HospitalInspections.org

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Based on observation and interview, the critical access hospital failed to ensure that hospital staff members removed patient care supplies from available use once they had exceeded the manufacturer's expiration date.
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Failure to maintain supplies places the patients at risk for infection from non-sterile supplies and for delays in treatment resulting from ineffective blood specimen collections.
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Findings:
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1. During the survey, Surveyor #1 made the following observations:
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a. On 5/12/2015 at 1:40 PM, in the medical-surgical unit: one anaerobic culture vial with an expiration date of 4/30/2015; one red topped specimen tube with an expiration date of 03/2015 and one 7.7 mm pediatric tracheostomy tube with a manufacturer's do not use beyond date of 03/2015.
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b. On 5/13/2015 at 10:00 AM, in the operating room: two yellow topped specimen tubes with an expiration date of 02/2015.
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c. On 5/14/2015 at 8:00 AM, in the medical ambulatory care unit: two yellow topped specimen tubes with an expiration date of 06/2014 and one yellow topped laboratory tube with an expiration date of 03/2014.
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2. On 5/12/2015 at 1:40 AM, Surveyor #1 interviewed the medical-surgical nurse manager (Staff Member #1) who stated the nursing staff was responsible for completion of monthly checks of outdated or expired patient supplies.
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Based on record review and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 3 patients reviewed (Patients #1, #2).
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Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.
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Findings:
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1. The hospital policy and procedure titled "Blood and Blood Product Transfusion" (Revised 7/11/2014) read: "Make sure that a written order is in the patient's medical record; the order should address preparation of the product and administration (including the start time and rate of infusion). . .Obtain and record the patient's vital signs (temperature, pulse, respirations, and blood pressure) within 30 minutes before initiating the transfusion to serve as a baseline for comparison. . .Obtain vital signs 15 minutes after the start of the transfusion and any time that the patient's condition warrants during the transfusion."
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2. On 5/14/2015 at 10:30 AM, Surveyor #1 reviewed the records of 3 patients who received blood transfusions during their hospital stay and observed the following:
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a. Nursing staff did not document the initial 15 minute vital signs upon beginning the blood administration for Patient #1 until the 25 minute mark (10 minutes late) as required by policy.
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b. Patient #2 had a physician order to receive four units of packed red blood cells and to transfuse each unit over four hours. Patient #2 received all four units faster than the prescribed transfusion rate (Unit #1 60 minutes early; Unit #2 40 minutes early; Unit #3 35 minutes early; and Unit #4 65 minutes early).
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Based on observation the critical access hospital failed to maintain a proper ventilation regimen in the micro-biology laboratory.

Failure on the part of the facilty to provide proper ventilation in the lab poses a risk of infection and or exposure to airborne contaminates.

References: ASHRAE/ASHE Standard 170-2008; Ventilation of Health Care Facilities, Table 7-1 Design Standards; and American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities 2006 ed., Table 2.1-2 Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities.

Finding:

On 5/12/2015 at 10:25 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 micro-biology laboratory. The flutter strip showed that the direction of air flow at the door of the micro-biology laboratory was out to the main laboratory area and not into the micro-biology 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 and review of hospital policies and procedures, the critical access hospital failed to ensure staff members followed its policy for monitoring restrained patients as demonstrated by review of 3 of 3 patients (Patients #3, #4, #5.)
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Failure to follow policies and procedures for monitoring restrained patients risks physical and psychological harm, loss of dignity, and violation of patient rights.
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Findings:
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1. The hospital's policy and procedure titled "Use of Restraints" (last revised 4/26/2013) read: "Each episode for restraints/seclusion should be documented on the restraint flow sheet and address the monitoring and assessment points . . . Patients will be monitored every hour or more often if patient condition warrants for correct restraint positioning and proper body alignment, circulation, movement, sensation and skin integrity as defined on the Safety/Restraint Flowsheet."
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2. Review of the records of three patients placed in restraints revealed the following:
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a. Patient #3 was an 84 year-old patient who was admitted on 10/11/2014 for metabolic alkalosis and severe hyperkalemia. The patient became disoriented, unable to follow instructions and attempted to pull out his/her medically necessary devices and was physically restrained on 10/12/2014 at 7:00 AM. Staff members initiated the restraint flow sheet with appropriate documentation until 3:00 PM with the next annotation in the electronic medical record at 7:00 PM, a period of over four hours without documentation for restraint monitoring.
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b. Patient #4 was a 81 year-old patient who was admitted on 11/25/2014 for right hip fracture. The patient became agitated and combative and was restrained on 11/26/2014. Staff members initiated the restraint flow sheet with appropriate documentation until 11:00 PM with the next annotation in the electronic medical record on 11/27/2014 at 6:48 AM, a period of over seven hours without documentation for restraint monitoring.
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c. Patient #5 was a 77 year-old patient who was admitted on 11/25/2014 for altered mental status, congestive heart failure, and chronic obstructive pulmonary disease. The patient was restrained on 11/28/2014 at 3:45 PM. Staff members initiated the restraint flow sheet with appropriate documentation until 8:00 PM with the next annotation in the electronic medical record at 11:00 PM, a period of three hours without documentation for restraint monitoring.
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Based on document review, the critical access hospital failed to ensure that its professional health care staff completed an annual review of all patient care policies.

