HospitalInspections.org

Based on observation the facility failed to maintain a safe environment for patients by allowing conditions to exist that could lead to scalding burns.

Failure on the part of the facility to provide a safe environment puts patients, staff and visitors of the facility at risk of harm.

Findings:

1. On 9/9/2014, at 2:05 PM, Surveyor #2 noted that the temperature of hot water at the hand wash sink in Room 206 was 127 degrees Fahrenheit.

2. On 9/12/2014, at 9:40 AM, Surveyor #2 noted that the temperature of hot water at the hand wash sink in room 307 was 131 degrees Fahrenheit.

Based on observation the facility failed to provide proper ventilation for certain areas of the facility. More specifically the clean utility room used for equipment reprocessing and the laboratory.

Failure on the part of the facility to maintain proper air relationships put patients at risk of infection.

Findings:

1. On 9/9/2014, at 10:45 AM, Surveyor #2 used a light weight flutter strip (tissue) to evaluate the air relationships between the "Clean Utility Room" used for the reprocessing of surgical equipment and its adjoining spaces. As a result it was determined that the clean utility room was negative to its adjoining spaces not positive as is required.

2. On 9/10/2014, at 4:00 PM, Surveyor #2 used a light weight flutter strip (tissue) to evaluate the air relationships between the laboratory and its adjoining spaces. As a result it was determined that the laboratory was positive to its adjoining spaces not negative as is required. The test was repeated a second time with the lab hood running and the same result (positive) was noted.

Based on observation and interview by Deputy State Fire Marshal, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the Critical Access Hospital Recertification Fire and Life Safety Survey.

Item #1 - Physician Orders - Restraints

Based on review of hospital policies and procedures, the Critical Access Hospital failed to identify requirements for physician orders when placing patients in restraints as required by Washington State hospital licensing regulations, as demonstrated by 2 of 3 patient records reviewed (Patients #3, #4).

Failure to develop policies and procedures for placing patients in restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

References:

WAC 246-320-226 Hospitals must:
(3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with CFR 42.482;

CFR 42.482(e)(5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

CFR 42.482(e)(8) Unless superseded by State law that is more restrictive--
(i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:
(A) 4 hours for adults 18 years of age or older;
(B) 2 hours for children and adolescents 9 to 17 years of age; or
(C) 1-hour for children under 9 years of age;

Findings:

1. Review of the medical records of three patients who were placed in restraints during their hospital stay for management of violent and self-destructive behavior revealed the following:

a) The records of Patient #3 did not include an order for application of restraints.
b) The records of Patient #4 did not include a renewal of the restraint orders every four hours as required by the regulation.

2. Review of the hospital's policy and procedure entitled "Restraints" (No reference number; Effective 3/30/2011) revealed the policy did not identify requirements for orders from a physician or other licensed independent practitioner when placing patients in restraints.

Item #2 - Policies and Procedures - Restraints

Based on record review, interview, and review of policies and procedures the Critical Access Hospital failed to follow its policy and procedure for restraining patients, as demonstrated by 2 of 3 patient records reviewed (Patients #2, #4).

Failure to follow policies and procedures for placing patients in restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Restraints" (Effective 3/30/2011) stated that a hospital staff member would document patient assessments in the patient's medical record every 15 minutes. The assessment was to include signs of injury associated with the application of the restraints, circulation and range of motion of the patient's extremities, the patient's physical and psychological status and comfort, and the patient's readiness for discontinuation of the restraints.

2. Review of the medical records of three patients who had been restrained while being treated in the emergency department revealed the following:

a) Patient #2 was placed in four point restraints on 6/8/2013, at 5:30 PM. Documentation in the patient's record indicated that the patient was released at 4:30 PM (date unknown). There was no evidence in the patient's record that the patient was assessed every 15 minutes while in restraints as directed by hospital policy.

b) Patient #4 was placed in four point restraints on 10/10/2013, at 2:40 PM and released from restraints on 10/12/2013 at 8:48 AM. There was no evidence in the patient's record that the patient was assessed every 15 minutes between 2:40 PM on 10/10/2013, and 7:00 PM on 10/11/2013.

