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Based on interview, review of policy and procedure and record review, the facility failed to demonstrate that information about the status of patients' advanced directives was obtained for 4 of 4 surgical patients.

Failure to do so creates risk that patients' rights to participate in health care decision making about medical treatments may not be included in determining the plan of care, especially when unanticipated events occur.

Findings:

1. In review of facility policy titled, "Advanced Directives" (Reviewed 2/09) it outlined the responsibility of various staff members to obtaining information about existing advanced directives and how to act upon the information provided by the patient. The types of staff members identified included the admitting staff, admitting nurse, hospital nursing staff and the charge nurse.

2. On 4/1/2015 at 12:15 PM Surveyor #2 interviewed Staff Member #2 who was responsible for registering patients for admission to the hospital (in the hospital lobby). S/he stated that s/he only asked about advanced directive status for patients going directly "upstairs" (to the inpatient unit). However, s/he did not inquire about advanced directives status during the initial admission process (registration) for patients proceeding directly to the surgery department.

Earlier that same day at 10:15 AM the Nursing Supervisor (Staff Member #2) of the pre-operative surgery area was interviewed about obtaining the advanced directive status on patients. S/he stated that only the admitting staff asked patients about their advanced directive status and that the nursing staff in the surgery department did not make those inquiries.
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3. In the medical record for the following procedural and surgical patients, documentation about advanced directive status could not be located:

a. Patient #3 was a 45 year old patient who had an esophagogastroduodenoscopy procedure on 12/16/2014.

b. Patient #4 was a 34 year old patient who had a colonoscopy on 2/9/2015.

c. Patient #5 was a 17 year old patient who had a tonsillectomy and adenoidectomy on 1/23/2015.

d. Patient#6 was a 19 year old patient who had an appendectomy on 12/25/2014.

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Based on interview the facility failed to have a system in place that would assure the safety and well being of patients, staff and visitors in the event of a non-medical emergency. More specifically, the facility failed to have a plan in place that would provide readily available potable water supply to patients, staff and visitors.

Failure to provide readily available potable water in the event of a non-medical emergency places patients safety and well being at risk.

Findings:

On 4/1/2015 at 9:00 AM during an interview with the hospital's plant manager (Staff Member #9) the surveyor was informed that the hospital did not have potable water readily available for patients, staff and visitors in the event of a non-medical emergency. The hospital could not provide a memorandum of understanding or agreements (MOU's) to assure that potable water would be delivered in a timely manner in case of a non-medical emergency event.

Based on interview, record review and review of documents, the facility failed to ensure that written orders for an invasive procedure were obtained prior to performing the procedure in 2 of 2 patients.
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Failure to do so creates risk that patients may undergo invasive procedures that are not medically authorized.
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Findings:
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1. According to facility document titled, "Rules and Regulations Medical Staff By-Laws" (Reviewed 3/25/10) under section 5.1.a. it stated, "All orders for treatment shall be in writing".
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2. On 4/01/2015 at 9:50 AM Surveyor #2 interviewed a RN (Staff Member #1) who was responsible for placing peripherally inserted central catheters (PICC) lines. The staff member was asked if written orders were obtained prior to insertion of the catheter. S/he stated that written orders were usually present in the record prior to line placement.
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3. In review of the following medical records, written and/or verbal orders for PICC line placement could not be located:
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a. Patient #1 was 21 years old patient who had severe pregnancy-related vomiting. A PICC line was inserted on 2/5/2015 for treatment with intravenous hydration.
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b. Patient #2 was 91 years old patient who had a urinary tract infection. A PICC line was inserted on 3/31/2015 for treatment with intravenous antibiotics.

