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Tag No.: C0151
A. Based on patient interview, review of policy and procedure and record review, the facility failed to assure that it followed its' policy and procedure related to health care advanced directives.
Failure to do so creates a risk that patients' directives about their health will not be adhered to which may result in undesired outcomes.
Reference: 42 CFR 489.102(a)
Findings:
1. During an interview on 9-12-12 with Patient #2 who was admitted for weakness and a lung and heart condition, s/he stated that s/he had a copy of his/her advanced directive at home. The patient clearly verbalized his/her wishes for the level of health care in the event of serious medical event. The patient did not recall any staff member talking with him/her about obtaining a copy of his/her advanced directive.
During an interview with Patient #1 on 9-13-12 s/he stated that s/he had a living will but did not recall anyone discussing that with her.
2. In review of a policy titled "Health Care Directive" (2-6-09) in section 3 under responsiblities it stated, "It is the responsibility of the nurse admitting the patient to determine if a health care directive has been completed, and if so, to obtain a copy for the patient record."
3. In review of the medical record for Patient #2 on 9-12-12 there was not nursing documentation related to an advanced directive during the admission process or thereafter and there was not a copy of the patient's advanced directive in the medical record.
In review of the record of Patient #1, it was noted that the Code Status was left blank on the admitting orders and the POLST form located in the record was also left blank. The record contained no nursing documentation about the status of an advanced directive (per surveyor interview that the patient had a living will).
B. Reference: 246-873-080 Drug procurement, distribution and control.
(1) General. Pharmaceutical service shall include: (b) A monthly inspection of all nursing care units or other areas of the hospital where medications are dispensed, administered or stored. Inspection reports shall be maintained for one year.
Based on interview and review of policy and procedure the facility failed to assure pharmacy accountability for completion of monthly inspections medication stored on the nursing units.
Failure to do so creates risk that the quality of pharmacy products cannot be assured by the pharmacy staff.
Findings:
1. During a staff interview on 9-14-12 with Staff Member #6, it was stated that nursing staff conducts inspections of the nursing units medication supplies to check for expired medication. Furthermore, the pharmacy service did not conduct monthly audits.
2. Upon review if policy titled " Monthly Inspection for Outdated Medications " it stated that " Monthly inspections will be supervised by the pharmacist or his/her designee to ensure that no outdated medications are available for use or distributed. "
Per the Pharmacy Policy and Procedure noted above the pharmacy service did not have a pharmcy system/audit in place to assure the quality of medication readiness completed by nursing staff.
3. On 9-14-12 during a tour of the nursing medication room with Staff #7, an opened and undated vial of Procrit 20,000 units per milliliter was located. This is a medication that should have been discarded from availability for patient care because it was not dated and therefore considered expired.
C. Based on pharmacy staff interview and review of policy and procedure the facility failed to review pharmacy policies and procedures annually.
Failure to do so creates a risk for poor quality pharmacy services based on inconsistent standards of care related to inconsistent or outdated practices.
Reference 246-873-080 Drug procurement, distribution and control.
(4) The director shall establish, annually review and update when necessary comprehensive written policies and procedures governing the responsibilities and functions of the pharmaceutical service...
Findings:
1. On 9-14-12 in interview with the pharmacist, Staff #6, it was confirmed that Pharmacy policy and procedures had not been updated in over 18 months.
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Tag No.: C0154
Based on record review, facility staff failed to assure contracted hospital staff were properly licensed or certified as required by state law.
Failure to maintain records of licensure or certification on contracted staff puts patients at risk for receiving care from improperly trained and/or qualified individuals .
Findings:
During human resources record review, the facility failed to provide licensure or certification information for contracted staff, including a physical therapist, occupational therapist and registered dietician.
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Tag No.: C0204
Based on observation and interview, facility staff failed to assure that sterile items used for common life-saving procedures were intact and ready to use for patient needs.
Failure to keep sterile items intact prior to use, puts patients at risk of inadequate care in the event of an emergency.
Findings:
On 9/12/2012 at 9:50 am, during a tour of "ER room #1", Surveyor #2 observed an open package containing an oral suction device with an outside label marked "Sterile- Do not use if opened". This package was left on a bedside tray table in the room. This finding was confirmed by the Staff #3.
