HospitalInspections.org

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Item # 1 Potable Water Safety

Based on observation and interview, the hospital failed to provide cross connection control measures to protect potable water supply.

Failure to provide appropriate cross connection control measures risks contamination of the hospital potable water supply by chemical or sewage backflow.

Reference: Washington Administrative Code (WAC) 246-320-525(4)(a) provide appropriate backflow prevention at points of potential cross-contamination.

Findings:

1. During a tour of the hospital on 07/30/2014 between 9:00 AM and 10:00 AM, it was observed by Surveyor #1 that the plumbing in the following locations did not meet the cross-connection control standards of the Department of Health:

a) Chemical dispenser at the sterile processing sink.
b) Chemical dispenser in the endoscope room.


Item #2 Hot Water Temperature

Based on observation, and interview the hospital failed to provide hot water for handwashing not exceeding 120 degrees Fahrenheit
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Failure to ensure that handwashing water is delivered at maximum 120 degrees Fahrenheit. risks injury to staff through scalding.

Reference: Washington Administrative Code (WAC) 246-320-29610 (b)(ii) Hot water supply for bathing and handwashing not exceeding 120 degrees Fahrenheit.
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Findings:

1. On 07/29/2014 between 10:00 AM and 11:00 AM, it was observed by Surveyor #1 that the temperature of hot water at the handwashing sink in cafeteria behind the hot holding station registered at 149 degrees Farinheit, this finding was confirmed by dietary manager (Staff Member #9) at that time.

Item #1 Isolation Precaution Standards

Based on review of policy and procedure, observation and interview, the facility failed to assure infection control isolation practices minimized the transmission of infectious diseases.

Failure to implement infection control practices creates potential risk for transmission of infections among patients, staff and visitors.

Findings:

1. In review of a policy titled, "GUIDELINE FOR ISOLATION PRECAUTIONS " (revised Jan 2013) it stated that Contact and Droplet Precautions isolation patients should be placed in a private rooms if available and, if unavailable it directed staff to attempt to cohort patients with the same organism. It also stated to "Avoid cohorting [room sharing] droplet patients with any surgery. . . patients."
The policy contained no provision for staff to seek consultation for optimal cohorting of patients, when necessary, to prevent transmission of organisms.

2. On 7/29/2014 at 10:30 AM during observation on the acute care unit, Surveyor #2 observed that the patient in Room #107-bed 1 (Patient #1) was on Droplet Precautions for pneumonia and her/his roommate (Patient #2) in bed 2 (next to the window) was on standard precautions (isolation precautions not required). The patient placement of a non-isolated patient with an isolated patient created circumstances where staff caring for Patient #2 (not isolated) passed through isolation precautions space (for Patient #1) to access Patient #2.

The Droplet Precautions signage posted outside of Room 107 indicated to patients, family and visitors that doctors and staff "must wear gloves, gowns, masks, and goggles while in the room and remove them on leaving."

At that time it was also observed that an occupational therapist (Staff Member #5) entered Room 107 without isolation attire and proceeded past Patient #1 (on Droplet Precautions isolation) in bed 1 with a wheelchair and subsequently transported Patient #2 via wheelchair to the occupational therapy rehabilitation space at a far alternate corner of the facility. At that other location, several patients were observed to be receiving therapy services.

3. At that time Surveyor #2 interviewed the charge nurse (Staff Member #1) about the above observation. The charge nurse stated that staff attempted to place isolation patients in separate rooms from non-isolation patients. At that time it was identified that there were 2 private rooms (103 and 104) on the unit that could have been utilized to separate isolation from non-isolation patients. Furthermore, the charge nurse identified that if those rooms had not been available then the standard arrangement would be to place a non-isolation patient next to the door (bed 1) and the isolation patient next to the window (bed 2).

The charge nurse also stated that on the previous day Patient #2 (on Droplet Precautions isolation) was located in different room with a different patient (Patient #3) who was on Contact Precautions isolation for an active MRSA (methicillin resistant staphlococcus aureus) infection. Patient #3 had a deep post-operative wound infection after an amputation of the right leg.

4. On 7/29/2014 at 3:00 PM the above policy was reviewed the Infection Preventionist (Staff Member #2). S/he acknowledged staff had not adhered to the policy and that the policy did not advise staff of a means to seek consultation to assure optimal adherence to the policy.


Item #2 Safe Injection Practices

Based on review of policy and procedure, staff observation and interview, the facility failed to assure that safe injection practices were implemented.

Failure to assure adherence to safe injection practices creates a risk for transmission of bloodborne infections.

