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Based on observation the hospital failed to maintain air pressure relationships as designed and consistent with Center for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health Care Facilities, 2003, Table B.2 .

The hospital failure to maintain ventilation relationships consistent with original design approval and CDC Table B.2, increases the risk of cross contamination, patient infection and compromises the quality of patient care.

Findings:

1. On 1/19/2011 using a light weight tissue, the surveyor checked the air flow at the doors of the clean and dirty utility room(s) located in the Operating Room area. The surveyor found that the respective spaces had air pressure relationship to the adjoining hallway reversed to that required (clean was in and dirty was out). It should be noted that clean supplies should be stored in rooms having a positive relationship to adjoining spaces and dirty utilities should have a negative relationship to adjoining spaces.

Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 1/192011 - 1/21/2011.

Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapter 19.3.2.7.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 1/19/2011- 1/21/2011 (Tag K-0211).

Based on document review and staff interview the facility failed in the granting of privileges for Allied Health Professionals to ensure that requested privileges had been delineated.

Failure on the part of the facility to ensure that privileges granted have been delineated puts patients at risk of treatment by individuals not having the necessary qualifications to provide safe and effective patient care.

Findings include:

1. On 1/21/2011 while reviewing credentialing documentation the surveyor noted that a list of delineated privileges for an Allied Health Professional (Physician Assistant) was not in the file. The surveyor was subsequently provided with a document entitled: "Physician Assistant Standardized Procedures Reference and Guidelines".

As explained to the surveyor the document "Physician Assistant Standardized Procedures Reference and Guidelines" was intended to serve as a list of those procedures the applicant could perform with the provison that certain supervisory provisions were undertaken by the sponsoring physician. The surveyor was subsequently informed that the document had not been utilized to delineate a list of procedures the applicant either chose or desired to perform. Nor had the document been reviewed and/or given written approval by the Board of Governance to be used as a "Core" list of privileges.

Per the Allied Health Professionals Manual Section 1.5 Procedures for Granting and Maintaining Privileges subsection 1.5-1 "In order to practice at the Hospital, AHPs must apply and qualify for such Privileges and be subject to biennial review thereof. Applications for initial Privileges and biennial renewal thereof shall be submitted and processed in a parallel manner to that provided in the Bylaws for other Practitioners unless otherwise specified in the Bylaws".

Nothing in the file indicated that the applicant had requested approval of a delineated or specific list of privileges.

1. Based on record review, and review of policy and procedure, the hospital failed to implement their policy for obtaining a physician order for restraints in 1 of 1 record reviewed (Patient #3).

Failure to require a physician's order for restraints risks loss of dignity and violation of patient rights.

Reference:

CFR 42.482.13 (e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)

Findings:

a. Review of the facility policy entitled "Restraints" (no effective date) revealed that #4 under "Procedure" stated "orders for the use of restraint must never be written as a standing order or on an as needed basis (PRN)."

b. Patient #3 was a 39 year-old patient admitted on 5/16/2010 after being found unconscious and transferred to the emergency department via ambulance. At some point during transport to the hospital the patient was placed in restraints for combative behavior. After evaluation in the emergency department Patient #3 was admitted to the medical unit. Patient #3 remained in restraints from the time of admission to the emergency department on 5/16/2010 at 12:30PM until the restraints were removed on the medical unit on 5/16/2010 at 7:00PM. Review of admission orders written on 5/16/2010 at 2:50 PM revealed that there was no order for restraints. The orders did include a physician's order for the nurses to initiate the CIWA [Clinical Institute Withdrawal Assessment] protocol. The CIWA protocol stated "Soft restraints as necessary for patient safety."

c. The director of nursing services confirmed the above findings.

1. Based on observation, interview, and review of policy and procedure, the hospital failed to follow standards of practice regarding labeling of multi-dose vials, and removal of expired medications.

Failure to adhere to such standards places all patients at risk of receiving outdated, potentially contaminated medications.