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Item #1- Emergency Procedures

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Based on observation, interview and review of documents, the facility failed to demonstrate knowledge of guidelines for the administration of medical cardiac defibrillations used for pediatric patients in emergency situations.
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Failure to do so creates risk that emergency medical care (specifically cardiac defibrillation) may not be properly delivered to pediatric patients which may cause harm.
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Findings:
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1. On 3/31/2015 at 10:30 AM Surveyor #2 interviewed the Nurse Supervisor (Staff Member #3) of the pre-surgical area ("Outpatient Services") about use of emergency equipment during a code, and more specifically about use of the department's cardiac defibrillator on pediatric patients. A specific discussion about how staff adjust defibrillator setting for delivery of electrical shock (measured in Joules) for pediatric patients occurred. The staff member stated that emergency room staff responded to pediatric codes in the surgery department and that a pediatric crash cart (including medications) was located in the Emergency Department. The staff member also stated that a reference tool (Broselow Pediatric Emergency tape) contained information about pediatric defibrillation.
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It was subsequently determined that the reference tool did not provide information about pediatric medical defibrillation. When asked if the department conducted drills for team response to pediatric medical emergencies, the staff members stated that drills were not conducted.
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On 3/31/2015 at 1:15 PM Surveyor #2 interviewed an emergency department (ED) nurse (Staff Member #7). S/he stated that the "pediatric code cart" had been de-commissioned approximately 6 months prior because its' content were determined to be redundant with other department medical supplies (cart had not included medications). A Broselow Pediatric Emergency reference tool in the department was reviewed and it provided information about medication doses for pediatric patients up to 36 pounds and did not provide information about defibrillation.
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When the ED nurse was asked about defibrillator adjustments for pediatric patients, s/he stated patients received an initial dose of 2 Joules per kilogram up to a "weight of around 100 pounds", after which adult level setting would be used.
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2. In review of the manufacturer's instructions for the defibrillator (Life Pak 20e and Life Pak 20 Medtronics Defibrillator Monitor), the following was noted:
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a. It referenced the American Heart Association guidelines for setting the Joule levels.
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b. The American Heart Association guidelines stated that the pediatric settings applied to patients weighing up to 22 kilograms (or 10 pounds). And that the initial dose was 2 Joules per kilogram with adjustments for subsequent shocks.
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Item #2 Procedural "Time-Out"
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Based on observation, interview and review of policy and procedure the facility failed to demonstrate that it performed a pre-procedure safety procedure ("time out").
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Failure to do so creates risk for errors in patient care associated with lack of preparation for patient safety, especially related to unanticipated events.
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Findings:
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1. In review of the facility policy for the Surgery Department titled, "IDENTIFICATION OF THE SURGICAL PATIENT, PROCEDURE AND SITE" (Review date: 6/12) under item III. A. it stated, "A time out is performed immediately prior to starting procedures". It further described the components of the time out procedure, including completion of a safety checklist.
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2. On 3/31/2015 at 9:50 AM Surveyor #2 observed the care of Patient #7 who had an esophagogastroduodenoscopy (EGD: a procedure performed with a scope to inspect the esophagus, stomach and upper portion of the intestines for abnormalities). Before the actual medical procedure began a "time out" team session was not performed although staff individually verified the patient's identity and procedure.
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3. On 4/2/5015 at 10:15 AM Surveyor #2 interviewed the Manager of the surgical services area (Staff Member #6). S/he stated that there were not facility procedures that applied solely to the area of the operating room where EGDs were performed and that general operating room policies applied to that area. S/he acknowledged that "time out" sessions were not performed for patients having scope procedures to visualize the digestive tract and stated that the facility should "start to do that".

Based on observation and review of policy and procedure the facility failed to ensure that potential cross-contamination of medical supplies and equipment was minimized.

Failure to do so creates risk for transmission of pathogenic organisms that may cause disease in patients and other staff members.

Item #-1 Equipment

Findings:

1.In review of the policy titled, "Hand Hygiene in the Perioperative Setting" (Effective 02/10) on page 2 under item II.A. it included information about when "hand wash" should be performed. It included "after removing gloves"...and "anytime there is a possibility that there has been contact with blood or other potentially infectious materials or surfaces ..."

2. On 3/31/2015 at 10:00 AM Surveyor #2 observed Patient #7 undergo a procedure called an esophagoduodenoscopy (EGD: inspection of the esophagus, stomach and upper intestines with a scope). During the course of the procedure a culture was obtained from inside the patient's stomach to test for a pathogenic organism that can cause stomach disorders.

