HospitalInspections.org

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Based on observation, interview, and review of hospital policy and procedure, the critical access hospital failed to ensure that patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.

Failure to maintain supplies properly places the patients at risk for delays in treatment and infections.

Findings included:

1. Document review of the hospital's policy titled, "Crash Carts," last review date 01/17/18, no policy number, showed that all items required for immediate patient care are in a secure area and that such items are within their manufacturing expiration dating. After an incident when the locks on the crash cart are broken, the nursing staff will review the cart for expiring items. The staff will replace or report to the responsible department any item that might be expiring by the end of the current month.

2. On 07/08/19 between 10:00 AM and 11:00 AM, Surveyor #3 toured the Emergency Department (ED). The surveyor inspected the crash cart and observed the following:

a. The crash cart located in room #1 contained one Nellcor colorimetric C02 detector with an expiration date of 05/30/19.

b. The crash cart located in room #2 contained one Nellcor colorimetric C02 detector with an expiration date of 05/30/19.

3. On 07/08/19 at 10:30 AM, Surveyor #3 interviewed the ED nurse (Staff #301) about checking the crash cart for outdated or expired patient care items. She stated that the crash cart is checked daily for cart lock status and defibrillator operational testing. If the crash cart is locked, all the items within the cart are assumed to be within the manufacturer's expiration date. Staff #301 stated that she had just inspected the crash cart in room #1. She had replaced items used in the cart as it had been opened recently. She was not aware that the Nellcor colorimetric C02 detector located in the crash cart was expired. Staff #301 was unable to tell the surveyor when other items within the cart might expired.
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Based on record review, interview and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for 1 of 3 patients (Patient #301).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings Included:

1. Document review of the hospital's policy titled, "Blood and Blood Product Transfusion," policy #10342, effective date 10/02/18, showed that the registered nurse will obtain a baseline set of vital signs including temperature, pulse, blood pressure, and respiratory rate immediately prior to infusion. The nurse will obtain vital signs again in 15 minutes after starting the blood product. Vital signs should be taken again at 30 minutes from transfusion start time and hourly until the infusion is completed.

2. On 07/09/19 at 10:15 AM, Surveyor #3 reviewed closed medical records for three patients who received blood transfusions during their hospitalization. The review showed the following:

a. Nursing staff caring for Patient #301 failed to document a set of vital signs at the required 30-minute time interval for the first unit of blood, recording it at the 1 hour and 1 minute mark or 31 minutes late.

b. Nursing staff caring for Patient #301 failed to document a set of vital signs at the required 30-minute time interval for the second unit of blood, recording it at the 1 hour and 13 minute mark or 43 minutes late.

3. At the time of the review, the Clinical Informatics' Manager (Staff # 304) acknowledged the hospital policy had not been followed as required.
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Based on observation, record review and staff interviews, the critical access hospital failed to provide a safe environment for the provision of patient care.

Failure to maintain an effective life safety program environment risks serious injury and death for patients, staff, and visitors.

Findings included:

The scope and severity of the findings documented on the accompanying Life Safety Code survey establish that the Condition of Participation for Physical Plant and Environment was NOT MET.

Cross Reference: C0222, C0231

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Based on observation, interview, and document review, the critical access hospital failed to inventory and maintain all equipment available for use by patients.

Failure to inventory and maintain patient care equipment puts patients at risk of harm from injury due to inadequate or inoperable equipment.

Findings included:

1. On 07/08/19 between 10:00 AM and 11:00 AM, Surveyor #3 toured the Emergency Department. The surveyor inspected the crash cart located in room #1. In reviewing the crash cart contents, Surveyor #3 observed a white colored transvenous temporary pacemaker labeled "Cordis Chronocoor III Standby Pacer Model 156B" with a crack running horizontally along the entire case near the terminal posts. No hospital biomedical maintenance tag could be located on the case.

2. On 07/08/19 at 10:30 AM, Surveyor #3 interviewed the emergency room nurse (Staff #301) about operational status of the transvenous pacemaker given the observation of the horizontal crack near the terminal posts. The surveyor asked the nurse if the biomedical maintenance personnel routinely checked this equipment. Staff #301 stated that she was unsure.

