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Based on interview and review of hospital job descriptions, the Critical Access Hospital failed to ensure that all healthcare staff members were appropriately licensed by the State of Washington.

Failure to ensure that the hospital's staff members are appropriately licensed to perform duties as described in their job description places patients at risk for harm by unqualified healthcare personnel.

References:

Washington Administrative Code (WAC) 246-841-400 Titled "Standards of Practice and Competencies for Nursing Assistants"

Revised Code of Washington (RCW) 18.36.050 "Authorized Duties [Medical Assistants]"

Findings:

1. On 4/13/2017 between the hours of 10:30 and 12:00 PM, Surveyor #2 reviewed a sample of hospital employee personnel files. The sample included the personnel files for Staff Member #17, an "Acute Care Technician". The employee's job description stated that the minimum qualification for this position was for the employee to be a Certified Nursing Assistant (CNA). Evidence in Staff Member #17's personnel file showed s/he was licensed by the State of Washington as a CNA.

Outlined in the "Acute Care Technician" job description under "Essential Job Duties", Surveyor #2 identified the following duties that were outside the scope of practice for a CNA:

"(3) Collection of bodily specimens for laboratory studies, capillary blood glucose determination, removal of uncomplicated sutures, removal of Foley catheters and peripheral intravenous access device as per training; (4) Assists registered nurse and physician with preparation and performing sterile procedures, cleansing of wounds and applications/changing dressings"

In addition, outlined in the "Job Summary" in the "Acute Care Technician" job description, the hospital referenced the duties as identified in "WAC 18.360.050". Surveyor #2 did not find a Washington Administrative Code (WAC) with that number but found a section of the Revised Code of Washington (RCW) with that number (RCW 18.360.050) which describes the scope of practice a "Medical Assistant", not a Certified Nursing Assistant.

2. On 4/13/2017 between the hours of 2:00 PM and 2:30 PM, Surveyor #2 interviewed the Acute Care nurse manager (Staff Member #6) who had developed the job description for an "Acute Care Technician". During the interview, the nurse manager stated that s/he developed the job description for Acute Care Tech by reviewing two other similar hospital job descriptions: An "OB [Obstetrical] Technician" and an "ED [Emergency Department] Technician". Review of the job descriptions for these positions revealed that the minimum qualification for these positions was for the employee to be a CNA.

The "Essential Job Duties" section of these job descriptions included duties that were outside the scope of practice for a CNA:

a. OB Tech: " ...(10) Collection of bodily specimens for laboratory studies, capillary blood glucose determination, removal of uncomplicated sutures, removal of Foley catheters and peripheral intravenous access device as per training ... (11) Assists registered nurse and physician with preparation and performing sterile procedures, cleansing of wounds and applications/changing dressings; ...(33) Demonstrates proficiency in providing care to newborns, including ... blood sugars"

b. ED Tech: (12) Assists registered nurse and physician with preparation and performing sterile procedures, cleansing of wounds and applications/changing dressings; (13) Obtains throat and nasopharyngeal culture specimens, collection of bodily specimens and venipunctures for laboratory studies, capillary blood glucose determination, obtain 12 EKG removal of uncomplicated sutures and staples, and performs visual acuity tests, removal of foley catheters and peripheral intravenous access device"
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Based on observation and interview, the Critical Access Hospital failed to ensure that all hospital staff members were trained and competent regarding access to emergency medical treatment supplies and equipment in the hospital's surgery department.

Failure to ensure hospital staff members are trained and competent regarding emergency response procedures risks delay of patient care during medical emergencies, which can result in patient harm and death.

Findings:

1. On 4/12/2017 at 7:30 AM, Surveyor #1 inspected the emergency equipment and supply cart in the hospital's pre-operative/post-operative care unit. During the inspection, Surveyor #1 interviewed a registered nurse (Staff Member #1) who was providing patient care in the unit regarding the contents of the cart. The nurse stated she was unfamiliar with the contents of the cart and that the cart was not opened unless there was an emergency. When asked if there was a tracheostomy set located in the surgery department for establishing an emergency airway, the nurse stated she did not know.

