HospitalInspections.org

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Based on record review and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 2 patients reviewed (Patients #3, #4).

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

Findings:

1. The hospital policy and procedure titled "Administration of Blood and Blood Products" (Last Approved 2/2017; PolicyStatID # 281405) under the section titled "Procedure" read in part: "Documentation of Blood Products . . . b. Vital Signs for Each Unit of Blood Product record: i. Patient's temperature, pulse, respiration and blood pressure before starting the transfusion (baseline up to 4 hours pre-transfusion). ii. After 15 minutes from transfusion initiation. iii. Every 60 minutes from previous vital signs until the transfusion is complete. iv. A final set of vital signs at the completion of the transfusion."

2. On 4/12/2017 between 1:00 PM and 4:00 PM, Surveyor #1 reviewed the medical records of 2 patients who received blood transfusions during their hospital stay and observed the following:

a. Nursing staff caring for Patient #3 failed to document a set of vital signs at the required 60-minute block time intervals (for two consecutive hours) for the first unit of blood administered. In addition, the nursing staff did not document vital signs for the initial 15-minute block of time upon starting the second unit of blood administration as required by policy.

b. Nursing staff caring for Patient #4 failed to document a complete set of vital signs at the end of the blood transfusion as required by policy.
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Based on observation 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 patients, staff, and visitor safety.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.
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Based on record review and review of hospital policy and procedure, the critical access hospital failed to ensure staff members follow its policy when caring for patients placed in restraints or seclusion for 2 of 2 patients reviewed (Patient #5, #6).

Failure to follow hospital processes for placing patients in restraints or seclusion risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital policy and procedure titled "Restraints" (Last Approved 2/2017; PolicyStatID # 3303495) under the section titled "Procedure for Violent Care Standard" read in part: "The RN/MD makes an assessment that the patient or others are in immediate danger and applies restraints. . . The RN/MD consult after the emergency situation is temporarily resolved and determine the least restrictive restraint intervention(s) possible and discontinues them at the earliest possible time."

2. On 4/12/2017 between 1:00 PM and 3:00 PM, Surveyor #1 reviewed the medical records of two patients placed in restraints and/or seclusion and noted the following:

a. Patient #5 was a 55-year old seen in the emergency department on 1/29/2017 for an acute mental evaluation and was determined to be a danger to self and others. The patient was placed in 2 point restraints on 1/30/2017 at 12:27 AM and released from restraints on 1/30/2017 at 4:19 PM.

b. Documentation of Patient #5's behavior on the restraint flow sheet was annotated as "sleeping" from 12:27 AM to 4:30 AM (a period of 4 hours and 3 minutes). Another period from 10:45 AM until 3:30 PM (a period of 4 hours and 45 minutes), the patient's behavior was documented as either "sleeping" or "calming down". The surveyor found no evidence during these periods to indicate the patient's behavior reflected an imminent danger to self or others. Further, no documentation in the medical record showed the staff attempted to reduce the total number of restraints or that the patient's behavior warranted continued application of restraints.

c. Patient #6 was a 43-year old admitted on 10/18/2017 to the acute care unit for extreme agitation. The patient was placed in seclusion at 11:00 PM for spitting and hitting others. The patient remained in seclusion until 10/19/2017 at 11:32 PM at which time he/she was transferred to another facility for further evaluation and treatment.

d. Documentation of Patient's behavior on the seclusion flowsheet was annotated as "sleeping" from 10/18/2017 at 11:00 PM until 9:45 AM (a period of 10 hours and 45 minutes). The surveyor found no evidence in the medical record to indicate the patient's behavior reflected an imminent danger to self or others or that the staff removed the patient from seclusion.

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Item #1 - Surgical Attire

Based on observation, interview, and review of hospital policy and procedures, the critical access hospital failed to ensure that surgical attire standards were adhered to.

Failure to adhere to surgical attire standards places patients at risk for infection.

Findings:

1. The hospital policy and procedure titled, "Surgical Attire" (Last Approved 12/2016; PolicyStat ID # 3044202) under the section titled "Procedure" read in part: "D) Jewelry that cannot be contained or confined within the scrub attire should not be worn within the semi restricted and restricted areas."