At the conclusion of the procedure, the proceduralist (Staff Member #4) touched the stretcher railing with gloves used during the procedure (rather than removing the gloves, doing hand hygiene and then touching the railing). The proceduralist's gloves were damp with bodily fluids from the mouth and digestive tract.

Then the patient was transported by the stretcher to the recovery room. Immediately upon arrival in that area, the recovery room nurse (Staff Member #1) touched the same area of the stretcher railing that came in contact with the proceduralist's gloves. Then the nurse reached over the same area of the stretcher railing to provide care to the patient and the front of her/his clothing (scrub top) came in contact with the potentially contaminated railing.

Item #2- Medication Syringes

On 3/31/2015 at 9:55 AM Surveyor #2 observed Patient #7 undergo an EGD procedure. The patient received 3 types of intravenous conscious sedation medications from an anesthesia provider (Staff Member #5). The provider documented care on papers affixed to a clipboard made of pressed board. At one point s/he placed the clipboard directly on top of the three medication syringes. After the syringes made contact with the clipboard, the provider picked up one of the syringes (Propofol) and administered the medication intravenously. The clipboard was soiled and made of material that was semi-porous and not capable of being disinfected for use in patient care.


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Item #3 Processing high level disinfection for endoscopes.

Based on interview, and document review, the critical access hospital failed to ensure the proper processing/cleaning of semi-critical equipment.

Failure to process semi-critical equipment consistent with manufacturer's guidelines puts patients at risk from infection caused by improper disinfection.

Reference: Titled, "Olympus endoscope cleaning and maintenance workshop" Chapter 5 pages 10 and 15 states in part, "A leak test on your endoscope should be preformed prior to pre-soaking and prior to cleaning your scope once a procedure is complete."

Findings:

1. On 3/31/2015 at 10:00 AM Surveyor #1 interviewed central processing manager (Staff Member #10) in regards to processing endoscopes. It was discovered during the interview the brushes to clean the endoscopes was being disinfected in the Automatic Endoscope Reprocessor and reused after being disinfected. Surveyor #1 reviewed the instruction for use on the package of the cleaning brushes which stated, "ESS Endoscopy Support Services DCB-5 Disposable Channel Brush 2.7mm; One directional disposable brushes; Single Use Only."

2. On 3/31/2015 at 10:30 AM during the same interview with the central processing manager (Staff Member #10) it was found that the process for leak testing the endoscopes were done weekly. After review of the manufacturer's instructions for use on 4/2/2015 at 12:00 PM it was discovered that the leak testing should occur after every procedure prior to pre-soaking and prior to cleaning once the procedure had been completed.
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Item #4 Proper use of ultrasound gel
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Based on interview and document review the facility failed to prevent contamination of product before patient care.

Failure to prevent contamination of product, places patients at risk for infections and communicable diseases.
Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012) , states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."
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Findings:

On 4/1/2015 at 11:15 AM during an interview with the ultra sound technician (Staff Member #11) surveyor #1 observed a large refill container and a small squeeze bottle of "Dynatron Ultrasound lotion" in the exam room. The ultra sound technician stated in part, "that they refill the squeeze bottle with the larger container of ultrasound lotion as needed".

Based on observation the Critical Access Hospital failed to implement policies and procedures to ensure compliance with the Rules and Regulations of the State Board of Health for Food Service (246-215 WAC).

Failure on the part of the CAH to comply with the food service codes puts patients, staff and visitors of the facility at risk of food borne illness.

Reference: USDA United States Department of Agriculture Food Safety and Inspection Service. Revised June 2011: Thermistors: Digital food thermometers stated in part, "that the thickness of the probe is approximately 1/ 8 of an inch and takes roughly 10 seconds to register the temperature on the digital display. Since the semiconductor is in the tip, thermistors can measure temperature in thin foods, as well as thick foods. Because the center of a food is usually cooler than the outer surface, place the tip in the center of the thickest part of the food."

If the hospital is using a Bimetal instant read thermometers it states in part, "Instant-Read Bimetal thermometers: Placement 2-2 1/2 inch deep in the thickest part of the food Can be used in roasts, casseroles, and soups. Temperature is averaged along probe, from the tip to 2-3 inches up the stem. Cannot measure thin foods unless inserted sideways."