2. On 4/12/2017 at 8:35 AM, Surveyor #1 interviewed the surgery charge nurse (Staff Member #2) and asked if s/he knew if there was a tracheostomy set located in the surgery area. The nurse stated she did not know.

3. On 4/12/2017 at 8:37 AM, Surveyor #1 interviewed a second nurse providing care in the hospital's pre-operative/post-operative care unit (Staff Member #3). During the interview, the nurse stated a tracheostomy set was located in Operating Room #1.
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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that its central line dressing change procedure included all the steps required to prevent infection of the line and maintain line patency.

Central line-associated bloodstream infections and complications resulting from a dislodged central line can result in patient harm and death.

Findings:

1. On 4/12/2017 at 2:15 PM, Surveyor #1 observed Staff Member #4 perform a peripherally inserted central catheter (PICC) dressing change for Patient #1 in room #5 of the hospital's acute care/swing bed unit. Staff Member #4 was the hospital's registered nurse expert regarding central line insertion and care.

2. During the observation, the surveyor compared the dressing change procedure identified in the hospital's written policy entitled "Central Line Dressing Change" (Policy #873-0037; Reviewed 8/19/2016) with the procedure performed by the nurse expert. The written policy did not include the following key steps:

a. Donning clean gloves prior to removal of the old PICC dressing
b. Removing the gloves and performing hand hygiene after removal of the dressing and prior to donning sterile gloves
c. Assessing the PICC line for patency.
d. Steps to take when the measurement of the external portion of the PICC line indicated that the line had been dislodged.

3. An interview with Staff Member #4 after completion of the dressing change confirmed that the written policy and procedure was incomplete.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that patient care policies and procedures were reviewed annually and updated as needed as directed by hospital policy.

Failure to review and update patient care policies risks medical errors and patient harm.

Findings:

1. The hospital's policy entitled "Policy/Procedure/Pre-Printed Orders Development" (Policy #860-0062; Reviewed 8/24/2015), under "Purpose", read in part: "Any policy, procedure, protocol, or pre-printed order used in the Hospital District will be developed and maintained subject to this policy. Under the section "Annual Review", the policy read in part: "1. On an annual basis, the author, department, manager/supervisor, or committee chairperson will review all policies, procedures, and pre-printed orders."

2. Review of the hospital's patient care policies for the anesthesia department, the laboratory, diagnostic imaging, therapy services, and infection control revealed the policies had not been reviewed since 2015.

3. On 4/12/2017 at 4:00 PM during an interview with Surveyor #1, the hospital's Chief Nursing Officer (Staff Member #5) confirmed the findings above.
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ITEM #1 - STERILE COMPOUNDING OF INTRAVENOUS MEDICATIONS

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that hospital staff members prepared intravenous medications as directed by hospital policy and procedure and in accordance with sterile compounding standards.

Failure to comply with sterile compounding standards when preparing intravenous medications risks contamination of the product and transmission of infectious diseases to patients during medication administration.

Reference: United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016)

Findings:

1. Review of hospital pharmacy policies and procedures revealed the following:

a. The hospital's policy and procedure entitled "IV Additives and Admixture Service" (Policy #717-0016; Reviewed 3/1/2017), under "Policy", read in part: Pharmacy will provide technical assistance in cases where IV additives are not prepared in the pharmacy and will prepare IV admixtures when necessary. Under "Procedure", the policy read in part: "Addition of more than 2 additives to a prepared IV fluid is considered compounding and must be performed by appropriate pharmacy personnel using the laminar flow hood."

b. The hospital's policy and procedure entitled "Pharmacy Infection Control" (Policy #717-0018; Reviewed 3/1/2017), under "Procedure", read in part: "Laminar-Flow Hood: Whenever possible, sterile compounding will be done in the laminar-flow hood."