2. On 4/12/2017 at 8:32 AM, Surveyor #1 observed a surgical procedure for Patient #1 and noted a surgeon (Staff Member #2) entered the operating room with dangling earrings. The surveyor observed the jewelry was not contained by the surgical bouffant and moved freely with movement.

3. Surveyor #1 discussed this finding with the Director of Surgical Services (Staff Member #2) who acknowledged the earrings should have been covered by the surgical headwear.

Item #2 Hand Hygiene

Based on observation and review of hospital policies and procedures, the critical access hospital failed to ensure staff members performed hand hygiene according to hospital policy.

Failure to perform proper hand hygiene can put patients at risk for health care associated infections.

Findings:

1. The hospital's policy and procedure titled, "Hand Hygiene" (Last Approved 12/2016; PolicyStatID # 3017276) under the section titled "Procedure" read in part: "Decontaminate hands by alcohol hand rub or hand washing (Gel or wash): Before having direct contact with patients; Before donning sterile or non-sterile/clean gloves; Before performing any invasive procedure with/on a patient; Before inserting invasive devices that do not require a surgical procedure; After contact with a patient's skin; After contact with body fluids or secretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. . . After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; After removing gloves."

2. On 4/11/2017 between 11:40 AM and 12:20 PM, Staff Member #10 and Surveyor #2 observed the terminal cleaning of Patient Room #323 following a patient discharge. Two members of the Environmental Services Staff (Staff Members # 11 and #12), completed the cleaning. Surveyor #2 observed Staff Member #11 change gloves three times without performing hand hygiene as required by policy.

3. On 4/11/2017, between 3:00 and 5:30 PM, Staff Member #10 and Surveyor #2 observed the terminal cleaning of Operating Room #2. One member of the Environmental Services Staff (Staff Member #13) initiated the procedure and was relieved at 4:10 PM by another Environmental Services Staff (Staff Member #14) who completed the cleaning. Surveyor #2 observed Staff Member #13 change gloves four times without performing hand hygiene. The surveyor observed Staff Member #14 change gloves six times without performing hand hygiene. Staff Member #10 confirmed this finding at the time of the observations.

4. On 4/12/2017 between 7:00 AM and 8:45 AM, Surveyor #1 observed a surgical procedure for Patient #1 and noted the following:

a. A certified nurse anesthetist (Staff Member #3) failed to perform hand hygiene between glove changes during the following procedures: removal of the patient's dentures; patient intubation (place artificial airway into patient's lungs); and placement of an oral gastric tube.

b. An operating room nurse (Staff Member #4) failed to perform hand hygiene between glove changes after performing a surgical skin scrub, repositioning a patient, and donning sterile gloves in preparation before a urinary catheterization (placing a tube into the patient's bladder).

Item #3 - Dietary

Based on interview, the critical access hospital failed to assure compliance with 2009 FDA Food Code.

Failure to comply with food service codes put patients, staff, and visitors at risk of foodborne illness.

Findings:

On 4/11/2017 at 9:30 AM, Surveyor #2 interviewed the Food Services Director (Staff Member #8) and the Dietary Supervisor (Staff Member #9), with the Infection Preventionist (Staff Member #10) observing. Staff Member #8 described noncontinuous cooking of chicken breast for meal service: a) brine soaking breasts under temperature control, b) breasts grilled for 1-2 minutes on each side, c) cooled in single layer on sheet pan in the walk-in refrigerator, d) cooked for service to 165 degrees Fahrenheit, e) hot-held above 141 degrees Fahrenheit on the service line.

Staff Member #8 and Staff Member #9 acknowledged the facility did not submit the written procedure for prior approval by Washington Department of Health as required by the food code.

Reference: 2009 FDA Food Code. Noncontinous Cooking 3-401.14

Item #4 - Isolation Precautions

Based on observation and document review, hospital staff failed to adhere to contact precautions during the daily cleaning of a room occupied by a patient under contact precautions.