Findings:

a. During a tour of the Emergency Department on 1/19/2011 the following multi-dose vials were found to be open and not dated or were past the 28-day expiration date for open multi-dose vials.

Novolin R 100u/ml - opened on 11/11/10
Novolog 100u/ml - could not read the date it was opened
Novolin N 100u/ml - opened on 11/29/2010
Propracaine Hydrochloride Ophthalmic - Not dated as to when opened
Lantus Insulin Glargine 100u/ml - Not dated as to when opened
Proparacaine Hydrochloride Ophthalmic - Not dated as to when opened

b. The hospital policy entitled "Dating of Sterile Containers" (Revision date: 10/7-8/2010) stated that "Multiple dose vials (with preservative): The vial will be retained for 30 days unless it has been contaminated or manufacturer has a specified shorter expiration date. The vial must be labeled with date and initials of person opening."

The hospital policy entitled "Use of Multi-dose Vials" (Revised 10/12/2007) stated that "multi-use vials are good for 28 days per USP-979 guidelines."

c. The Emergency Department manager confirmed the above findings and stated that the open multi-dose vials should have been discarded. The medications was discarded at the time of the survey.


2. Based on observation, interview, and record review, the hospital failed to implement its policy and procedure for emergency outpatient medications that met the requirements in Chapter 246-873 Pharmacy - Hospital Standards.

Failure to do so places patients at risk for medication errors, and unrecognized adverse drug events, and risks tampering and diversion of controlled substances.

Reference:
WAC 246-873-060 Emergency Outpatient Medications

The director of pharmacy of a hospital shall, in concert with the appropriate committee of the hospital medical staff, develop policies and procedures, which shall be implemented, to provide emergency pharmaceuticals to outpatients during hours when normal community or hospital pharmacy services are not available ....

Such policies shall allow the designated registered nurse(s) to deliver medications other than controlled substances ....

(7) The procedures outlined in this rule may not be used for controlled substances except at the following rural hospitals which met all three of the rural access project criteria on May 17, 1989:

Hospital City

Lake Chelan Community Hospital Chelan
St. Joseph ' s Hospital Chewelah
Whitman Community Hospital Colfax
Lincoln Hospital Davenport
Dayton General Hospital Dayton
Ocean Beach Hospital Ilwaco
Newport Community Hospital Newport
Jefferson General Hospital Port Townsend
Ritzville Memorial Hospital Ritzville
Willapa Harbor Hospital South Bend

Findings:

a. An interview with Staff member #1 on 1/19/2011 revealed that nurses dispensed home medication packs from the electronic system for emergency department patients. Some of the home medication packs included controlled substances, such as Vicodin and Percocet.

b. Review of two patient records (Patient #1, #2) on 1/21/2011 revealed that a Percocet prepack was dispensed by nursing staff on 1/18/2011 for Patient #1 and a Vicodin prepack was dispensed by nursing staff on 1/18/2011 for Patient #2.

c. The hospital policy entitled "Emergency Department After-Hours Prescriptions" (Revision date: 8/2010) read as follows "Under no circumstances shall controlled substance ED pre-packs be dispensed to outpatients by a nursing supervisor. The attending physician or the ED physician can dispense the medications."

Based on observation the facility failed to implement policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC). Failure on the part of the facility to comply with the food service codes puts patients of the facility at risk of food borne illness.

References:

Washington State Retail Food Code Working Document; Chapter 4-502.11(B)

Findings include:

1. On 1/20/2011 the surveyor asked a member of the staff to demonstrate that a bi-metal analog stem thermometer used in the kitchen had been properly calibrated. Staff placed the thermometer into a container containing an ice and water mixture along side a digital stem thermometer provided by the surveyor. The temperature reading on the surveyor's thermometer was 32.4F. degrees while that tested by the staff member was approximately 36F which demonstrated that the facility thermometer was not in calibration. Subsequent to this finding three (3) additional facility thermometers were tested. Temperature readings of 42F, 52F and 38F were noted while the surveyor's thermometer indicated 32.4F.