2. On 4/12/2017 at 1:30 PM, Surveyor #1 interviewed the hospital's Chief Nursing Officer (Staff Member #5), Acute Care nurse manager (Staff Member #6), and an Acute Care staff nurse (Staff Member #7). During the interview, the staff members stated that intravenous medications for immediate use (within one hour) were routinely prepared in the Acute Care medication preparation and storage room. This included preparation of multivitamin solutions that required more than two additives.

3. On 4/12/2017 at 1:45 PM, Surveyor #1 interviewed the hospital's pharmacy director (Staff Member #9) regarding preparation and administration of intravenous medications. The interview confirmed that hospital nursing staff members prepared all intravenous medication solutions for immediate use outside of the pharmacy. The interview revealed that pharmacy's laminar-flow hood was non-operational.


ITEM #2 - EXPIRED MEDICATIONS

Based on observation, interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that all drug storage areas were inspected monthly to prevent administration of outdated medications, as directed by hospital policy.

Failure to inspect medication storage areas and to remove and discard medications that have exceeded their manufacture's expiration date risks administration of medications that are no longer effective, which can result in patient harm.

Findings:

1. The hospital's policy and procedure entitled "Medication Storage Area Inspections" (Policy #717-0051; Reviewed 2/28/2017) read in part: "A pharmacist or technician will make a monthly inspection of all medications stored in nursing stations, specialty units, outpatient clinics for which the pharmacy is responsible, and any other location where drugs may be stored. The following check will be accomplished on these inspections: ...2. Outdated items - Remove and automatically replace."

2. On 4/12/2017 at 3:00 PM, Surveyor #1 inspected two anesthesia medication storage carts in Operating Room #1 and Operating Room #2 of the hospital's surgery department. The inspection revealed the carts contained the following:

a. Hurricane spray (local anesthetic) - Expired 12/2016
b. Succinylcholine chloride - 1-10 cc syringe (100 mg/ml) - Expired 4/3/2017
c. Succinylcholine chloride - 1-20 ml vial (20 mg/ml) - Not dated when removed from refrigeration; unstable at room temperature after 14 days
d. Cisatracurium besylate (Nimbex) - 1-20 ml vial (2 mg/ml) - Expired 3/1/2017
e. Etomidate (Amidate) - 2-10 ml vials (2 mg/ml) - 1 expired 1/1/2017; 1 expired 10/1/2016
f. Vasopressin (Vasostrict) - 1-1 ml vials (20 units/ml) - Expired 12/2016
g. Oxytocin (Pitocin) - 2-1 ml vials (10 unit/ml) - Expired 2/2017 and 11/2016
h. Adenocine - 3-2 ml vials (3 mg/ml) - Expired 11/2016

3. On 4/12/2017 at 3:15 PM, Surveyor #1 interviewed the hospital's pharmacy director (Staff Member #9) regarding the process for monthly inspections of medication storage areas. During the interview, the pharmacy director stated s/he was not aware that medications were being stored in anesthesia carts. The director confirmed the medications above should have been discarded.
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ITEM #1 - SAFE INJECTION PRACTICES

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that 1) multi-dose vials of medications accessed in the surgical suite were used only for one patient and discarded after use; and 2) all medication syringes removed from their protective wrapping were discarded after each surgical procedure.

Failure to ensure multi-dose vials of medications accessed in patient care areas are used for only one patient; and that all medication needles and syringes are discarded after use risks administration of contaminated medications and transmission of infectious diseases from one patient to another.

Reference: "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings - Safe Injection Practices" (Centers for Disease Prevention and Control, 2007)

Findings:

1. The hospital's policy and procedure entitled "Medication Sterile Vials" (Policy #717-0010; Reviewed 3/1/2017), under "Procedure", read in part: "All vials access in patient care areas, including the operating room, must be discarded and may not be reused."