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Tag No.: C0278
Based on record review, facility staff failed to develop and implement a policy regarding methicillin-resistant staphylococcus aureus (MRSA) screening for patients who enter the hospital.
Failure to adopt a policy for MRSA puts patients, staff and visitors at risk for infection with a multi-drug resistant organism as defined in the Health Care Infection Control Practices Advisory Committee (HICPAC) Guideline "Management of Multidrug-Resistant Organisms In Healthcare Settings,2006".
Findings:
1. On 9/13/2012 during a review of infection control policies, Surveyor #2 failed to find a facility policy on MRSA for patients entering the hospital. A follow-up e-mail from Staff
#1, received on 9/18/2012 , confirmed there was no written policy for their current practice related to the prevention of MRSA transmission in the hospital.
Tag No.: C0279
31312
A. Based on interview and record review that facility failed to meet the nutritional needs of its inpatients by implementing policies and procedures to assure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC).
Specific references made in the findings below are found in the Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code.
1. During a facility tour on 9/13/2012 at 10:00am, Surveyor #2 observed Staff #2 change gloves between tasks without performing hand hygiene. Staff should perform hand hygiene prior to putting on gloves to work with food. Ref: Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code, chapter 2-301.14 (F).
2. During a facility tour on 9/13/2012 at 10:30 am, Surveyor #2 observed dirt and grease built up on a ceiling vent located directly above the food preparation table. This finding was confirmed with Staff #1.
Ref: Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code, chapter 6-202.12
3. During a facility tour on 9/13/2012 at 11:15 am, Surveyor #2 observed shell eggs in the refrigerator without evidence of having been pasteurized. This finding was confirmed by Staff #2. Hospitals serve highly susceptible populations and must serve pasteurized shell eggs or pasteurized liquid, frozen or dry eggs or egg product.
Ref: Chapter 246-215 Washington Administrative Code (WAC) and Modification of 2001 FDA Food Code, chapter 3-801.11(B).
B. Based on, and review of policy and procedure , record review and staff interview, the facility failed to assure the provision of dietary services by a dietician for 3 of 3 patients.
Failure to do so creates a risk that patients' nutritional problems will be unaddressed which may result in undesired health outcomes.
Findings:
1. During a review of a policy titled " Patient Nutritional Risk Screen " (02/21/2012) , it stated that patients will have a nutritional risk screen completed by nursing personnel within 24 hours of admission. If the patient scored " greater than 5 " then a copy of the screen and the " dietitian review form " was to be faxed to the dietician for review.
The policy did not specify any related follow-up to be provided by facility staff or by the dietician to whom the form had been faxed to besides placing a form in the chart.
In another policy titled " Dietary and Nutritional Services " (04/10/2008) for swing bed patients, item #6 stated " Dietary consults are available by Dietary personnel upon request of nursing or the physician. "
2. The following patients charts were reviewed 09/12/12 by Surveyor #1:
a. Patient #1 was admitted on 9-4-2012 after a surgical repair of a hip fracture and had a nutritional screen completed on the admission day. The patient's at risk score was 7 which was considered moderate risk and required faxing to the dietician.
b. Patient #2 was admitted on 09/05/12 for weakness and a chronic lung and heart condition and had a nutrition screen completed on the admission day. The patient ' s at risk score was 6 which was considered moderate risk and required faxing to the dietician.
3. On 9-12-12 during a phone interview Surveyor #1and the dietician, Staff #8, s/he denied receiving any dietary referrals from the facility. S/he was not aware of any system to assure dietician receipt of referrals (i.e. a referral log or email confirmation) and stated that there had been problems with obtaining referrals in the past.
Per the facility defined criteria, the noted patients should have had a "dietician consult within 48 hours. "
4. On 9-13-12 in review by Surveyor #1of another patient's chart, Patient #3, who was admitted on 10-28-11 with respiratory failure, diabetes, a heart condition and decubitus ulcers, the risk screen score was determined to be 8. A score of 8 is considered high risk and requires a consult within 24 hours. There was no dietary consult in the record during the patients stay between 10-28-11 and the time of discharge on 11-03-11.