Failure to remove personal protective equipment before leaving a patient's room risks exposure of patients, staff, and visitors to infectious agents.

Findings:

1. The hospital policy titled, "Isolation Precautions" (Last Revised 12/2016; PolicyStat ID: 3017619), under the title, "Procedure, Contact Precautions, Gowns" stated in part; "The gown should be removed before leaving the patient's room," and under Donning and Doffing of PPE (Personal Protective Equipment); "When removing PPE, remember that isolation gear should be removed before you leave the patient's room."

2. On 4/12/2017 at 9:20 AM, Staff Member #10 and Surveyor #2 observed the daily cleaning of Patient Room 327 by Staff Member #12. The room was occupied by a patient ordered for contact isolation precautions. During the course of the room cleaning, Staff Member #12 exited the room to collect supplies twice without removing PPE. Staff Member #10 stopped Staff Member #12 from exiting a third time and reminded him/her of the requirement that the gown should be removed before leaving the patient's room.

Item #5 - Semi-Critical Device

Based on observation and document review, the critical access hospital failed to prevent cross contamination during high-level disinfection (HLD) of patient care equipment.

Failure to follow endoscope reprocessing procedures put patients and staff at increased risk of infection.

Reference:

SGNA (Society of Gastroenterology Nurses and Associates, Inc.) Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes, 2016 edition, stated in part; under Endoscope Reprocessing Protocol, 3. Manual Cleaning, step d. "Wash all debris from the exterior of the endoscope by brushing and wiping the instrument while submerged in the detergent solution. The endoscope should be submerged in the detergent solution when performing all subsequent cleaning steps to prevent splashing of contaminated fluid and aerosolization of bioburden."

Findings:

1. The hospital policy titled, "Reprocessing Flexible Gastrointestinal Endoscopes in Surgical Services" (Last Revised 2/2017; PolicyStat ID: 3169479), under the title "Procedure: VI. Cleaning and High-Level Disinfection, C. Manual Cleaning" stated in part: "3. Place the endoscope in the solution, keeping it below the fluid level fully submerged."

2. On 4/11/2017 at 2:15 PM, Staff Member #10 and Surveyor #2 observed a surgical technologist (Staff Member #15) as s/he reprocessed an Olympus 190 series colonoscope in the main hospital endoscope reprocessing room. During the manual cleaning step the colonoscope was not submerged in the disinfectant solution when Staff Member #15 washed the exterior, or passed a brush through the channels as required.

3. On 4/12/2017 at 2:40 PM, in the Surgery and Endoscopy Clinic, the Clinc Lead RN (Staff Member #16), Staff Member #10, and Surveyor #2 observed a registered nurse (Staff Member #17) as s/he reprocessed an Olympus 190 series colonoscope. During the manual cleaning step the colonoscope was not submerged in the disinfectant solution when Staff Member #17 washed the exterior, or passed a brush through the channels as required.

4. Staff Member #10 consulted the Olympus reprocessing manual and concurred that the manufacturer recommended that endoscopes should be immersed in disinfectant solution during the manual cleaning step of the procedure.
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Based on record review and review of hospital policy and procedures, the critical access hospital failed to ensure proper informed consents were obtained for 1 of 3 surgical charts reviewed (Patient #2).

Failure to properly obtain an informed consent risks patients not being fully informed of potential risks.

Findings:

1. The hospital's policy and procedure titled "Informed Consent" (Last Approved 2/2017; PolicyStatID # 3336935) under the section titled "Responsibility" read in part: "For treatment which requires specific consent (such as blood transfusion and surgical procedures) the treating physician is responsible for explaining medical treatment and procedures to the patient, sign/date the surgeon's attestation, and obtaining a properly filled out and executed consent form and sign the surgeon's attestation."

2. On 4/13/2017 between 1:00 PM and 5:00 PM, Surveyor #1 reviewed the surgical record of Patient #2 who underwent a laparoscopic cholecystectomy (procedure to remove the gall bladder) The surveyor could find no evidence that the surgeon's signature was documented in the surgical consent form.