Failure to conduct an annual policy review puts patients at risk of unsafe or inadequate care.
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Findings:

On 5/12/2015 - 5/15/2015, Surveyor #1 reviewed the hospital's patient care policies and found several policies had not been reviewed within the last year. Examples of the out-of-date policies include:

a. Hospital policy titled "Expiration of Multiple Dose Vials and Single Dose Vials" last revised 1/09/2012.

b. Hospital policy titled "Read-back of Verbal and Telephone Orders for Medications" last revised 10/02/2002.

c. Hospital policy titled "Anesthesia Service Drug Handling" last revised 9/19/2011.

d. Hospital policy titled "Triage" last revised 9/22/2011.

e. Hospital policy titled "Medical Screening Exam" last revised 9/22/2011.

f. Hospital policy titled "Hand-off Communication - Discharge or Transfer to Another Facility or Level of Care" last revised 11/30/2006.

g. Hospital policy titled "PACU Discharge Criteria" last revised 6/1/2000.

h. Hospital policy titled "Discharge Criteria for Outpatient Surgery" last revised 5/01/2011.
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ITEM #1 - MULTIDOSE VIALS
Based on observation and review of hospital policies and procedures, the critical access hospital failed to ensure that all drug storage areas were inspected to prevent administration of outdated or unusable medications.

Failure to assure medication storage areas are devoid of outdated or otherwise unusable medicatons puts patients at risk for receiving medications with compromised sterility, integrity or stability.

Findings:
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1. The hospital's policy and procedure titled "Expiration of Multiple Dose Vials and Single Dose Vials" (Revised 1/9/2012) read: "Multi-dose vials will expire 30 days after they are opened. The date that they are opened shall be written in permanent marker on each vial."
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2. On 5/12/2015 at 1:40 PM during a survey of the medical-surgical nursing unit medication storage area, Surveyor #1 found one opened and un-dated multidose vial of Novolin 70/30 insulin; one opened multidose vial of Novolin N insulin with a date marked 1/1/2015; and one open multidose vial of Novolin R insulin with a date sticker stating "do not use after 5/9/2015".
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3. On 5/13/2015 at 11:00 AM during a tour of the operating room, Surveyor #1 found one opened multidose 50 ml vial of Lidocaine 1% with a date marked "2/6".
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ITEM#2 UNLABELED SYRINGES
Based on observation and review of hospital policies and procedures, the critical access hospital failed to implement its policy to ensure that staff members labeled intravenous medications prepared in pre-drawn syringes according to accepted standards of practice.
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Failure to label pre-drawn syringes of medications risks medication errors and transmission of communicable diseases to patients.
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Findings:
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1. The anesthesia department's (Anesthesia Associates Northwest LLC) policy and procedure titled "Medication and Solution Administration in the OR" (Effective 11/11/2014) read, "All medications in the perioperative area shall be labeled. This includes medications and solutions on and off the sterile field. The label will include: The name of the medication/solution; Strength of the medication/solution; Amount (if not apparent from the container) Original Volume; Time of expiration, when the medication/solution expires in less than 24 hours . . . Note that correct and complete labeling of all syringes must be performed if the medication is not immediately administered."
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2. On 5/13/2015 at 9:30 AM, in the hospital's operating room, Surveyor #1 observed four prepared syringes in the anesthesia cart. One syringe was labeled midazolam 1mg/ml; one syringe labeled fentanyl 50mcg/ml; and one syringe labeled lidocaine 50mg and propofol 10mg/ml. None of the prepared syringes observed contained the date, time prepared, or initials of the person who prepared the medication. A fifth syringe was found in the anesthesia cart labeled succinylcholine 20mg/ml marked 5/12/2015 and "0700 hrs" and the initials of the preparer.
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ITEM #1 - Terminal Cleaning:
Based on observation and interview the critical access hospital (CAH) failed to ensure the control of potential infections by implementing appropriate nationally recognized standards of prevention. More specifically, the CAH failed to perform terminal case cleaning of an operating room in the manner prescribed by a nationally recognized body and the facility's own policy.