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Tag No.: C0280
Based on interview and review of policies and procedures the facility failed to review patient care policies and procedures at least annually.
Failure to do so creates risk for breaches in quality of patient care due to inconsistent and/or outdated practice.
Findings:
1. In interview with Staff #1 on 9-12-12 s/he confirmed that numerous policies and procedures related to patient care had not been updated in the past year. Per discussion, the facility is in the process of updating policies and procedures however patient care policies and procedures were not being managed as a priority for annual review.
That day it was also noted that the majority of policies and procedures related to patient care for swing patients were greater than 12 months old.
2. On 9-14-12 in interview with the pharmacist, Staff #6, it was confirmed that Pharmacy policy and procedures had not been updated in approximately 18 months.
3. After the above interview Staff #1 provided a facility document titled "Guide to Writing Policy and Procedure Documents " however there was no document content related to a required time interval(s) for review.
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Tag No.: C0294
Based on review of policy and procedure, the facility failed to follow its procedure for the administration of blood and blood products.
Failure to do so creates a risk that patients may incur complications related to the administration of blood, including lack of recognition of the complication.
Finding:
1. On 9-13-12 in review of facility policy titled " Blood and Blood Products Administration " (5-2-12) page4, section " h " included information related to patient monitoring prior to the administration of blood. The policy stated " Within 30 minutes before starting transfusion, obtain base line vital signs (T, P, R, B/P), assess and chart Skin and Lung sounds. "
On page 5 related to the administration of packed red blood cells after the infusion was started, item " xi. " stated " After 15 minutes, reassess patient and chart vital signs (T,P,R,B/P) skin assessment and lung sounds. Item " xvi. " stated " A complete set of vital signs with skin and lung sounds will be documented at the completion of infusion.
The above policy was reviewed with Staff Member #7.
2. On 9-13-12 in review of patient records with Staff #7 the following was identified:
a. Patient #4 received 3 units of packed red blood cells on 8-23-11. During the infusion which lasted over approximately 6 hours, 8 of 10 blood pressure readings were abnormal. Those reading had a systolic reading (upper number) of less than 90 mm of mercury and a diastolic readings (lower number) in the 40s for 9 of 10 readings. Adult blood pressure readings less than 90/60 are considered abnormally low. There was no documentation related to evaluation of the blood pressure readings. Additionally, there were no lung sounds or skin assessments recorded per facility over an approximate 6 hour period.
b. Patient#5 also had 3 units of packed red blood cells infused and there were no lung sound assessments recorded per facility policy over an approximate 9 hour period.
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Tag No.: C0361
Based on patient and staff interview, record review and review of policy and procedure the facility failed to assure protection and promotion of swing bed patient rights, including providing them with notification of their rights.
Failure to do so creates a risk that patients and/or surrogate decision makers may not be able to exercise those rights which may result in undesired health outcomes, including negative effects on quality of care.
Findings:
1. The following information was obtained from patient interviews and chart reviews on 9-12-12 and 9-13-12 respectively:
a. Patient #1 was admitted on 9-4-2012 after a surgical repair of a hip fracture and stated that no one discussed patients rights with him/her and that s/he had not received any written information about patient rights from facility staff. There was no patient rights information located in the in the record or in the patient ' s room per their report.
b. Patient #2 was admitted on 09/05/12 for weakness and a chronic lung and heart condition and stated that no one discussed patients rights with him/her and that s/he had not received any written information about patient rights from facility staff. There was no patient rights information located in the in the record or in the patient's room per their report.
2. On 9-12-12 at 1130 am Staff #7 presented a policy titled " Swing Bed Admission Procedure " (4-7-11). Part " 2 " was titled " Ward Clerk Responsibilities " and part " b " stated " Review patient rights and provide a copy for the patient and family. "
3. On 9-16-12 upon interview with the Registration Clerk, Staff #4, s/he stated that registration staff was responsible for providing swing patients with copies of their swing patient rights, including providing that information to them at their bedsides as necessary. That information was confirmed by another Ward Clerk, Staff #5.
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