HospitalInspections.org

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Based on interview and record review, the hospital failed to ensure hospital staff members followed hospital policies and procedures related to the use of physical restraints for 1 of 3 patient records reviewed (Patient #5).

Failure to follow policies and procedures related to the use of physical restraints put patients at risk for injury or death, as well as leaving patients in restraints longer then deemed necessary.

Findings:

1. The hospital's policy and procedure entitled "Restraint Management" (Policy Number: 5.33A, Revision Date: February 2012), in part reads "IV. Monitoring/Reassessment A. Observation & monitoring of patients on the psychiatric units and in the Emergency Department will occur at least every 15 minutes. Observation & monitoring of other restrained patients will occur at least every two hours." " VII. Discontinuing Restraints: Restraint is discontinued as soon as the unsafe situation no longer exists based on the determination by the licensed independent practitioner (LIP) or qualified RN that the need is no longer present or that the patient's needs can be addressed with less restrictive methods..." "VIII. Documentation A. The use of restraint is recorded in the patient's medical record. Documentation of the ongoing nursing care related to restraint reduction occurs at least every four hours. Documentation will include, but not limited to: 1. Relevant orders for use; 2. Patient's behavior, condition or symptoms that warrant the use of restraints; 3. Less restrictive interventions considered or attempted (as applicable); 4. Intervention used; 5. Results of patient monitoring; 6. Reassessment; 7. Significant changes in the patient's condition; 8. Patient's response to the intervention; 9. Rationale for the continued use of restraint ..."


2. On 12/11/2014 at 3:30 PM, Surveyor #6 reviewed closed medical records for patients (non-violent behavior, non-self-destructive) who had been placed in restraints. Patient #5's record revealed a 66-year-old patient who had been admitted to the hospital's 4 East unit on 11/7/2014 for treatment of increased shortness of breath, hepatitis C, cirrhosis, and dementia. The patient was placed in 3-point restraints on 11/9/2014 at 1:00 PM for safety and fall prevention. Documentation on 11/11/2014 at 8:14 PM showed the patient remained in restraints. The patient was transferred to the medical intensive care unit (MICU) on 11/12/2014 due to deteriorating health status. The patient's record revealed that he/she remained in restraints on 11/13/2014 at 4:35 PM. The patient's medical record did not include evidence that the patient's need for restraints had been assessed every four hours by nursing staff members. There was no documentation in the medical record indicating when the restraints had been removed. The record did not include an assessment, by the LIP or qualified RN, determining the patient was safe to be out of restraints.

3. These findings were confirmed by the acute care clinical nurse specialist (Staff Member #6) and cardiology clinical nurse specialist (Staff Member #7) during an interview with Surveyor #6 on 12/11/2014 at 4:00 pm.

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Based on interview and record review, the hospital staff failed to complete the initial admission assessment according to policy for 3 of 10 patients reviewed (Patients #2, #3, #4).

Failure to complete the medical record places patients at risk of receiving or not receiving care and services required.
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Findings:
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1. The hospital's policy and procedure entitled "Documentation of Nursing Care and Interdisciplinary Care Planning (Inpatient)" read in part: "1. Admission Assessment: The initial patient assessment is located on the Admission History PowerForm and will be initiated by the RN immediately upon patient arrival and completed within 24 hours of the admission. The typical assessment may include: Patient history and physical assessment. . . Past medical health history. . .Nutritional and functional status screening and presence of pressure ulcers. . . II Exceptions to Admission Assessment Standards: B. Psychiatric Units may have the admission history/assessment initiated by the Mental Health Specialist with review and co-signature from the RN. . . D. The inability to obtain historical medical information will be documented on the Admission History PowerForm".
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2. On 12/9/2014 at 3:30 PM in the adult psychiatric unit, an open medical record review of two patients revealed:
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a. Patient #2's initial admission assessment did not have the required registered nurse review and co-signature. Patient #2 was admitted on 11/11/2014.
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b. Patient #3's initial admission assessment did not include a past medical or surgical history and was left blank. Patient #3 was admitted on 11/5/2014.
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c. An interview on 12/9/2014 at 3:30 PM with the Nurse Manager of the psychiatric unit (Staff Member #4) confirmed these findings.
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3. On 12/12/2014 at 9:00 AM, a closed medical record review revealed that Patient #4 did not have a nutritional screening done during the initial admission assessment. Patient #4 underwent left neck dissection for cancer. This finding was confirmed by a patient care information system analyst (Staff Member #5).