3. The hospital's Chief Nursing Officer (Staff Member #6) confirmed the findings above at the time of the record review.

Item #3 - Patient Rights

Based on interview and review of patient rights information, the Critical Access Hospital failed to ensure that patients admitted as observation patients or inpatients received a list of patient rights as required by Washington State hospital licensing regulations.

Reference:

WAC 246-320-141 Hospitals must: (2) Provide each patient a written statement of patient rights from subsection (1) of this section.

Findings:

1. On 9/9/2014, at 10:45 AM, during an interview with Surveyor #1, the hospital's registration supervisor (Staff Member #7) presented a copy of patient rights that the supervisor stated was given to all observation patients and inpatients on admission to the hospital. These rights were entitled "Resident Rights and Admission, Transfer, and Discharge Rights". The rights described the rights of long-term care patients and not the rights of inpatients and observation patients.

2. The hospital's Chief Nursing Officer (Staff Member #6) confirmed the findings above at the time of the interview.

Item #4 - Staff Education - Infection Control

Based on interview and review of hospital training records, the Critical Access Hospital failed to ensure hospital staff members received annual infection prevention and control training as required by Washington State hospital licensing regulations.

Reference:

WAC 246-320-156 Hospitals must (8) Give infection control information to staff upon hire and annually which includes: (b) Education specific to infection control for multidrug-resistant organisms; (c) General and specific infection control measures related to the patient care areas where staff work.

Findings:

On 9/11/2014, at 3:15 PM during an interview with Surveyor #1, the hospital's Director of Human Resources (Staff Member #5) stated that when hospital staff members were hired, they viewed a video regarding infection prevention and control practices and completed a hand hygiene competency. The director stated the hospital did not conduct annual infection control education and training of hospital staff members.

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that policies and procedure were developed and implemented for the hospital's anesthesia services.

Failure to develop and implement policies and procedures that reflect regulatory standards and accepted standards of practice risks unsafe anesthesia practice during surgical and diagnostic procedures.

Findings:

On 9/10/2014, at 3:35 PM, an interview with the hospital's surgery supervisor (Staff Member #8) revealed that policies and procedures for the hospital's anesthesia services had been developed in March of 2013. The policies and procedures had not been finalized and approved by hospital administrative staff members.

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a policy and procedure for verifying that medication refrigerator temperatures were within a safe range for medication storage.

Failure to store medications within an acceptable temperature range risks alteration of medication efficacy and patient harm.

Findings:

1. During an interview with Surveyor #1 on 9/12/2014, at 8:55 AM, the hospital's Chief Nursing Officer (Staff Member #6) stated that the charge nurse was expected to check the medication refrigerator temperatures of the acute care unit's medication refrigerator and the hospital pharmacy refrigerator every shift.

2. Review of the medication refrigerator temperature logs for the acute care unit on 9/12/2014, revealed there was no evidence that the temperatures had been checked for 10 of 62 shifts during August 2014 and for 3 of19 shifts for September 2014.

3. The hospital's policy entitled "Floor Stock" (Reference #200.14; Effective 11/1/2009), under "Inspection" read as follows: "3. Refrigerators used to store pharmaceuticals and biologicals will have temperatures monitored and documented as outlined in the policy for refrigerated food and medications."

Review of the hospital's policy entitled "Drug Storage Temperatures" revealed the policy did not include how often medication refrigerator temperatures were to be checked and documented.

Based on observation, record review and interview the facility failed to develop its infection control program in such a manner as to be better able to address infection control issues.

Failure on the part of the facility to have its infection control program developed adequately puts patients, staff and visitors of the facility at risk of infection.

Findings:

1. On 9/11/2014, at 10:45 AM, Surveyor #2 reviewed the hospital's infection control policies and procedures during the course of interviewing the hospital infection preventionist (Staff Member #12). The policies and procedures contained required elements of the hospital's infection prevention and control program, but there was no comprehensive unifying document that identified the program's structure, scope and responsibilities.

