dietary services in a manner consistent with the Washington State Retail Food Code (Washington Administrative Code 246-215).

Failure to maintain acceptable standards of practice for food service put patients at risk of food borne illness.

Findings:

1. On 11/4/2015 between the hours of 9:00 AM and 12:30 PM Surveyor #3 noted that the hospital kitchen staff had sponges available for the cleaning of work and food contact surfaces in the cold preparation area and at the three compartment sink near the scullery.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart A, 04125 Multiuse - Sponges, use limitation (2009 FDA Food Code 4-101.16)

2. On 11/4/2015 between the hours of 9:00 AM and 12:30 PM Surveyor #3 noted that a food utility cart used for the staging of cookies (loosely covered) and various utensils was parked next to a handwash sink. The cart's proximity to the hand wash sink was such that there was a high risk of cross contamination of the items placed on the cart.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 3, Subsection C, 03351 Preventing contamination from the premises - Food storage (2009 FDA Food Code 3-305.11(1)(b))

3. On 11/4/2015 between the hours of 9:00 AM and 12:30 PM Surveyor #3 noted that the sanitizing rinse chamber of the kitchen's 3-compartment sink had no sanitizer as demonstrated by a test strip. Subsequent to the finding it was determined by hospital staff that the automatic sanitizer dispenser was not working properly.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart G, 04710 (3) Methods - Hot water and chemical (2009 FDA Food Code 4-703.11)

4. On 11/4/2015 between the hours of 9:00 AM and 12:30 PM Surveyor #3 noted that a red bucket (sanitizer) in the cold production area had no sanitizer as demonstrated by a test strip. Subsequent to the finding it was determined by hospital staff that the automatic sanitizer dispenser was not working properly.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart G, 04710 (3) Methods - Hot water and chemical (2009 FDA Food Code 4-703.11)

5. On 11/4/2015 at 11:25 AM Surveyor #3 checked the food temperatures of various items on the cafeteria salad bar. Using a thin stem digital thermometer the surveyor noted that potentially hazardous food items (cut leafy greens) were at temperatures higher than allowed by code, i.e. 41 degrees Fahrenheit. Leaf lettuce was found being kept at 45 degrees Fahrenheit; salad mix at 43.1 degrees Fahrenheit and spinach at 43 degrees Fahrenheit.

ITEM #2 - INTERVENTIONAL RADIOLOGY

Based on observation, the hospital failed to meet recognized standards of practice for maintaining "sterile technique" during an interventional radiology procedure.

Failure on the part of the hospital to employ recognized standards of practice for interventional radiology put patients at risk of infection.

Reference: STANDARDS OF PRACTICE; Joint Practice Guideline for Sterile Technique during Vascular and Interventional Radiology Procedures: From the Society of Interventional Radiology, Association of periOperative Registered Nurses, and Association for Radiologic and Imaging Nursing, for the Society of Interventional Radiology.

Finding:

On 11/4/2015 at 3:05 PM Surveyor #3 noted that during a case being performed in the Interventional Radiology (IR) procedure room the door leading from the procedure room to the control room and the door from the control room to the adjacent corridor were in the open position, not closed as is recommended by current standards of practice.

ITEM #3 - SURGICAL ENVIRONMENT

Based on observation the hospital failed to properly maintain the surgical environment in such a manner as to limit the potential for surgical site infections (SSI's).

Failure on the part of the hospital to maintain the surgical environment put patients at risk of infection.

Findings:

1. On 11/4/2015 between the hours of 4:00 PM and 4:30 PM Surveyor #3 noted the following:

a. Adhesive tape had been used to secure radio antennas to the walls of operating rooms #2 and #3;

b. Adhesive tape had been used in operating room #3 to cover holes on the back wall;

c. A split seam was noted at the interface of the floor and the base coving in operating room #1;

d. Walls in operating room #1 were gouged and certain areas were missing paint making them difficult to properly clean; and

e. A member of the surgical team, a Registered Nurse (Staff Member #16), was observed leaning a mop handle against a wall surface in operating room (OR) #3. The wall surface had just been wiped and disinfected during the course of the room being cleaned between cases. When asked if the mop handle had been wiped/disinfected before bringing it into the OR the RN indicated that it had not been wiped/disinfected after use in another setting.


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ITEM #4 - HAND HYGIENE

Based on observation and review of policy and procedure, the facility failed to ensure that hand hygiene was performed as required for patient care.

Failure to do so created risk that patients may be exposed to infections and develop infections.

Findings:

1 a.. In review of facility policy and procedure titled "Hand Hygiene Policy" (Revised 01/14) it outlined the indications for hand hygiene on page 2 under section B. Item 5 stated, "After contact with inanimate environment (i.e. anything that has come in contact with floor, cell phone, pen, pencil) sources likely to be contaminated". Another part of the policy identified times to perform hand hygiene ". . . Before patient contact. . .6. After contact with patients and patient care equipment... 7. After removing gloves."

b. In review of another policy titled, "Mosby's Isolation Precautions: Personal Protective Equipment Quicksheet" it provided instructions for donning a gown. Item "11" stated to "Perform hand hygiene" just prior to donning a [protective] gown.

