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Based on observation, the facility staff failed to maintain air pressure relationships consistent with industry standards for ventilation.

Failure to maintain the correct environment and air pressure in an endoscopy procedure room places the patients at risk for infectious diseases.

Findings:

1. On 10/9/2012, during a tour of the endoscopy suites, Surveyor #2 used a lightweight string to assess airflow between a gastro-endoscopy procedure room and the corridor. The direction of air-flow was negative to the corridor rather than positive, as required by industry standard.

Ref: ANSI/ASHRAE/ASHE Addendum b to ANSI/ASHRAE/ASHE Standard 170-2008

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Based on observation and interview, facility staff failed to follow hospital policies and procedures for hand hygiene during patient care activities. Failure to adhere to hospital hand hygiene policies puts patients, staff and visitors at risk for infectious diseases.


Findings:

1. On 10/10/12 at 12:10 pm during a tour of the "medical/surgical" unit, Surveyor #2 observed Staff #10 go into a patient room, help the patient with his/her lunch meal and exit the room again, all without performing hand hygiene, per the facility's "Gel in/Gel out" policy.

2. On 10/11/12 at 2:25 pm, during a tour of the "medical/surgical" unit, Surveyor #2 observed Staff #11 enter a patient room, wash hands, put on gloves, obtain a patient blood sample, then remove gloves and exit the room without performing hand hygiene per the facility's "Gel in/Gel out" policy. This observation was confirmed during an interview with both Staff #11 and Staff #9.

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Based on observation and staff interview the facility staff 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 State Food Code puts patients, staff and visitors of the facility at risk of food borne illness.

Findings:

1. On 10/10/12, during a tour of the facility kitchen, Surveyor #2 observed a bucket with sanitizer and a wipe rag, located in a sink with a soap dispenser and a hand towel dispenser. An interview with Staff #6 confirmed that the sink was a designated handsink, but facility staff used it as a service sink. Handwashing aides such as towel and soap dispensers should not be present at a service sink.

Ref: Washington State Retail Food Code Working Document Chapter 246-215 Washington Administrative Code (WAC) Modification of 2001 FDA Food Code
Chapter 6-301.13.

2. On 10/10/12 during a tour of the facility kitchen, Surveyor #2 observed a staff member's personal canned drink left open in a food preparation area. The container did not have a handle or cover as required in the State Retail Food Code.

Ref: Washington State Retail Food Code Working Document Chapter 246-215 Washington Administrative Code (WAC) Modification of 2001 FDA Food Code
Chapter 2-401.11 (B).

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Based on policy review and interview, hospital leaders failed to conduct an annual review of all patient care policies and procedures as required by the Code of Federal Regulations (CFR) 42 (Public Health) ? 485.635 (a) (4).

Failure to conduct a timely review and update of healthcare policies and procedures places patients at risk for poor outcomes, including serious disability and death, related to inadequate and/or inconsistent healthcare quality.

Findings:

1. During a review of a sample of patient care policies, 3 of 3 policies had creation dates greater than one year prior to the current date and 3 of 3 had no documentation indicating the policies had been reviewed by facility medical staff as required by
42 CFR ? 485.635 (a) (2). This finding was confirmed by Staff #9, who indicated the facility had not been able to review all patient care polices on an annual basis as required.

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Based on review of facility policies and administrative staff interview, the facility failed to ensure that patient care services provided by contractors or through agreement or arrangement were evaluated as part of an integrated quality program.

Failure to develop a systematic method for evaluating patient care contractor performance risks provision of improper or inadequate care and adverse patient outcomes.

Ref: 42 CFR 485.641(a)(i) The purpose of the [annual CAH program] evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed.

Findings:

1. On 10/11/12, during a review of contracted services documents, Surveyor #2 found no evidence that the facility required periodic evaluation of its contracted services as a part of its quality program. This finding was confirmed by Staff # 9.

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Based on record review, the facility failed to assure complete assessment of areas of skin breakdown for 2 of 2 patients who entered the facility with a skin breakdown.