2. On 9/11/2014, at 10:45 AM, Surveyor #2 reviewed the hospital's infection control policies and procedures during the course of interviewing the hospital infection preventionist (Staff Member #12). During the course of the review it was noted that certain expected policies and procedures were not available. These policies and procedures include but are not limited to the following: Outbreak investigation and intervention; Prevention of cross-contamination between clean and soiled items; Approval and use of disinfectants; Surgical scrub/surgical prep technique; Pharmacy and Therapeutics policy and procedures. It was noted during the course of the interview that certain policies not maintained by the infection control practitioner may be kept by the various units within the hospital I.E. surgery, pharmacy and environmental services.

3. On 9/9/2014, at 10:30 AM, Surveyor #2 observed a blue foam pad (egg crate) being stored on the floor under a shelving unit of the surgical anesthesia closet.

4. On 9/9/2014, at 11:00 AM, Surveyor #2 observed a surgical technician (Staff Member #3) performing high level disinfection of an endoscope. During the processing of the endoscope the technician failed to perform a required leak test of the device before submerging it in enzymatic detergent.

5. On 9/9/2014, at 2:20 PM, Surveyor #2 noted that Cidex OPA test strips being used to check the efficacy of the disinfectant used on transvaginal probes had expired 5/2014.

6. On 9/12/2014, at 8:00 AM, Surveyor #2 reviewed Attest logs for biological monitoring of the facility's steam sterilization process. As a result it was noted that the following information was not recorded in the log book.

a) Biological Indicator Results: Results were not entered/recorded for sterilization runs performed on 11/4/2013, 3/27/2014, 4/22/2014, 4/29/2014, 5/6/2014 and 8/18/2014.

b) Smart Pack Results: Results were not entered/recorded for sterilization runs performed on 11/12/2013, 1/7/2014, 1/13/2014 and 4/6/2014.

c) Chemical Indicator Results: Results were not entered/recorded for sterilization runs performed on 11/12/2013, 11/13/2013, 12/3/2013, 2/10/2014, 5/8/2014 and 8/4/2014.

7. On 9/9/2014, at 12:30 PM, Surveyor #1 observed a registered nurse (Staff Member #1) while performing a blood glucose test for Patient #1. After performing the test, the nurse did not clean and disinfect the blood glucose meter prior to replacing the meter in its carrying case.

Review of hospital policies and procedures revealed the hospital did not have a policy and procedure for cleaning patient care equipment after use.

8. The hospital's policy and procedure entitled "Hand Hygiene" (Reference #095.21; Effective 7/19/2013), under " Procedure: Hand Hygiene Indications" read as follows: "Perform hand hygiene ... 6. Immediately after removing sterile and non-sterile gloves."

On 9/9/2014, at 1:00 PM, Surveyor #1 observed a registered nurse (Staff Member #2) and a surgical technician (Staff Member #3) remove their gloves and not perform hand hygiene prior to touching items in the patient care environment.

9. On 9/9/2014, at 1:15 PM, Surveyor #1 observed a certified registered nurse anesthetist (Staff Member #4) prepare medications prior to an endoscopy procedure. The anesthetist did not disinfect the top of the medication vial with an alcohol swab prior to piercing the diaphragm of the vial with a needle and withdrawing the contents of the vial into a syringe.

(Reference: Association for Professionals in Infection Control and Epidemiology (APIC) position paper: "Safe injection, infusion, and medication vial practices in health care" (2010) - "Cleanse the access diaphragm of vials using friction and a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab. Allow the diaphragm to dry before inserting any device into the vial.")

The anesthetist then placed the syringe of medication into his/her pocket. The pocket also contained the head of the anesthetist's stethoscope and the anesthetist's pen.

(Reference: Association for Professionals in Infection Control and Epidemiology (APIC) position paper: "Safe injection, infusion, and medication vial practices in health care" (2010) - "Never store or transport syringes in clothing or pockets.")

10. The hospitals' policy and procedure entitled "Sterile Pharmaceuticals" (Reference #7170.29; Effective 1/10/213), under "General Information/Policy", read as follows: "Multi-dose vials shall be dated when opened and expire in 30 days."

The hospital policy did not state that multi-dose vials accessed in patient care areas would be considered single-patient vials.

On 9/9/2014, at 1:20 PM, Surveyor #1 inspected the contents of the anesthesia cart in the hospital's surgical suite. The cart contained two multi-dose vials of medications, a vial of rocuronium bromide and a vial of lidocaine. The vials had been opened but not dated. The medication was available for multiple patients.