2. a. On 11/3/2015 at 12:00 PM Surveyor #2 observed a nurse (Staff Member #1) obtain medications from the intensive care unit's medication storage cabinet (using a keyboard and obtaining medication out of locked compartments) for administration to Patient #1. After the nurse used the equipment s/he brought the medication to the outside of the patient's room. Without performing hand hygiene s/he donned a protective gown and gloves (the patient was on isolation precautions), entered the room and proceeded to provide patient care including, but not limited to, injection of intravenous medication.

b. On 11/3/2015 at 11:45 AM Surveyor #2 observed another nurse (Staff Member #2) obtain medications for another patient (Patient #2) and did not perform hand hygiene prior to gown and glove placement, then entered the patient's room (on isolation precautions) to administer oral medications.

c. On 11/4/2015 at 10:30 AM Surveyor #2 observed a nurse (Staff member #3) enter a patient's isolation room (Patient #3) to administer medications (including intravenous medication) without performing hand hygiene prior to gown and glove placement.

3. On 11/4/2015 at 2:00 PM Surveyor #2 observed a nurse (Staff Member #5) assist another nurse in the verifying procedure prior to the administration of blood. The nurse did not perform hand hygiene prior to making patient contact to read the patient's identification band. When the nurse completed the procedure, s/he exited the room and was not observed to perform hand hygiene after patient contact.

4. On 11/4/2015 Surveyor #1 observed the following failures to perform hand hygiene (HH) in accordance with hospital policy.

a. In Operating Room #2, on 11/4/2015 at 2:00 PM, an anesthesiologist (Staff Member #11) removed her/his gloves then without performing hand hygiene, donned a new pair of gloves.

b. At 2:15 PM the same staff member (Staff Member #11) retrieved a syringe s/he dropped on the floor and did not change gloves or perform hand hygiene before proceeding to other patient care activities.



ITEM #5 - PERSONAL PROTECTIVE EQUIPMENT (PPE)

Based on review of policy and procedure the facility failed to assure that staff adhered to standards for donning personal protective equipment.

Failure to do so creates risk that infection may be transmitted between patients being care for by staff.

Findings:

1. In review of facility document titled, "Mosby's Isolation Precautions: Personal Protective Equipment" (Copyright 2006-2015 Elsevier), it provided information about donning a gown. Under item 12 it stated, "a. Ensure the gown covers the torso from the neck to the knees, arms to the end of the wrists, and wraps around the back. . . c. Fasten the gown securely at the back of the neck and the waist." It further described technique and then item #15 stated, "Don gloves, bringing the glove cuff over the edge of the gown sleeves."

2. a. On 11/3/2015 at 12:00 PM Surveyor #2 observed a nurse (Staff Member #1) don PPE to provide care to Patient #1 who was on isolation precautions. The protective gown was worn in a manner that it was open in the back and therefore her/his uniform was not protected from potential cross-contamination.

During that same time period a respiratory therapist was providing care in the patient's room. His/her protective gown was worn in a manner that it was also open in the back.

b. On 11/3/2015 at 11:45 AM Surveyor #2 observed a nurse (Staff Member #2) don PPE to provide care to Patient #2 who was on isolation precautions. The protective gown was worn in a manner that it was open in the back and therefore her/his uniform was not protected from potential cross-contamination.

c. On 11/4/2015 at 10:30 AM Surveyor #2 observed a nurse (Staff member #3) don PPE to provide care to Patient #3. The protective gown was in a manner that it was open in the back and therefore her/his uniform was not protected from potential cross-contamination .






36018

Based on observation, interview and review of hospital policy the hospital failed to follow recommended practice for protecting patients from infection by containing all hair and facial hair during surgical procedures.

Failure to follow recommended practice for containing hair and facial hair posed a risk of contamination of the sterile field and possible infection to patients.

Reference: Association of Perioperative Registered Nurses (AORN) "Guideline for Surgical Attire, 2015", Recommendation III a. " A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of neck should be worn. "

Findings:

1. On 11/4/2015 at 1:00 PM, the Perioperative Director (Staff Member #5) stated that the facility followed AORN guidelines in the formulation of their policies and procedures.

2. The hospital's policy and procedure entitled "Attire in Sterile Procedure Areas" (Policy# SURG-93, Approved 3/25/2015) read as follows: . . . " II. Procedure: A. Scrub Clothing: . . . 5. Head Covers: Disposable and Reusable head covers must cover all hair on the head and replaced daily. 6. All personnel entering the restricted area of the operating room suite should wear high filtration masks . . . b. If mask does not cover all facial hair including beards and sideburns, then a hood must be worn."

3. On 11/4/2015 at 1:40 PM, Surveyor #1 observed the following in Operating Room #2 during surgical setup and during an arthroplasty (a surgical procedure to replace a joint) of a toe joint performed on (Patient #8).

a. At 1:45 PM, Surveyor #1 observed a surgical technician (Staff Member #13) who wore a disposable bouffant type head cover which did not completely contain hair at the sides and back of the head.

b. At 2:20 PM, the surgeon (Staff Member #14) wore a disposable bouffant type head cover that did not cover his/her sideburns.

4. On 11/4/2016 at 4:20 PM Surveyor #3 observed a doctor (Staff Member #15 ) on the surgical team enter operating room (OR) #2. At the time of the observation the doctor was not wearing his/her surgical mask in the appropriate manner. Instead of securing the mask with the use of its ties the doctor merely held it to his/her face when entering the OR. Shortly thereafter the doctor was observed affixing the mask properly by using its ties.

5. On 11/5/2015 at 2:45 PM Surveyor #3 observed a member of the medical staff (Staff Member #17) at the 2nd floor nurses station. At the time of the observation the staff member had a surgical mask hanging from his/her neck. At that time it was acknowledged by the doctor that the mask should have been removed and disposed of in the restricted OR area due to its potential of having been contaminated while being worn in that area.