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Based on observation and interview the facility failed to provide certain emergency patient care supplies for appropriate care and treatment of patients.

Failure to do so places patients at risk for delays in treatment and the potential for inaccurate laboratory test results.

Findings:

During tour of the Acute Care unit on 3/15/11 approximately 10:00 AM the surveyor found the following expired patient care items in the small hall cabinets outside patient rooms:
? One Serrocult slide expired 2/11
? One Gastrocult slide expired 2/11
? One bottle of Serrocult solution expired 10/10

During the same tour, the following items were found in the unit's soiled utility room:
? One bottle of Serrocult solution expired 10/10
? Three bottles of Gastrocult solution expired 2/11
? One box of Gastrocult slides expired 2/11

The above items are used to detect blood in cases where it cannot be directly visualized or in which confirmation is needed; reliance on items which have passed their expiration date could result in inaccurate test results and inappropriate treatment or lack of treatment. The above observations were confirmed by Staff #2.

Based on observation, interview, and record review, the facility failed to implement policies and procedures to secure, track, and inventory controlled substances according to Washington State Board of Pharmacy regulations.

Failure to secure and closely track controlled substances risks diversion, tampering, and/or unauthorized use, which can endanger staff and patients, and in this situation risks not having the drugs available when needed.

Reference: WAC 246-873-080 -- Drug procurement, distribution and control.
(7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations.


Findings:

Inspection of the Acute Care unit's mobile crash cart on 3/15/11 showed that it was secured by a tamper-evident seal, and was not locked. Examination of the cart's contents revealed that controlled substances were stocked on the cart, in the same drawer as the rest of the drugs, and were not in a locked container. There was no documentation found that staff were counting these drugs to assure their presence. The drugs included:
? Valium, five syringes, 10mg/2ml (a tranquilizer, sedative, and anti-seizure drug)
? Versed, five vials, 5mg/5ml (a drug typically used to sedate patients for uncomfortable procedures)

The above findings were confirmed by Staff #2, who stated that all crash carts in the hospital were identical; that two others existed, one each in the Post Anesthesia Care Unit and one in the Emergency Department. Staff #2 acknowledged that the drugs were not locked, a requirement for all controlled substances not in use or continually visualized. S/he also stated there was no mechanism for counting them at the change of shift, a requirement for all controlled substances stored on nursing units.

Based on document review the facility failed to assure that life saving emergency equipment would be available (functioning) if needed during an emergency.

Failure on the part of the facility to assure that life saving emergency equipment will function when needed puts patients at risk of death.

Findings include:

1. On 3/15/2011 during rounds of the facility the surveyor noted that the defibrillator located on the crash cart in the OR had only been checked on 8 of 15 days (March 1 through March 15). According to staff the dates on which the defibrillator operational checks were made and logged corresponded to those days on which surgery cases had been scheduled.

Based on interview the facility failed to have a system in place that would assure the safety of patients, staff and visitors of the facility during non-medical emergencies. More specifically, the facility failed to have a plan in place that would protect vital supplies of emergency fuel and water.

Findings include:

1. On 3/17/2011 during discussions with Environmental Services staff the surveyor was informed that a needs assessment for fuel and water had not been performed and that no written plan was available specifying how those resources would be prioritized and protected in time of need until adequate supplies of both were available. It was indicated that informal agreements had been made with suppliers but no written agreements had been entered into with the suppliers.

Based on observation and interview, the facility failed to develop and/or implement and maintain policies and procedures for specific infection prevention issues.

Failure to do so places patients, staff, and visitors at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.

Findings:

The following breaches of infection control standards, policies and procedures were observed by two surveyors during the three days of the survey. Surveyor 18001 made the following observations:

? During tour of the acute care unit on 3/15/11 approximately 9:30 AM Staff #2 dropped an item on the floor, retrieved and disposed of it, but did not subsequently perform hand hygiene. Staff #2 repeated these actions approximately 10:30 AM that morning.
? On 3/16/11 during tour of the peri-operative area the surveyor observed that the straps on the operating room (OR) bed dragged on the floor; these straps were subsequently wrapped up and around the patient.
? In the OR on 3/16/11 approximately 8:30 AM Staff #4 picked up a footstool and positioned it for another staff member, without performing hand hygiene afterwards.
? About the same time Staff #5 picked an item up from the OR floor, disposed of it, but did not perform hand hygiene before returning to patient care duties.
? While observing in the OR on 3/16/11 approximately 8:50 AM the surveyor observed that the hampers used for soiled linen and trash were pushed up against boxes of clean gloves mounted on the wall, thus contaminating them. These hampers were also in direct contact with cabinets used to store sterile items.
? The surveyor observed a tote bag located on a stack of footstools in the OR on 3/16/11 approximately 9:10 AM. Staff #5 stated s/he brought it in and out of the OR, that it contained professional journals and literature. Staff #5 acknowledged that s/he also used it to store " snacks " for long procedures. The bringing of personal items in and out of the OR, as well as eating in patient care areas, both risk cross-contamination potential.
? On 3/16/11 approximately 9:50 AM the surgeon (Staff #6) removed bloody gloves and gown, but did not perform hand hygiene before moving on to document information in the patient record.
? At approximately the same time Staff #7 twice removed items from the floor, disposed of them, but didn't perform hand hygiene before moving on to contact with the patient.
? Approximately 10:00 AM on 3/16/11 Staff #5 completed patient care involving airway management and removed gloves, but did not perform hand hygiene.
? On 3/16/11 approximately 10:00 AM Staff #7 removed used gloves but did not perform hand hygiene afterwards.
? On 3/17/11 approximately 10:30 AM during record review the surveyor observed Staff #8 repeatedly licking fingers to make turning pages quicker. Staff #8 continued to do so despite being advised by the surveyor that it was a cross-contamination problem.
? Throughout the course of the three days on-site the surveyor observed several staff members touching their mouths or noses, even blowing noses, without performing hand hygiene afterwards.
? During the Infection Control program meeting on 3/17/11 the surveyor observed Staff #9 drop items on the floor and retrieve them, without performing hand hygiene afterwards.


Surveyor #17188 made the following observations:

Finding #1
Reference: Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Infection; 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

On 3/15/2011 while touring the facility surveyor 17188 observed a staff member (Staff #10) donning personal protective equipment (gown and gloves) in a manner not meeting recognized standards. He/she put on gloves, then put on an isolation gown. Subsequent to the finding the staff person acknowledged the error made.
Finding #2
On 3/16/2011 during discussions with a staff member (Staff #12) responsible for surgical instrument processing, surveyor 17188 learned that the practice of flash sterilization was routinely performed on those days when eye surgeries were scheduled.
Staff #12 indicated that the surgeon performing eye surgeries had four (4) eye instrument sets available for use and that as many as 12 to 18 eye cases could be scheduled on a given day. Because of the volume of eye surgery cases being performed the facility had to rely on flash sterilization to meet the demand for sterile instruments.
As described instruments were not wrapped or processed in covered rigid containers. Instead, the instruments were placed in open pans or pans with perforated lids. They were then sterilized using an abbreviated or short cycle after which they were transported to the operating room (OR). Covered sterile containers or the pan used for processing would be used for transporting instruments to the OR.

Informed of the above observations by both surveyors, Staff #1 and #2 stated that the actions were not in keeping with infection control standards and facility policies, and were in need of correction.

Based on interview and record review, the facility failed to consistently implement its policy and procedure for administration of blood and blood products, by failing to administer blood as ordered by the practitioner.

Failure to do so places patients at risk for transfusion complications, resulting in discomfort and debility.

Findings:

The surveyor reviewed closed records on 3/17/11 for two former patients who had received blood (Patients #1-2). Discrepancies from policy were found in both records.

Review of Patient #1's record contained a physician's order to transfuse two units of blood over a period of four hours each, and that the patient was to receive lasix between the two units (a drug which removes excess fluid from the body and helps prevent complications from fluid overload). The transfusion records, however, revealed that each of the units had been transfused over three hours, instead of the ordered four.

Review of Patient #2's record showed that s/he had physician orders to receive two units of blood over a period of three hours each. However, the documentation showed that the first unit was given in 2.5 hours.

Staff #2 confirmed the above findings. Staff #2 described the blood administration policy, confirming that transfusion rates specified in practitioner orders are to be followed unless there is a clinical reason to vary from the order. In such a situation the nurse should contact the practitioner and if appropriate, obtain a different order.

Based on record review and interview the facility failed to reappoint members to the medical staff who had been found to be competent in the performance of their duties. More specifically a finding of competency based on an evaluation by peers or others who by virtue of their professional training are capable or rendering such an evaluation.

Failure on the part of the facility to reappoint members to the medical staff without benefit of a determination of competency puts patients at risk from medical staff who may not be capable of rendering appropriate medical care.

Findings include:

1. On 3/17/2011 the surveyor noted that nothing in the records made available for review showed that CRNA's who had been reappointed to the medical staff had had an assessment of their performance completed prior to their being reappointed to the medical staff.

2. On 3/17/2011 the surveyor was informed that peer review (internal and/or external) was not performed or being sought for the facility's CRNA's.

3. Per the Medical Staff Bylaws of Ocean Beach Hospital, January 15, 2003, Chapter 9.1.2 Requirements; a finding of practitioner competence should have been made prior to a recommendation for re-appointment.