References: CDC One and Only Campaign: DURING THE PROCEDURE: . . Use a new needle and syringe for every injection; CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Recommendation IV.H.3. . . . Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set 453. Category IB

Findings:

1. Review of facility policy titled "Opening/Dating Sterile Vials" (Revised 7/14) provided guidance about the use of solutions to be administered intravenously. However, it did not address injection practices related to the frequency and manner of sterile access of containers for sterile injection.

2. On 8/30/2014 between 9:15-9:40 AM, Surveyor #2 observed an endoscopic procedure for Patient #4. During the course of the procedure that patient received a total of 5 intravenous injections of 2 different types of conscious sedation medications (Versed and Fentanyl) by a RN (Staff Member #3). Three vials of Versed were accessed repeatedly with one needle and syringe and 2 ampules of fentanyl were separately accessed repeatedly with another needle and syringe.

3. On 8/30/2014 at 3:30 PM the RN Pharmacy Coordinator (Staff Member #6) acknowledged that the above activities were not in adherance with safe injection practices and that the facility did not have an existing procedure directing staff accordingly.


Item #3 Hand Hygiene

Based on review of policy and procedure and staff observation, the facility failed to assure that hand hygiene standards were adhered to.

Failure to adhere to hand hygiene standards creates risk for cross contamination and infection among patients, staff and visitors.

Findings:

1. In review of a policy titled, "INFECTION CONTROL-HAND HYGIENE" (revised Feb 2013) in the section titled, "Indications for handwashing/antisepsis" it stated to decontaminate hands "After patient contact" and "After removing gloves."

2. On 8/30/2014 between 9:15-9:40 AM, Surveyor #2 observed an endoscopic procedure for Patient #4. During the course of the procedure the RN (Staff Member #3) wore protective gloves and s/he assisted with care by holding the patient's head and neck in position to ensure adequate oxygen exchange. Subsequently, the RN removed her/his gloves and did not perform hand hygiene. S/he then proceeded to perform other activities in the room over a 4 minute period including, but not limited to, handling the medical record, recording items in the record and handling a plastic box used to house patients' intravenous medication containers.








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Item #4 Product Safety

Based on observation, interview and record review the facility failed to ensure product safety.

Failure to implement infection control measures on reusable products puts patients at risk from nosocomial infection.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012) , states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings:

1. On 7/29/2014 at 1:45 PM Surveyor #1 observed unlabeled bottles filled with ultrasound gel in the physical therapy department. Surveyor #1 confirmed with physical therapist manager (Staff Member #7), that the ultrasound bottles were being refilled and not discarded when emptied.

Item #5 Cleaning of Equipment

Based on observation the facility staff failed to sanitize equipment between patient use in 1 of 1 patient care situations.

Failure to sanitize equipment between patient use puts patients at risk from nosocomial infection.

1. On 7/31/2014 between 1:00 PM and 2:00 PM Surveyor #1 observed physical therapy aide (Staff Member #8) in the physical therapy room moving a patient from the treadmill to the stationary bike and then back to the treadmill without sanitizing equipment before or after use.

Based on review of facility documents and staff interview, the facility failed to inform swing bed residents of their right to work or not work.

Failure to do so creates a risk that residents may not benefit fom exercising work rights due to lack of knowledge.

Reference: ?483.10(b) Notice of Rights and Services. The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights . . .during the stay in the facility. . . Receipt of such information, and any amendments to it, must be acknowledged in writing; . . . Work or not work (?483.10(h));


Findings:

1. In review of facility policy titled, "Swingbed Resident Rights" (Reviewed 9/09) it stated "The resident will be informed both orally and in writing ...of his or her rights ..."

2. In review of facility document titled, "NEWPORT HOSPITAL & HEALTH SERVICES SWING BED PATIENT RIGHTS" (10.15.10) it did not contain language related to swing bed residents' right to work/not work. Another pamphlet document titled, "SWING BED PROGRAM" did not provide information about swing bed residents' work options.

3. On 7/31/2014 at 12:00 PM this finding about swing bed resident work options was confirmed by a RN, Staff Member #4.

Based on record review the facility failed to complete the social work portion of the comprehensive assessment within 14 days of admission for 1 of 2 swing bed residents.

Failure to complete a portion(s) of the comprehensive assessment creates a risk that the resident's plan of care may be incomplete and/or potentially harmful.

Findings:

In review of the record of swing bed resident (Patient #5) it was noted that a social work assessment was completed on 4/17/2014, greater than 14 days after the patient was admitted (on 3/28/2014) to a swing bed. The resident was 89 years old who was admitted for rehabilitative care after a fall that resulted in a right hip fracture requiring surgical repair.

This finding was acknowledged by a RN (Staff Member #4).