Failures to do so creates risk that abnormal skin conditions may worsen/not heal without staff awareness and/or needed changes to the plan of care.

Reference: 485.635(d)(2)

Findings:

1. In review of a policy titled, " Pressure Ulcer Prevention " (revised 2-2012) section " I.A " . stated " Head-to-toe skin assessments will be completed by the registered nurse upon admission and twice daily thereafter for the duration of the patient ' s hospital stay. Assessment will be performed in sufficient lighting to allow for adequate visualization of skin integrity. "
On page 1 item " I.C. " stated " Photographs of each area of concern ...will be completed at that time of the initial skin assessment or immediately upon detection ...Item number " Item " I.3. " provided information about dating and labeling requirements for photographs to become a part of the permanent record. " "
On page 4 under " Procedure " , item " IV. " it stated, " Measure wound surface area Length and width can be measured with a disposable measuring guide/ruler. "

2. On 10-11-12 in review of 2 medical records for patients that entered the facility with skin breakdown the following omissions were noted related to the policy above.
a. Patient #6 was 47 year old patient admitted on 9-21-12 for treatment forearm cellulitis (skin infection). The patient ' s condition eventually required transfer to another facility for ongoing care related to infection. Per the initial RN assessment the forearm skin problem was a Stage 1 (lower level). There were no photographs or measurements completed in the medical record of the forearm area.

b. Patient #7 was another 47 year old patient admitted on 6-12-12 for treatment of a multi-drug resistant urinary tract infection with other medical problems, including a chronic lung condition, diabetes and being bedridden. The patient entered the facility with skin breakdown and the record contained unlabelled photographs in the medical record of two areas of skin breakdown. However, wound measurements were obtained only for one area of breakdown and that did not occur until 2 days after initial hospital admission.

The above assessments did not conform to the facility policy and procedure.
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A. Based on review of policy and procedure and record review, the facility failed to ensure that 1 of 2 patients with continuous narcotic infusions received pain assessments during the initial post-operative period on the medical-surgical floor.

Failures to provide pain assessments creates a risk that patients ' pain will not be well managed and/or that they will experience complications of the pain management interventions that would not be assessed/treated.

1. In review of the policy and procedure titled " Patient Controlled Analgesia/Continuous and Bolus Narcotic Infusion " (5-21-12) it was noted on page 2, item " III.B. 1. " contained information the frequency of assessments. It stated that patients should received an assessment at a minimum of every 4 hours. The more frequent intervals leading up to the every 4 hour minimum interval were defined as well.

In review of a policy titled " Epidural Medications " (4-1-07), it stated on page 2 section 13 that licensed nurse will be responsible for " notifying the Anesthesia Provider if the patient has abnormal vital signs or sensorimotor, respiratory, cardiac or neurologic changes from baseline. "

2. In review of the medical record of Patient #3 it was noted that s/he had a continuous epidural infusion of medications (Fentanyl and Ropivicaine) after having surgery for a total knee replacement on 9-5-12. Epidural infusions are designed to administer pain relieving medication into a region of the spinal canal.
The patient arrived on the inpatient nursing unit at around noon that day and there was no recorded pain assessment until approximately 8 hours later, at 8:20 pm. This finding was confirmed by Staff #1 and #2.


B. Based on observation and staff interview the facility failed to assure safe medication practices in preparation for administration of intravenous conscious sedation in the gastro-intestinal (GI) patient care area.

Failures to do so creates risk for medications errors and opportunity for patients to receive medications without assurance of quality which may cause patient harm.

Findings:

1. On 10-10-12 at around 9:30 am during a tour of the GI patient care area, several unlabelled syringes containing solution were found in locked draws in Room #1 and #2. The full syringes had empty medication vials of versed (a sedative) and fentanyl (a narcotic) taped to them. There were standard pre-printed syringe labels for each drug in the drawer where the medication was located however the labels were not used/affixed to the syringes.
Five unlabelled syringes (in the manner described above) were located in Room #1 and there were 3 syringes were located in Room #2. The intent of drawing up the intravenous medications in advance was to have them available for patient care later in the day. The Nursing Director of Surgical Services (Staff #3) was present during the observations.

