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I. Based on observation and interview, the hospital failed to post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for each shift as required by Washington State law (RCW 70.41.420).

Failure to post the nurse staffing plan and the current nurse staffing schedule risks violation of an employee, patient or visitor's right to know that there was adequate and safe staffing levels to care for patients on each patient care unit.

Reference:

RCW 70.41.420 (7) Each hospital shall post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. The staffing plan and current staffing levels must also be made available to patients and visitors upon requests.

Findings:

1. A tour of patient care units on 8/3/2011 with the Director of Patient Care Services (Staff Member #1) revealed the following:

-Acute Care/Observation/Intensive Care Unit - The nurse staffing plan and the nurse staffing schedule were not posted.
-Peri-Operative Services - The nurse staffing plan and the nurse staffing schedule were not posted. Staff posted daily assignments in each patient room but not in a public area for all patient, staff and visitors to read.
-Emergency Department - Nurse staffing plan was not posted.
-Endoscopy Unit - Nurse staffing plan was not posted.
-Family Birth Center - Nurse staffing plan was not posted.

2. The Director of Patient Care Services (Staff Member #1) confirmed that the nurse staffing plans and nurse staffing schedules were not posted on all nursing units as required by state law.



II. Based on interview and document review, the hospital failed to review and update its nurse staffing plan as required by Washington State law (RCW 70.41.420).

Failure to review and update the staffing plan risks unmet patient needs and potential harm related to inadequate and unsafe nurse staffing levels.

Reference:

RCW 70.41.420(3) Primary responsibilities of the nurse staffing committee shall include: (b) Semiannual review of the staffing plan against patient need and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital.

Findings:

1. Review of the document entitled "Fiscal Year 2010 Patient Care Staffing Plans" (Date 9/8/2009) revealed that the nurse staffing plan had not been reviewed or updated since it was approved on 9/8/2009.

2. An interview with the Director of Patient Care Services (Staff Member #1) on 8/3/2011 revealed that the hospital's nurse staffing committee did not hold meetings from March 2010 to February 2011. The Director of Patient Care Services stated that the staffing committee resumed meetings in May of 2011.

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Based on record review and review of policy and procedure, the hospital failed to follow its policy and procedure for authorizing, monitoring, and documenting restraint use in 3 of 3 records reviewed (Patients #16, #17, #18).

Failure to follow established utilization guidelines for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.


Findings:

1. The hospital's policy and procedure entitled "Restraint Policy" (PROT 964.00; Approval date 12/2009; Revised 10/2010) read as follows:

"Any use of a restraint must be initiated by a physician (or licensed independent designee) ... The order must include the type and duration of the restraint. The medical surgical restraint may be ordered for up to a 24 hour period."

"To assure an appropriate order, a physician's order should be obtained and documented on the FHS approved pre-printed "Restraint/Assessment/Order Sheet" (Medical-Surgical) prior to the use of restraint."

"The RN shall modify and individualize the Plan of Care initially and daily to reflect type of restraint, monitoring and care required for patients in restraint."

The section entitled "Assessment and Monitoring of the Patient with Medical-Surgical Restraints" read as follows:

Assess and document every 2 hours: correct placement, signs of injury, circulation/skin integrity, positioning, emotional well-being; offer use of toilet, bedpan, urinal; and offer nutrition and fluid replacement.

Provide range of motion at least 3 times per day.

2. Review of the records of 3 patients who were restrained during their hospital stay revealed the following:

a. Patient #16 was an 87 year-old patient who was admitted on 7/15/2011due to a decreased level of consciousness. Review of the patient's medical record revealed the patient's wrists were restrained using soft limb restraints bilaterally to prevent the patient from pulling out tubes and lines. According to the medical record the soft limb restraints were applied on 7/18/2011 and removed on 7/20/2011.

Review of physician orders in Patient #16's medical record revealed that there was an order for restraint monitoring dated 7/18/2011 but the physician did not sign the pre-printed restraint order form as required by hospital policy.

Review of Patient #16's Plan of Care revealed that the modification to the Plan of Care to reflect type of restraint, monitoring and care did not occur until 7/20/2011 on the day the restraints were removed. The Plan of Care was not modified and updated according to hospital policy and procedure.

b. Patient #17 was a 35 year-old patient who was admitted on 7/10/2011 for replacement/revision of a gastrostomy tube and intravenous hydration. Review of the patient's medical record revealed the patient's wrists were restrained using soft limb restraints bilaterally for agitation and to prevent the patient from pulling on tubes and lines. According to the medical record the soft limb restraints were applied on 7/10/2011 and removed on 7/12/2011.

Review of Patient #17's Plan of Care revealed that the modification to the Plan of Care to reflect type of restraint, monitoring and care did not occur until 7/12/2011 on the day the restraints were removed. The Plan of Care was not modified and updated according to hospital policy and procedure.

c. Patient #18 was an 82 year-old patient who was admitted on 7/4/2011 for diagnosis and treatment of pelvic pain. Review of the patient's medical record revealed that the patient's wrists were restrained using soft limb restraints bilaterally for agitation and to prevent the patient from pulling on tubes and lines. According to the medical record the soft limb restraints were applied on 7/8/2011 and removed on 7/12/2011.

Review of Patient #18's medical record revealed that nursing staff documented required restraint assessments/interventions on 7/8/2011 at 7:00 PM and 11:00 PM, and 7/9/2011 at 3:00 AM and 6:39 PM. During this period of time, Nursing staff did not assess and document every 2 hours as required by hospital policy and procedure.