Failure on the part of the CAH to implement nationally recognized infection control standards and facility policy puts patients at risk of nosocomial infection.

References: Association for the Prevention of Infection Control (APIC) Text of Infection Control & Epidemiology, Vol. II: Scientific & Practice Elements; Second Edition, January 2005; Chapter 102-2 Environmental Services; and

Whidbey General Hospital and Clinics Environmental Services Policy Title: Surgical Terminal Case Cleaning, Original Date: 2/2011

Findings:

1. On 5/12/2015 between the hours of 3:00 PM and 4:00 PM, Surveyor #2 observed the terminal cleaning of an operating room by two members of the Environmental Services (EVS) staff (Staff Members #4 and #5). During the course of the cleaning process the following breaches of infection control standards were observed:

a. Window blinds and sills of the operating room were not cleaned and disinfected;

b. Blood was left on the exterior surface of a sharps disposal container;
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c. A cleaning cloth used to clean and disinfect a mayo stand was allowed to touch the floor while the stand's wheel casters were being wiped down.The same cleaning cloth was then used to clean additional vertical surfaces of the stand such as its legs.

ITEM #2 - Food Services
Based on observation and interview the critical access 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 puts patients at risk of food borne illness.

Findings:
1. On 5/13/2015 at 9:30 AM, Surveyor #2 noted in the left walk-in freezer, food products(butter chips and pizza dough) were being kept on the floor of the freezer. Further, in the left walk-in cooler, food products (corn and pork chops) were being kept on the floor as well.

Reference: Washington State Retail Food Code Working Document; Part 3: Food; Subsection C Preventing Contamination After Receiving; 03351 (1)(c) Preventing contamination from the premises - Food storage (2009 FDA Food Code 3-305.11).

2. On 5/13/2015 at 9:40 AM, Surveyor #2 noted that pots were being stored in such a manner and location that they were subject to splash from an adjacent hand wash sink. More specifically, the pots were stored below the level of the hand wash sink and were not inverted to prevent potential contamination of their food contact surfaces. This deficiency was corrected at the time of the finding.

Reference: Washington State Retail Food Code Working Document; Part 4: Equipment, Utensils and Linens, Subpart I - Protection of Clean Items; 04920 (1)(b) and (2)(b) Storing - Equipment, utensils, linens, and single-service and single-use articles (2009 FDA Food Code 4-903.11).
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Based on interview, record review, and review of hospital policies and procedures, the critical access hospital failed to ensure staff members follow the hospital's policy and procedure for medication administration (Patient #6)
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Failure to follow policies and procedures for medication administration puts patients at risk of medication errors.
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Findings:
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1. The hospital policy and procedure titled "Administration of Medications: Recording in Patient's Record" (revised 1/2012) read "Properly record every dose of every medication administered in the patient's record after administration. Clearly enter or identify the time of administration and the person administering each dose."
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2. On 5/13/2015 at 3:30 PM in the Family Birth Center, Surveyor #1 reviewed the routine newborn care protocol orders for Patient #6, an infant who was born the previous day. The protocol orders prescribed Erythromycin ophthalmic ointment to each eye within 1 hour of birth and intramuscular Vitamin K (1 mg) within 4 hours of birth. There was no evidence in the electronic medical record that the medications had been administered as ordered by the physician.
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3. An interview with the registered nurse (Staff Member #2) immediately following the record review confirmed the above findings. A subsequent and immediate follow-up phone call on 5/13/2015 by Staff Member #2 to the nursing staff member who provided care for the infant on the day of delivery confirmed Patient #6 had received the two medications but failed to record them in the electronic medical record.
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