(Reference: "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 (CDC); IV.H. Safe Injection Practices - IV.H.7 " Do not keep multi-dose vials in the immediate patient treatment area." The CDC includes operating rooms in its definition of "immediate patient treatment area".)

11. On 9/11/2014, Surveyor #1 interviewed the Director of Human Resources (Staff Member #5) regarding the curriculum for staff education and training regarding infection control. The hospital's infection control education and training program did not include elements required by state hospital regulations.

(Cross reference: C0270)

Based on interview and review of facility policies and procedures, the Critical Access Hospital failed to ensure that patient care policies and procedures were reviewed on an annual basis.

Failure to systematically review policies and procedures risk delivery of inappropriate or ineffective patient care.

Findings:

1. The hospital's policy entitled "Policy Review" (Reference #8710.6100; Effective 9/1/2014) stated that patient care policies would be reviewed at least annually.

2. Review of the hospital's policies and procedures on 9/11/2014 revealed the following:

a) There was no evidence that the hospital's pharmacy policies and procedures had been reviewed since November 2009.
b) There was no evidence that the hospital's dietary policies and procedures had been reviewed since December 2012.
c) There was no evidence that the hospital's infection prevention and control policies and procedures had been reviewed since September 2010
d) There was no evidence that the hospital's swing bed program policies and procedures had been reviewed since December 2012.
e) There was no evidence that the hospital's emergency department policies and procedures had been reviewed since December 2012.
f) There was no evidence that the hospital's Central Services policies and procedures had been reviewed since June 2009.

3. During an interview with Surveyor #1 on 9/11/2014 at 1:00 PM, the hospital's Quality Manager (Staff Member #9) confirmed there was no process to track the annual review of hospital policies and procedures.

Based on interview, record review, and review of hospital policies, the Critical Access Hospital failed to develop a policy and procedure for planning nursing care for patients, including how plans were to be reviewed and revised as necessary, as demonstrated by 3 of 3 patient records reviewed (Patients #5, #6, #7).

Failure to develop an individualized nursing care plan and to evaluate and revise the plan as necessary can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. Review of the records of three patients hospitalized between 4/9/2014, and 6/8/2014, revealed the following:

a) Patient #5 was a 10 year-old patient who had been admitted on 6/4/2014, with acute appendicitis. The patient underwent a surgical procedure on 6/4/2014, to remove his/her appendix. The patient's condition deteriorated during his/her hospital stay, and the patient was transferred to a children's hospital on 6/8/2014.

Review of the patient's post-operative nursing care plan revealed that problems identified included pain and activity intolerance. The problems had been entered into the patient's electronic medical record, but there was no evidence that the problems had been reviewed and revised according to changes in the patient's condition.

b) Review of the nursing care plans for Patient #6 and #7 revealed similar findings. The care plans for these patients had been initiated but not reviewed to evaluate the effectiveness of the plans and determine if revision of these plans was necessary.

2. During an interview with Surveyor #1 on 9/11/2014, at 3:00 PM, the hospital's Chief Nursing Officer (CNO) (Staff Member #6) stated that nursing staff members were expected to review the patient's plan of care every shift, to evaluate the plan's effectiveness, to record the patient's status toward problem resolution, and to revise the plan as necessary. The CNO stated the hospital had no written policy and procedure for nursing care planning.

Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to develop a process for retrieving assessment data from the electronic medical records of long-term care ("Swing Bed") patients in order to determine changes in the patient's condition that would warrant completion of a Comprehensive Assessment, as demonstrated by 3 of 3 patient records reviewed (Patients #8, #9, #10)

Failure to have a systematic process for comparing data regarding the patient's condition over time limits the hospital's ability to detect deterioration of the patient's health status.

Reference: Comprehensive assessment - when required (§483.20(b)(2) "(ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)"

Findings:

1. The hospital's policy and procedure entitled "Swing Bed Patient Assessment Policy" (Effective 7/30/2009), under "Frequency of Assessment", read as follows: "Significant change assessments will be completed as soon as needed to provide appropriate care to the swing bed patient, but in no case later than 14 days of determining a significant change in the patient's condition has occurred."