2. On 4/12/2017 at 3:00 PM, Surveyor #1 inspected two anesthesia medication storage carts in Operating Room (OR) #1 and Operating Room (OR) #2 of the hospital's surgery department. The inspection revealed the carts contained the following:

a. Cisatracurium besylate (Nimbex) - 1-20 ml vial (2 mg/ml) - Expired 3/1/2017; Multi-dose vial open, not dated, replaced in the medication drawer (OR #2).
b. Ketamine - 1-5 ml vial (500 mg/ml) - Multi-dose vial open, not dated, replaced in the medication drawer (OR #2).
c. Two empty 3-cc syringes with attached needles, removed from their protective wrappers and placed on top of the anesthesia cart (OR #1).
d. One empty 10-cc syringe with an attached needle, removed from its' protective wrapper and placed on top of the anesthesia cart (OR #2).

3. During an interview with Surveyor #1 at the time of the observation, an anesthesia provider (Staff Members #8) confirmed the findings above and stated the medication vials and syringes should have been discarded after the end of the surgical procedure.

4. On 4/12/2017 at 3:15 PM, Surveyor #1 interviewed the hospital's pharmacy director (Staff Member #9) regarding the open multi-dose vials that were found in the anesthesia carts. The director confirmed that multi-dose vials of medications accessed during surgical procedures were to be used for one patient and then discarded.


ITEM #2 - GLOVING AND HAND HYGIENE

Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement a policy and procedure to ensure that all hospital staff members performed gloving and hand hygiene according to acceptable standards of practice, as demonstrated by 3 staff members observed (Staff Members #8, #10, #13).

Failure to perform hand hygiene while providing patient care risks transmission of infectious diseases to patients and caregivers.

Reference: "Guidelines for Hand Hygiene in Healthcare Settings" (Centers for Disease Control and Prevention, 2008)

Findings:

1. During a surgical procedure tracer conducted in Operating Room #1 on 4/12/2017 between 7:55 AM and 8:30 AM , Surveyor #1 observed the following:

a. Staff Member #8 did not perform hand hygiene prior to donning sterile gloves and inserting a tube into Patient #2's trachea.

b. Staff Member #10 removed his/her gloves and put them in his/her pocket.

c. Staff Member #10 did not perform hand hygiene prior to donning sterile gloves and inserting a urinary catheter into Patient #2's bladder.

d. Staff Member #8 did not remove his/her gloves, perform hand hygiene, and don clean gloves after picking up an item from the floor and prior to continuing patient care.

e. Staff Member #10 did not perform hand hygiene prior to donning sterile gloves and performing a surgical scrub of Patient #2's knee and leg.

f. Staff Member #8 did not remove his/her gloves, perform hand hygiene, and don clean gloves after picking up an item from the floor and prior to continuing with patient care (two observations).

2. During the survey, Surveyor #2 observed the following:

a. On 4/11/2017 between 1:00 PM and 2:30 PM during inspection of the hospital's kitchen , Surveyor #2 observed a dietary cook (Staff Member #13) change gloves without performing hand hygiene.

b. On 4/12/2017 at 8:35 AM, during observation of daily cleaning of a patient room (Room #10), Surveyor #2 observed a housekeeper (Staff Member #15) clean the patient's restroom, then touch the patient's water cup and paper towels in the dispenser with contaminated gloves.

3. Review of the hospital's policy and procedure entitled, "Hand Hygiene" (Policy #871-0010; Reviewed 6/26/2015), revealed that the policy provided "recommendations" for gloving and hand hygiene practice. It did not provide hospital staff members with direct instructions for hand hygiene to minimize risk of transmission of infectious diseases.


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ITEM #3 - INFECTION CONTROL IN DIETARY SERVICES

Based on observation the Critical Access Hospital failed to implement policies and procedures to ensure compliance with the Rules and Regulations with Washington State Administrative Code for Food Service (246-215 WAC).

