HospitalInspections.org

.
Based on document review and interview, the critical access hospital failed to identify critical patient care equipment as a part of the overall equipment inventory.

Failure to identify critical patient care equipment as part of the hospital's total inventory puts patients at risk from injury and death in the event of an equipment malfunction.

Findings included:

1. Record review of the hospital policy titled "Preventive Maintenance", dated 07/20/16, showed the hospital process for maintaining both biomedical and non-medical patient care equipment, but failed to describe how the hospital determined which items it deemed critical for patient use.

2. On 10/18/17 at 3:05 PM, Surveyor #1 interviewed the Environmental Services manager (Staff #8) about the hospital's process for maintaining bio-medical equipment. He stated that the current system did not identify critical items within the hospital's inventory.



.

.
Item #1- Expired Stock Medication
.
Based on observation, interview, and review of hospital policies and procedures, the critical access hospital staff failed to complete monthly inspections on all drug and supply storage areas to prevent administration of outdated medications and supplies, as directed by hospital policy.
.
Failure to inspect medication storage areas and to remove and discard medications that have exceeded their manufacturer's expiration date risks administration of medications that are no longer effective, which could result in patient harm.
.
Findings included:
.
1. The hospital's policy titled, "Drugs and Biologicals" #13559, effective 3/08/16, stated that drugs would be checked monthly as well as each time used to avoid using outdated medications.
.
2. On 10/17/17 at 9:00 AM, Surveyor #2 and the Chief Nursing Officer (Staff #1) toured the facility's emergency room. Surveyor #2 found two containers of cream labeled as "cast cream" on a cart set up with orthopedic casting supplies. The observation showed that the cream had expired in 2001. An emergency medical technician (Staff #2) noted that the cream was no longer used for patient care and it was not clear why the containers were still on the cart. Hospital staff removed the cream at the time of the observation.
.
Item #2- Drugs or Biologicals Storage
.
Based on observation, interview, and review of hospital policies and procedure, the critical access hospital failed to keep all drugs and biologicals in the manufacture's container as directed by hospital policy.
.
Failure to keep drugs or biologicals in the original container could lead to degradation and reduced efficacy of the product.
.
Findings included:
.
1. The hospital's policy titled, "Drugs and Biologicals" #13559, effective 3/08/16 stated that drugs should be stored in the manufacturer's original container and that the storage area would be kept clean at all times.
.
2. During inspection of the Emergency Room supply area, Surveyor #2 and the Chief Nursing Officer (Staff #1) found a 250 cc intravenous solution of 50% dextrose that was not in the original dust cover. Staff #1 verified that if not used, the solution should be discarded once the plastic dust cover was removed. The solution was disposed of at the time of the survey.
.
Item #3- Cleanliness of Drug Storage Area
.
Based on observation, interview, and review of hospital policies and procedures, the critical access hospital staff failed to clean devices used to crush pills after each use.
.
Failure to clean pill-crushing devices could lead to contamination or mixing of medications that could be harmful to patients.
.
Findings included:

1. The hospital's policy titled, "Drugs and Biologicals" Policy #13559, effective 3/08/16, stated that drugs are to be stored in an area that it kept clean and neat at all times.
.
2. During inspection of the medication area in the Emergency Room, Surveyor #2 found 2 devices used to crush oral medications that had white residue still present in the device. The Chief Nursing Officer noted that the devices should have been wiped after use.


.

.
Item #1- Hand Hygiene

Based on observation, interview, and review of the critical access hospital's Contact Isolation signage, hospital staff failed to adhere to hand hygiene standards during care of a patient in isolation.
.
Failure to comply with hand hygiene guidelines creates a risk for transmission of infections to other patients, visitors, and staff.
.
Findings included:
.
1. The Washington State Hospital Association (WSHA) placard for contact isolation was posted outside the patient's room. The placard stated that cleaning hands should be done before and after care for a patient in Contact Isolation.
.
2. On 10/17/17 at 10:00 AM, Surveyor #2 observed a Certified Nursing Assistant (CNA) (Staff #3) as she cared for a patient in room 205. The patient was in contact isolation with the WSHA placard posted outside the room. The observation showed that the CNA donned a gown and wore gloves to enter the room and care for the patient. After providing care, the CNA moved toward another location in the room. The CNA pushed up her glasses with her gloved hand causing potential contamination. The Chief Nursing Officer (Staff #1) observed the action and agreed it could lead to potential contamination of the staff member and other patients.

Item #2- Maintenance of Ice Dispensers

Based on document review and interview, the critical access hospital failed to maintain ice machines as indicated in the manufacturer's operating manual.

Failure to comply with manufacturer's instructions for maintaining automated ice dispensers puts patients, visitors, and staff at risk of exposure to waterborne organisms.

Findings included:

1. On 10/18/17 at 3:30 PM during a review of the hospital's equipment maintenance program, Surveyor #1 asked the environmental services manager (Staff #8) about the process for maintaining ice machine/dispensers throughout the facility. At the time of the interview, the staff member was unable to show evidence of completed preventive maintenance for the machines, but stated that they had been done every six months.

2. On 10/19/17 at 1:15 PM, Staff #8 provided two printouts from the hospital's computerized work order system that showed that the maintenance staff completed service of the 5 listed ice machines for 02/06/17, but did not show completion of work on the service ticket initiated on 08/07/17.

.
Based on interview, policy, and document review, hospital staff failed to follow their policy for responding in writing to initial complaints and documenting the resolution of the complaint follow up.
.
Failure to respond to complaints after receipt and tracking follow-up until their conclusion, could lead to a failure to identify problems that lead to substandard patient care.
.
Findings included:
.
1. The hospital's policy, "Concern/Grievance/Complaint Reporting" #13515, effective 04/18/16, stated that the Quality Director logs complaints in the Complaint Notebook and sends a letter to the complainant informing them that the issue is under inquiry or investigation. The policy further stated that within 30 days of receipt of the complaint, the complainant would receive a status update or resolution letter.
.
2. During review of complaints and grievances, Surveyor #2 found 1 of 3 complaints reviewed had no record that an initial or resolution letter had been sent to the complainant for a grievance filed on 06/19/17. The Director of Quality (Staff #6) agreed with the findings at the time of the review.