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Based on observation and interview, the hospital failed to ensure that all drug storage areas were inspected to prevent administration of outdated or unusable medications.
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Failure to assure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, or stability.
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Findings:
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1. During the survey, Surveyor #2 found the following:
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a. On 12/10/2014 at 2:00 PM during an inspection of the pulmonary function laboratory clinic medication storage area: one vial of injectable Lidocaine 1% 10ml dated "10/28" and three syringes labeled provocholine 0.025mg/ml with the annotation "prep 12/4/2014".
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An interview on 12/10/2014 at 3:00 PM with the Director of Pharmacy Services, (Staff Member #2) confirmed that syringes prepared outside of the pharmacy are for immediate use only and should not be prepared in advance.
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b. On 12/10/2014 at 3:00 PM during inspection of the spine center procedural medication storage area: one open single dose vial of injectable Lidocaine 1% 50mg/5ml with the annotation "12/9" and the word "Buf".
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c. On 12/11/2014 at 10:30 AM during inspection of the eye institute medication storage areas: eleven bottles of "Kupers (Ped) Opthalmic solution" with a best used date of 11/20/2014 and five bottles of Rose Bengal 3ml solution with a best used date of 11/30/2014.
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d. On 12/11/2014 at 4:00 PM during inspection of the intravenous fluid warmer in the Interventional Radiology suite revealed one 100ml bag of 0.9% sodium chloride with a expiration date sticker of 21 June 2014.

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Item #1: - Food Service
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Based on observation the facility failed to comply with the 2009 FDA Food Code and/or the Washington State Retail Food Code Chapter 246-215 Washington Administrative Code (WAC).
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Failure on the part of the facility to comply with the FDA Food Code and/or state regulations for food service put patients, staff and visitors of the facility at risk of food borne illness.
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Reference: Section 02330 Jewelry - - Prohibition (2009 FDA Food Code 2-302.11.
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Findings:
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On 12/10/2014 at 11:30 AM, Surveyor #3 noted that a kitchen worker (Staff Member #8) was preparing food while wearing a wristwatch.
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Item #2: - Ventilation
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Based on observation the facility failed to provide ventilation in certain areas of the facility that meet recognized standards.
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Failure on the part of the facility to provide proper ventilation puts patients at risk of airborne infection.
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Reference: 2010 Edition of the Guidelines for Design and Construction of Health Care Facilities as published by the American Society for Healthcare Engineering of the American Hospital Association.
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Findings:
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On 11/9/2014 between the hours of 11:20 AM and 2:00 PM Surveyor #3 used a light weight flutter strip to assess the direction of air flow into and out of soiled and clean utility rooms. This in turn allowed the surveyor to determine the air pressure relationships between the rooms tested and the adjoining corridor(s). The following improper air pressure relationships were noted:
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a. Trauma ICU room 9ME 963, a clean utility, was noted as being negative to the adjoining corridor;
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b. Burn Step-Down rooms 8EH 19 and 27, clean utility rooms, were noted as being negative to the adjoining corridor;
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c. General Surgery room 7EH 27, a clean utility, was noted as being negative to the adjoining corridor; and
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d. Orthopedics room 6EH 31, a clean utility, was noted as being negative to the adjoining corridor.

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Item #1 - Hand Hygiene

Based on observation certain staff of the facility failed to perform hand hygiene when required.