Failure to comply with the food service codes puts patients, staff and visitors of the facility at risk of food borne illness.

Findings:

On 4/11/2017 between the hours of 1:00 PM and 2:30 PM Surveyor #2 observed a dietary cook (Staff Member #13) walk through the main kitchen drinking out of a water bottle with gloves on, then proceed to change gloves without doing hand hygiene.

Reference: Washington State Administrative Code (WAC 246-215-02400) Food contamination prevention - Eating, drinking, or using tobacco (2009 FDA Food Code 2-401.11) "Employee may drink only in designated area; may drink from a closed beverage container if the container is handled to prevent contamination of hands; the container; exposed food; or equipment and utensils."

Reference: "Washington State Administrative Code (WAC 246-215-02310) Hands and arms - When to wash (2009 FDA Food Code 2-301.14) "(4)... after drinking"; "(8) before donning gloves..."


ITEM #5 - TRANSPORTATION OF ENDOSCOPES

Based on observation, and document review, the Critical Access Hospital failed to assure that infection control measures were in place when transporting an endoscope from a dirty room to a clean room.

Failure to implement infection control practices places patients at risk of infections.

Reference: "American Society for Gastrointestinal Endoscopy Quality Assurance in Endoscopy Committee et al., 2011). In section H. Transport the soiled endoscope to the reprocessing area in a closed container that prevents exposure to staff, patients, or the environment to potentially infectious organisms."

Findings:

On 4/12/2017 between the hours of 11:00 AM and 12:00 PM Surveyor #2 observed a central sterile technician (Staff Member #14) disinfecting an endoscope. Towards the end of the cleaning process, the technician removed the endoscope from the sink and carried it to the automatic endoscope reprocessor (AER) which was located in central sterile room. This is considered a "clean room". The endoscope was allowed to drip on the floor and near a pushcart potentially contaminating the "clean" area.


ITEM #6 - ENVIRONMENTAL CLEANING PROCEDURES

Based on observation, and review of the hospital's policy and procedures, the hospital failed to ensure housekeeping staff used infection control techniques that prevented cross contamination when cleaning operating rooms.

Failure to prevent cross contamination during the cleaning process places patients and staff at risk of infection.

Findings:

1. On 4/12/2017 at 4:00 PM Surveyor #2 observed the terminal cleaning procedure of an operating suite. During this process, the housekeeper (Staff Member #16) cleaned all low level surfaces (i.e. equipment, surgical table) then cleaned the ceiling, thereby potentially re-contaminating the low level surfaces.

2. The hospital's policy and procedure entitled "Cleaning Procedures of the Operating Rooms and Associated Areas" (Policy #846-0016; Reviewed 11/17/2016), under "Terminal Cleaning", stated hospital staff members were to start cleaning at the highest point furthest from the door in each operating room. However, in part 6 of the procedure, it directed staff to clean the lower level items first, i.e. all furniture before cleaning the ceiling. Cleaning the ceiling was not identified until part 10 of the procedure. The policy and procedure was inconsistent and did not prevent cross contamination.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a process for assessment of and planning for healthcare needs following discharge according to facility policy and procedure, as demonstrated by 1 of 5 patients reviewed (Patient #3).

Failure to assess and plan for healthcare needs following discharge from the hospital risks discharging patients to a harmful living environment.

Findings:

1. The hospital's policy and procedure entitled "Discharge Planning Program" (Policy #873-0080; Reviewed 8/20/2016), under "Procedure: Discharge Planning Model", read in part: "PMH Medical Center's discharge planning is a multidisciplinary model. Each patient's needs for continuing care are assessed in an ongoing fashion by all members of the healthcare team. This assessment may begin prior to admission or is conducted during the nursing admission assessment."