3. On 07/10/19 at 8:25 AM, Surveyor #4 interviewed the facilities manager (Staff #404) about tracking and maintenance of equipment in the hospital. During the review of the hospital's biomedical inventory, Staff #404 acknowledged that not all patient care equipment was included and tracked for preventive maintenance.

Surveyor #4 also asked Staff #404 about the maintenance status of the transvenous temporary pacemaker. The staff member stated that he was not aware of items kept in the crash cart.
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Based on observation, document review and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to meet the Life Safety Code of the National Fire Protection Association risks injury to patients, staff, and visitors during a fire.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.
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Based on interview, record review, and review of hospital policies and procedures, the critical access hospital failed to ensure that hospital staff members followed the hospital's restraint policy when caring for patients placed in restraints for 1 of 3 patients reviewed (Patients #302).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints - Chemical or Physical", policy # 10623, last revised 09/18/17, showed that a licensed independent practitioner will order restraints after less restrictive option have failed to keep the patient safe. Staff will document continuous observation and patient response (level of activity, calming or still combative) for patients placed in violent (behavioral) restraints.

2. On 07/09/19 at 12:20 PM, Surveyor #3 reviewed the medical records of three patients who were restrained during their hospital stay. The review showed the following:

a. Patient #302 was a 31 year-old patient who was treated in the emergency department (ED) on 05/15/19 to 05/17/19 for psychosis, mild dehydration and early rhabdomyolysis (illness where muscle tissue is rapidly broken down leading to kidney failure).

-Physician ED progress notes on 05/15/19 showed that the patient was restrained chemically against his wishes and placed in soft restraints in order to draw his blood despite multiple attempts to have a conversation with patient about the urgent need to evaluate his illness.

-ED Nurse Narrative notes on 05/14/19 at 2:23 PM showed a physician order for chemical restraints. The patient received 10 mg Haldol (an antipsychotic medication) and Benadryl 50 mg (an antihistamine medication used for sedation) by intramuscular injection.

-A Physician order written on 05/14/19 at 2:27 PM showed "Use soft restraints for patient safety x 6 hrs".

-ED Nurse narrative notes written on 05/14/19 at 3:10 PM showed restraints removed.

b. The patient's medical record did not document when the patient was placed in restraints or how many restraints were used. The record also did not document patient assessments or observations during the restraint period.

3. During an interview with Surveyor #3 at the time of the record review, the Clinical Informatics Manger (Staff #304) stated that was no documentation to indicate what occur during the restraint period.
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Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure that medications that exceeded their manufacturer's expiration date were not available for administration to patients.

Failure to ensure medication storage areas do not contain outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, and efficacy.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Disposal of Expired Medication" at Pacific Family Health Clinic, last reviewed 12/19/18, showed that Willapa Harbor Hospital pharmacy personnel will check clinic-supplied medications at least monthly and remove medications from stock not fit for patient use. The licensed practical nurse will process final disposal of expired sample medications.

Review of the job description for pharmacy technician, last reviewed 08/10/18, showed that technician responsibilities include monitoring, verifying and pulling expired medications. This includes routine monitoring throughout the pharmacy and monthly floor stock checks as assigned.

Document review of the Willapa Harbor Hospital monthly unit inspection sheet listed the "Dr. Hing Clinic", Dr. Oatfield Clinic, and PFHC Clinic as areas routinely inspected by the pharmacy service.

2. On 07/10/19 at 10:25 AM, Surveyor #3 inspected the outpatient services area which are a hospital-based clinic used by Dr. Hing and Dr. Oatfield. An inspection of the medication room showed the following:

a. One 4 ml bottle of tetracaine ophthalmic solution 0.5 % with an expiration date of 06/18.

b. 27 packages of two-tablet "Prilosec OTC" 20 mg drug samples with an expiration date of 12/18.