2. On 9/9/2014, at 2:30 PM, Surveyor #1 reviewed the medical records of three long-term care ("Swing Bed") patients. Patient #8 had been admitted to the hospital as a swing bed patient on 11/19/2013. Patient #9 had been admitted as a swing bed patient on 10/1/2013. Patient #10 had been admitted as a swing bed patient on 11/18/2013.

At the time of the record review, Surveyor #1 interviewed the hospital's long-term care nursing supervisor (Staff Member #10) and information technology staff member (Staff Member #11).

During the record review and interview, the hospital staff members were unable to locate and retrieve information entered into the patients' electronic medical record (EMR) that had been used to complete the patients' initial comprehensive assessments. There was no process for retrieving previous assessment data from EMR, comparing the assessment data to the patients' current assessments, and to determine if a significant change in the patients' condition had occurred.

Based on interview and review of the hospital's quality program, the hospital failed to develop a systematic process for tracking and evaluating action plans to improve hospital performance.

Findings:

1. On 9/11/2014, at 9:00 AM, Surveyors #1 and #2 reviewed the hospital's quality program and interviewed the Quality Manager (Staff Member #8). The hospital's 2013 quality plan (Approved 2/25/2013) read as follows: "6. The Quality Manager. The Quality Manager is appointed with the overall authority and responsibility under the direction of the BOC [Board of Commissioners] and the CEO [Chief Executive Officer], to coordinate the functions of the Quality Plan. The Manager's responsibilities include: ... 6. To monitor and report Process Improvement Team progress to the Quality Improvement Committee."

2. On 9/11/2014, at 9:00 AM, Surveyors #1 and #2 reviewed the hospital's quality program and interviewed the Quality Manager (Staff Member #8). During the review, the Quality Manager stated that performance and process improvement projects were conducted at the department level. Department managers were expected to report the status of these projects periodically to the Quality Improvement Committee. The manager did not know what performance improvement projects were being conducted throughout the hospital at the time of the interview. The interview revealed there was no systematic process for tracking and evaluating action plans to improve hospital performance.

Item #1 - Policy and Procedure - Discharge/Transfer of Swing Bed Patients

Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to develop a policy and procedure for notifying long-term care ("Swing Bed") patients of the reason for their discharge or transfer.

Failure to notify long-term care patients of the reason for discharge impedes their right to appeal this discharge or transfer to the state's long-term care ombudsman.

Findings:

During an interview on 9/10/2014, at 3:35 PM with Surveyor #2, the long-term care nursing supervisor (Staff Member #10) stated that the hospital did not provide long-term care patients with a written notice that included the reason for their discharge or transfer; and the contact information for the state's long-term care ombudsman.

Item #2 - Patient Rights - Discharge/Transfer of Swing Bed Patients

Based on review of patient rights information, the Critical Access Hospital failed to inform long-term care ("Swing Bed") patients of their right to be notified of the reason for their discharge or transfer

Failure to notify long-term care patients of the reason for discharge impedes their right to appeal this discharge to the state's long-term care ombudsman.

Findings:

Review of information given to Swing Bed patients on admission to the hospital revealed the information did not include the patient's right to be notified of the reason for their discharge or transfer; and to appeal this discharge to the state's long-term care ombudsman.

Based on interview, the Critical Access Hospital did not have a policy and procedure for assisting long-term care ("Swing Bed") patients to obtain dental care as needed.

Findings:

During an interview on 9/10/2014, at 4:00 PM with Surveyor #2, the long-term care nursing supervisor (Staff Member #10) stated that the hospital did not have a policy and procedure for assisting swing bed patients to obtain dental care as needed.

Based on interview and review of the hospital's patient rights information, the Critical Access Hospital failed to develop a process for informing patient's of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f).

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

Findings:

On 9/9/2014, at 10:45 AM, during an interview with Surveyor #1, the hospital's registration supervisor (Staff Member #7) presented a copy of patient rights information that was given to patients who were admitted to the hospital for outpatient services. The supervisor also presented a brochure entitled "Resident Rights and Admission, Transfer, and Discharge Rights" that was given to long-term care ("Swing Bed") patients on admission to the hospital.

Review of the contents of this patient rights information revealed the information did not include the patient's visitation rights identified under 42 CFR 485.635(f)(2).