Failure on the part of staff to perform hand hygiene when required puts patients and staff at risk of infection.

Findings:

1. Harborview Medical Center Infection Control Manual; Hand Hygiene Policy, Effective Date: 01/2008, Review Date: 11/2013 states in part: " . . . Hand hygiene should be performed before donning and removing gloves".

2. On 12/9/2014 at 11:30 AM Surveyor #3 observed a Food Service Ambassador (Staff Member #9) donning personal protective equipment so as to enter room 809 that was posted for contact precautions. During the donning activities the ambassador failed to perform hand hygiene prior to putting on his/her gloves.

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Item #2 - Personal Protective Equipment (PPE)

Based on observation certain staff of the facility failed to properly put on or remove personal protective equipment.

Failure to put on or take off personal protective equipment per recommended practice puts patients, staff and visitors of the facility at risk of infection.

Findings

1. On 12/9/2014 at 11:00 AM Surveyor #3 observed a Registered Nurse (Staff Member #10) enter Room #911E that was posted for contact precautions. At the time of entry the nurse was wearing a gown but failed to put on gloves until after entering the room. Contact precaution signage indicates that gown and gloves are to be put on at the door.

2. On 12/9/2014 at 11:02 AM Surveyor #3 observed a Respiratory Therapist (Staff Member #11) tending to the needs of a patient in Room #910E. At the time of the observation the staff member was wearing both a gown and gloves. However, the gown was being worn loosely (open in back) as the back ties had not been securely tied.

3. On 12/9/2014 at 11:45 AM, Surveyor #5 observed a registered nurse (Staff Member #1) exit contact isolation precaution room #714. S/he removed her/his gown first and then gloves before performing hand hygiene.

The hospital's contact precaution placard (a modified Washington State Hospital Association placard) reads in part: " . . . Personal Protective Equipment: . . . Take off & dispose in this order: 1. Gloves 2. Gown 3. WASH or GEL HANDS 4. Mask and eye cover, if needed 5. Wash or GEL HANDS (even if gloves used)".

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Item #3 - Re-processing
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Based on observation and document review, the hospital failed to ensure infection control practices were implemented.
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Failure to implement infection control practices creates risk for the transmission of communicable diseases.
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Findings:
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1. The hospital's policy and procedure entitled, "UW Medicine/ Harborview Medical Center Skills Validation Procedure Disinfection of Endoscope using Olympus OER-Pro Automated Endoscope Re-processor" (review date 08/14/2014) on page 2, #12, read in part; when transporting an endoscope, "Transport the endoscope to the reprocessing area in the approved container".
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2. On 12/10/2014 at 3:00 PM during a terminal clean of an operating room that was presumptive for clostridium difficile, Surveyor #1 observed an anesthesia technician (Staff Member #12) taking a bronchoscope (while still attached to the monitor) and draping it over the cart allowing the tip of the scope to potentially leak onto the floor. He/she then moved the cart outside of the operating room down the hallway to another location for further disinfection.

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Based on record review and interview, the hospital failed to ensure that a pre-operative medical history and physical was completed within 30 days of surgery for 1 of 5 patient records reviewed (Patient #1).

Failure to complete a history and physical exam prior to surgery places patients at risk for poor outcomes due to changes in unknown or known co-morbid conditions.

Findings:

1. On 12/11/2014 at 10:30 AM, a closed medical review of two eye patients who underwent surgical procedures revealed the history and physical for Patient #1 was completed on 11/3/2014 at 1:40 PM. Patient #1 underwent a cataract extraction surgical procedure on 12/9/2014.
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2. During an interview on 12/11/2014 at 10:30 AM at the eye institute, the assistant nurse manager (Staff Member #3) confirmed that the history and physical for Patient #1 was completed outside of the required 30 day period. The required review and update of the history and physical on the day of the surgical procedure was performed according to hospital policy.

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