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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, staff and visitors of the facility at risk of food borne illness.

Specific references made in the findings below are found in the Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code.


Findings include:

1. On 8/1/2011 the surveyor observed a member of the dietary staff removing a chicken patty from a refrigeration unit for deep fat frying. The individual was then observed removing a bun (ready to eat food) from a package so as to complete the chicken sandwich being prepared. The bun had been handled/touched by the glove that had been worn when removing the chicken patty from the refrigerator. (see chapters 3-304.15)

2. On 8/2/2011 the surveyor observed a member of the dietary staff who was wearing gloves enter a walk-in cooler. The staff member was then observed putting tomatoes (ready to eat food) in a bowl. The bowl was handled in such a way that the staff member placed a gloved thumb into the bowl making contact with the food contact surface. He/she was still wearing the gloves worn while entering the walk-in cooler. (see chapters 3-304.15)


3. On 8/2/2011 the surveyor checked the internal temperature of Won Tons that had been reheated for service. Internal temperatures achieved in the final preparation stage (reheating) and verified using a digital stem thermometer showed some of the product had only reached an internal temperature of 157 degrees F. Reheating requires that an internal temperature of 165 degrees F. be achieved. (see chapter 3-401.11(3))

4. On 8/2/2011 the surveyor observed a cooked product being placed in a shallow 2 inch pan for cooling. The product was stacked in the pan to a height in excess of 2 inches as determined by using the top of the pan as the 2 inch reference point. (see chapter 3-501.14 (3)(a))

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Based on interview and record review, the facility failed to develop policies and procedures which defined the components for completion of the pre-operative anesthesia assessment, including documentation of physical status classification.

Failure to do so, creates potential for patients to develop unexpected complications/outcomes related to their risk for anesthesia care.

Findings:
1. On 8-2-11, when CRNA Staff member #3 was asked about the documentation of the ASA classification on Patient #2 admitted to the hospital on 7-16-11, he/she stated that he could not locate it in the record and, related to that, the record was "incomplete". He/she also stated that ASA classification assignment did not have a standard location on the facility pre-anesthesia assessment form.

2. The American Society of Anesthesiology has a standard of care titled "STATEMENT ON DOCUMENATION OF ANESTHESIA CARE " (amended October 22, 2008). Related to the pre-anesthesia evaluation, the statement reads "The record should include documentation of" ........ "Assignment of ASA physical status, including emergent status when applicable".

3. Per facility document related to Anesthesia Services, titled "Anesthesia Practices" section a. stated as follow; "There is a pre-anesthesia evaluation of each patient for whom anesthesia is planned which includes:
" 1. Capability to undergo anesthesia
2. Review of objective diagnostic data
3. Interview of patient for pertinent history
4. Patient physical examination
5. Formulation of an anesthesia plan
6. Anesthesia Consent "

Section b. stated that the " Anesthesia provider determines if patient is an appropriate candidate for anesthesia according to the plan" and there was no plan guidelines per ASA classification within the plan.

4. Medical review of the medical records of Patients #1-5 revealed that none of the patients had documentation of an ASA assignment in the pre-anesthesia record prior to their surgery for team review. Among the group, Patient #1 went to the operating room emergently for bleeding on 8-31-11and Patient #2 was admitted to the hospital on 7-16-11and was in the intensive care pre-operatively with multiple co-morbidities.

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Based on record review and review of policy and procedure, the facility failed to provide written notice to residents/family members of impending discharge or transfer.

Failure to do so creates potential for residents/family members to be unable to make informed decisions and/or exercise their discharge rights related to the discharge plan, including access to the State ' s long term care ombudsman.

Reference:?483.12(a)(6) Contents of the notice. The written notice specified in paragraph (a)(4) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii)The location to which the resident is transferred or discharged;
(iv) A statement that the resident has the right to appeal the action to the State;
(v) The name, address and telephone number of the State long term care ombudsman;
(vi) For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and
(vii) For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.

Findings:
1. Upon review of a facility document titled, " ENUMCLAW REGIONAL HOSPITAL SWING BED CONTRACT Standards of Care and Program Provisions " item #2 states " Appropriate documentation of discharge or transfers will be included in the medical record. "
Item #3 addresses the timing of the notification and an exception to 30 days in advance of discharge or transfer. However, it is not complete in noting that 493.12(a) (5) allows for the written notice to be provided to the patient and family " as soon as practicable before transfer or discharge " and therefore does not negate provision of written notification.

2. Per Swing Bed Services policy titled, "Discharge Planning, " the Care Manager was identified as performing several activities related to resident discharge, including various aspects as a key resource person. Per Staff member #1, the discharge plan was coordinated mostly by the discharge planner. However, in the policy there was no reference to staff duties realted to informing resident/family members in writing of their discharge rights.

3. In a review of the record of three swing patients (Patient #13, 14 &15), there was no documentation that the residents/family members received prior written notification of the transfer or discharge per content noted above.

4. Per facility Staff member #1, upon admission as hospital inpatients (which included Patient #13 and #15) received a document titled " AN IMPORTANT MESSAGE FROM MEDICARE ABOUT YOUR RIGHTS. " That notice did not meet the requirements for the advance written notice to swing bed residents of discharge and transfer as noted above. Additionally, the notice of discharge is not to occur more than 2 calendar days in advance of discharge.