Under "Discharge Screening Criteria", the policy read in part: "Adult high-risk patients include: Those who live alone with limited support system, suspected cases of abuse; ... Repeated prior hospitalization for same or related illness; ...Patients with newly diagnosed chronic or terminal disease; ...Chronic illness, particularly if two (2) or more disabilities; ...Patients who can no longer live alone and need to be considered for placement..."

Under "Roles in Discharge Planning", the policy read in part: "The nurse, in collaboration with the patient, family, and other healthcare providers, will complete the initial assessment and develop a plan of care that maximizes treatment and services.. Based on the assessment, patients that demonstrate more complex discharge planning needs are referred to other disciplines (i.e.... Social Services)..."

2. On 4/11/2016 at 9:15 AM, Surveyor #1 interviewed and reviewed the medical records of Patient #3. The interview and record review revealed that Patient #3 had presented to the hospital's emergency department (ED) on 4/7/2017, had been treated with diuretics, and had been discharged to his/her home. The patient returned to the ED on 4/9/2017 and was admitted for treatment of congestive heart failure and complications of diabetes mellitus, including post-operative treatment of a partially amputated foot.

Review of the nursing admission assessment completed on 4/9/2017 revealed that the assessment did not include all of the high-risk discharge planning triggers identified in the hospital's discharge planning policy. There was no evidence that the patient had been referred to the hospital's social services unit.

3. On 4/11/2017 at 2:20 PM during an interview with Surveyor #1, the Acute Care nurse manager (Staff Member #6) and Social Services staff member (Staff Member #11) confirmed that the nursing admission assessment did not include all of the high risk discharge planning triggers.
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Based on interview and review of patient rights information, the the Critical Access Hospital failed to develop a process for informing all patient's of their rights as long-term care ("swing bed") residents according to Federal regulations.

Failure to inform all patients of their rights limits the patient's ability to exercise those rights

Reference: 42 CFR §483.10(b) Notice of Rights and Services
(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing;

Findings:

1. On 4/11/2017 at 2:20 PM during an interview with Surveyor #1, the Acute Care nurse manager (Staff Member #6) and Social Services staff member (Staff Member #11) stated that patients were given a copy of a pamphlet entitled "Patient Rights and Responsibilities, PMH Medical Center" on admission to the hospital's swing bed program.

2. Review of this pamphlet revealed it did not include all of the patient's rights as long-term care patients identified in current federal regulations. It did not inform patients that they had the right to choose a personal attending physician [§483.10(d)]; perform services for the facility or refuse to work [§483.10(h)]; to send and receive mail unopened [§483.10(i)]; the right to retain and use personal property and possessions [§483.10(l)]; the right to share a room with a spouse [§483.10(m)]; and their transfer and discharge rights [§483.12(a)(2)].

3. During the interview, the nurse manager and social services staff member confirmed the pamphlet did not include all of the patients' rights as long-term care residents.
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Based on interview and review of discharge notification policies, procedures and documents, the Critical Access Hospital failed to develop a process for notifying long-term care ("swing bed") patient's of an impending transfer or discharge that included all of the required elements.

Failure to notify swing bed patients of the reason for transfer or discharge, the effective date, the location to which the resident is being transferred or discharges, and information regarding the appeal process risks violation of the patient's rights as long-term care residents.

Findings:

1. On 4/11/2017 at 1:30 PM, Surveyor #1 interviewed the hospital's swing bed program coordinator (Staff Member #12) regarding how patients are notified of an impending transfer or discharge. The coordinator stated that patients were given a notification form entitled "Notice of Medicare Provider Non-Coverage" (CMS-10123; Approved 2011) in accordance with the hospital's policy and procedure entitled "Swing Bed Notice of Non-coverage" (Policy #607-0016; Reviewed 8/19/2016).

2. The interview and policy review revealed the notice notified the patients of probable non-payment by Medicare for skilled nursing services. The notice did not inform the patient the date they were to be discharged or transferred; the location to which the patient was to be discharged or transferred; and the name, address, and phone number of Washington State's long term care ombudsman.
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