3. On 07/10/19 at 10:30 AM, Surveyor #3 interviewed a licensed practical nurse (Staff #302) about checking the medication room for outdated medications. Staff #302 stated that the pharmacy performs monthly medication inspections for any medications that they supply the clinic. However, the nursing staff is responsible for checking the drug sample packages for outdates.

4. On 07/09/19 at 8:15 AM, Surveyor #3 interviewed the Director of Pharmacy (Staff #303) about pharmaceutical services and operations. Staff #303 stated that a monthly inspection is done for all areas where the pharmacy supplies any medication. The surveyor asked Staff #303 if the hospital allows drug samples in their hospital-based clinics. The Pharmacy Director stated that drug samples are allowed in the hospital-based clinics but that clinic personnel are responsible for checking them for expiration dates.
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Based on observation, interview and document review, the critical access hospital failed to provide a system to control infections and communicable diseases of patients and personnel including failure to properly clean and disinfect surfaces in patient care areas (1), failure to follow manufacturer's instructions for use of testing equipment for high-level disinfection and sterilization of instruments (2), failure to design and implement testing protocols for their water management plan (3), and failure to store soiled and clean items in separate utility rooms (4).

Failure to provide a system to control infections and communicable diseases puts patients, staff and visitors at risk of harm from exposure to pathogenic bacteria and viruses.

Findings included:

Item #1- Cleaning and Disinfection of Patient Care Areas

1. Document review of the hospital policy titled, "Terminal Cleaning Patient Room after Discharge", last reviewed 07/05/19, showed that staff should wipe all high touch areas including bedside tables with disinfectant.

Document review of the hospital policy titled,"Operating Room Housekeeping Procedures", last reviewed 12/03/18, showed that staff are to use low linting cloths or mops for cleaning.

2. On 07/08/19 at 1:45 PM, Surveyor #4 toured the acute care area of the hospital. During the tour, the surveyor entered patient room #107, which was unoccupied. The observation showed that the over-bed table had food debris in the seams of the table.

3. On 07/10/19 between 8:50 AM and 9:50 AM, Surveyor #4 observed staff as they cleaned the operating room. The observation showed:

a. The cleaning cloth used to disinfect the mayo stand left behind lint particles on the surface of the tray.

b. The housekeeper (Staff #401) "double dipped", placing the used rags back into the disinfectant for reuse, rather than soaking a new, clean cloth in the cleaning solution.

Item #2- Equipment high-level disinfection and sterilization

1. Document review of Steris' "Verify Dual Species Self-Contained Biological Indicator " Technical Data sheet stated that the validated incubation time for steam sterilization is 24 hours.

2. On 07/09/19 at 10:15 AM, Surveyor #4 observed reprocessing of an Olympus endoscope. During the disinfection process, the surveyor inspected the bottle of Rapicide chemical test strips (used to check the efficacy of the high-level disinfectant). Under the heading "Important Precautions", the instructions for use showed that the test strips should not be used beyond 90 days from the bottle's open date.

3. At the time of the observation, the surveyor asked the surgical technician (Staff #402) if staff documented the opening date for the bottle. The staff member stated that the date is usually marked, but that staff had failed to mark the current bottle of test strips.

4. On 07/10/19 at 10:30 AM, Surveyor #4 toured the sterile processing department. During the tour, the surveyor reviewed the documentation log for the steam sterilizer biologic indicator results. The surveyor observed that on multiple dates, the documented reading time and date of the result occurred less than 24 hours from the initiation time of the incubation.

5. At the time of the observation, the surgical technician (Staff #402) stated that she did not always wait 24 hours to read the outcome of the indicator if the control ampoule had already changed color.

Item #3- Water Management Plan

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter QSO 17-30 (REVISED 07.06.2018): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.

Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit.

Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

Maintains compliance with other applicable Federal, State and local requirements.

1. On 07/09/19 at 8:30 AM, Surveyor #4 reviewed the hospital's water management plan with the Infection Preventionist (Staff #403). During the review, the surveyor and the staff member reviewed the hospital's current water management plan activities. The review showed that the facility had not yet developed or implemented testing protocols.