Reference per USP 797: Opened or needle-punctured single-dose containers shall be used within one hour if opened.

2. On the same day in interview with a RN (Staff #3) who worked in the GI area, s/he stated that s/he had drawn up medications in Room #2 and thought that taping the empty vials to the syringe was a labeling method. There was no notation of date, time or staff initials related to vials being opened/syringes being drawn up.
The practice of pre-drawing medication syringes was routine in that patient care area per discussion. The plan was for the medication in each syringe to be administered to one patient only. The unused portion was wasted per staff report and record review.

3. On 10-10-12 the charge nurse in the GI area (Staff #5) stated that there were no medication administration procedures in the GI area. On 10-11-12 a policy was requested related to RN labeling of syringes throughout the facility. Per the Director of Pharmacy (Staff # 4) and the Chief Nursing Officer (Staff #2) stated that there was not a policy about RN labeling of medication syringes.

C. Based on review of policy and procedure and record review, the facility failed to assure that 2 of 2 pediatric patients who received inhaled medication treatments had those treatments verified by 2 staff members prior to administration.

Failures to do so creates a risk that the pediatric patients may experience a medication error(s) that would cause patient harm.

Findings:
1. In review of a Pharmacy policy and procedure titled, " Paragon Medication Administration " (6-27-12) in the section titled " Definitions it stated " 1.Medications administered which require witness (double independent verification) .....B Pediatric Patients (children newborn through 14) ...vii. All medications .... "

2. In review of patient records on 10-10-12 the following omissions regarding double verification (completed by two staff members) of a pediatric medication prior to administration was noted:

a. Patient #1 was a 4 year old child admitted with severe asthma from 9-27-12 to 9-28-12. During the hospital stay the patient received 4 inhalation treatments, including xopenex and proventil. Of those doses, there was a treatment administered on 9-27-12 at 1427 that dosage was not verified by a second staff person prior to administration.

b. Patient #2 was an 8 year old child admitted with pneumonia and shortness of breath from 9-2-12 to 9-4-12. During the 2 days of the patient ' s stay (9-3 to 9-4-12) there were a total of 6 doses of inhaled albuterol administered. Three of 6 doses were not verified by a second staff member. The dates and times that the omissions occurred included 9-03-12 at 2:51pm, 9-4-12 at 7:29am and 11:06am.

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Based on review of policy and procedure and record review, the facility failed to assure complete post-anesthesia evaluations for 3 of 3 patients.

Failures to do so creates a risk that patients may be discharged from the care of anesthesia prior to a complete evaluation which may compromise the quality of patient care.

Findings:

1. In review of the " Medical Staff Rules and Regulation " (7-26-12) on page 5 under " General Rules Regarding Surgical Care " item #3 stated, " The anesthetist shall maintain a complete anesthesia record to include ....and the post-anesthetic follow up of the patient ' s condition. " The rules and regulations did not include a requirement for inclusion of cardiopulmonary status, level of consciousness, any follow-up care or observation and any complications occurring during post-procedure recovery.
The above components are listed as minimum per Critical Access Hospital regulation 485.639(b) under " Anesthetic Risk and Evaluation " .

2. In review of the medical records the same omissions were noted except that in each record the anesthetist checked the box for " No anesthetic related complications were noted " . There were no notations in the record space provided regarding cardiopulmonary status, level of consciousness or any follow up care and/or observations.
a. Patient #3 was a 70 years old and had a total knee replacement on 9-5-12 with an epidural catheter in place to administer narcotic medications into the spine.
b. Patient #4 was a 74 years old and had a total knee replacement on 9-28-12 with intravenous morphine running for pain medication.
c. Patient #5 was a 57 years old and had a bowel resection on 9-18-12 and had an epidural catheter in place to administer narcotic medication into the spine.
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