2. At the time of the review, Staff #403 acknowledged the lack of implementation of the testing protocol.

Item #4 - Storage of Soiled and Clean Medical Equipment

Reference: Guidelines for Design and Construction of Health Care Facilities 2006; The Facility Guidelines Institute. Section 2.3 Support Areas for Patient Care: 2.3.7 Clean Workroom or Clean Supply Room shall be separate from and have no direct connection with soiled workrooms or soiled holding rooms; 2.3.8 Soiled Workroom or Soiled Holding Room shall be separate from and have no direct connection with clean workrooms or clean supply rooms.

1. On 07/08/19 at 10:15 AM, Surveyor #3 toured the emergency department (ED) with the Chief Nursing Officer (Staff #305). The surveyor observed two pediatric papoose immobilizer boards (temporary medical board used to limit a patient's freedom of movement to decrease risk of injury while performing medical procedures like venipuncture) and one adult slide board patient transfer sheet stored in the soiled utility room.

2. At the time of the observation, Surveyor #3 asked the Staff #305 why clean items were stored in the soiled utility room. Staff #305 stated that she was unaware of that practice and directed the nursing staff to store those items in another location.
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Based on observation, interview, record review, and review of hospital policy and procedure, the critical access hospital failed to ensure staff members adequately monitored 1 of 1 patient's identified at risk for suicide (Patient #303).

Failure to adequately monitor patients identified at risk for suicide risks serious injury or death of patients.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Precautions," policy #10199, last reviewed 03/05/13, showed that if the patient has already attempted suicide and a life-threatening condition is either present or possible, immediate interventions must be instituted. Those interventions include not leaving the patient alone and having the patient close to the nursing station so that they can be closely monitored. Any potentially harmful objects such as sharps, glasses, toxic substances, phone cords, and supply carts must be remove from the room.

2. On 07/08/19 at 10:15 AM, Surveyor #3 toured the Emergency Department (ED) with the Chief Nursing Office (Staff #305). There was one patient in the ED, Patient #303 had been admitted for an attempted suicide, including self-inflicted cuts to both arms. The observation showed the following:

a. The ED nursing staff stood at the nurse's station with only a partial view of the patient's feet in the bed.

b. The patient's arms and head were partially covered by a blanket.

c. The bed's call light had a cord greater than 8 feet in length, which was coiled in a basket on a wall near the patient.

3. On 07/08/19 at 10:30 AM, Surveyor #3 interviewed the ED registered nurse (Staff #306) about what it meant to be on suicide or assault precautions. Staff #306 stated that the patient would be observed in line of sight of the hospital staff at all times. All harmful objects would be removed from the patient's room or secured. When asked by the surveyor how she could maintain line of sight monitoring of the patient from the nurse's station, the nurse stated that she could see the patient's feet but acknowledged she could not see the patient's head or arms. The surveyor then asked the nurse why the patient's call light cord was left in the room. Staff #306 stated that it could not be removed because the call system would continuously alarm and there was no method to shut the alarm system off. Staff #306 stated that she had coiled the call system cord and stuffed it in a basket located on a wall in an effort to make it less available for the patient to access.

4. On 07/08/19 at 11:00 AM, Surveyor #3 and a registered nurse (Staff #306) reviewed the medical record of Patient #303. Patient #303 was admitted to the ED on 07/08/19 at 4:39 AM. The medical record review showed the following:

a. An ED provider note showed that the patient drank 8 beers and then cut both of her arms with a razor knife within one hour of presenting for care. The right forearm wound required sutures to close the wound. The left forearm required wound adhesive to close the wound.

b. The Suicide Assessment and Mental Status Evaluation showed the patient was rated as high risk for suicide.

c. The Columbia-Suicide Severity Rating Scale showed the patient marked "yes" to the question "have you ever done anything, started to do anything, or prepared to do anything to end your life?" Also marked "yes" was a follow-up question "Was this within the past three months?".

d. The ED nursing assessment note showed the mobile crisis team evaluated the patient and recommended voluntary bed placement at a mental health inpatient facility. Patient #303 accepted voluntary placement for inpatient treatment.