Findings:

Item #1 Inaccurate use of food thermometers

On 3/31/2015 at 11:20 AM Surveyor #1 observed the dietary cook (Staff Member #8) place hot food items in a steam table, surveyor #1 used the hospital's thin stem probe thermometer to take temperature of the chicken in the steam table. The chicken temperature tempted between 161 degrees Fahrenheit and 163 degrees Fahrenheit, the required temperature for poultry under Washington State Retail Food Code is 165 degrees Fahrenheit. Surveyor #1 asked to see the temperature logs for the chicken. The temperature for the chicken was not recorded on the logs. Surveyor #1 asked dietary staff to temp the chicken. The dietary staff pierced through several pieces of chicken using a bi-metal thermometer thereby giving an inaccurate reading.
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Surveyor #1 asked dietary staff to use a thin stem probe thermometer to temp the chicken. The dietary staff pierced through several pieces of chicken to the point where the tip of the thermometer was touching the bottom of the pan thereby giving an inaccurate reading of internal temperature of the chicken. Due to the staff inability to demonstrate the use of the thermometers and to provide temperature logs for the chicken, The chicken was re-heated to above 165 degrees Fahrenheit and placed back into the steam table.

Reference: WAC-215-04335 Utensils, temperature measuring devices, and testing devices -- Food temperature measuring devices (2009 FDA Food Code 4-302.12). (2) A TEMPERATURE MEASURING DEVICE with a suitable diameter probe that is designed to measure the temperature of thin masses must be provided and readily accessible to accurately measure the temperature in thin FOODS such as MEAT patties and FISH fillets.

Item #2 Unnecessary personnel in dietary kitchen area.

On 3/31/2015 at 11:45 AM Surveyor #1 observed hospital staff coming into the kitchen for food service. A portion of the kitchen was set up with a mobile steam table; mobile salad bar; refrigerators and a cashier inside of the kitchen area. Surveyor #1 asked if the kitchen was also open to the general public. The dietary cook (staff member #8) stated in part that they served a senior group on a routine basis.

Reference: "246-215-02115 Duties-Person In Charge (2009 FDA Food Code 2-103.11) (2) Persons unnecessary to the operation are not allowed in the food preparation, food storage, or warewashing areas, except that brief visits and tours may be authorized by the person in charge if steps are taken to ensure that exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles are protected from contamination."
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Item #3 Current Therapeutic Diet Manual
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Based on interview, the critical access hospital failed to ensure that a current therapeutic diet manual was used to provide therapeutic diet for its patients.

Failure to provide a current therapeutic diet manual for staff reference puts patients at risk for receiving inadequate or inappropriate nutrition.
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Findings:
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On 4/1/2015 at 12:10 PM, Surveyor #1 interviewed the Dietary Manager (Staff Member #12) to review the therapeutic diet manual. The hospital's therapeutic diet manual titled, "IOWA Simplified Diet Manual 10th edition, last reviewed and signed by the dietitian was 3/30/2008". After review, it was found that the hospital was not using the latest edition.

Based on interview, record review and review of policy and procedure, the facility failed to ensure that written consents were obtained for placement of a semi-permanent central line infusion catheters from 2 of 2 patient record reviews.

Failure to do so creates risk that patients may not be fully informed and consent to an invasive procedure prior to the procedure occurring.

Findings:

1. In review of facility policy titled, "Informed Consents" (Reviewed 10/01) under item A. it stated "A written signed informed consent shall be obtained by the provider prior to an invasive procedure". Item H stated, "The following procedures require informed consent ...5. Central line insertion ..."

2. On 4/1/2015 at 9:50 AM Surveyor #2 interviewed a RN (Staff Member #1) who was responsible for placing peripherally inserted central catheters (PICCs). The staff member was asked if written consent was obtained from patient(s) prior to line placement. S/he stated that verbal consents were obtained but written consents were not obtained from patients for that procedure.

3. In review of the following medical records, written consents for PICC line placement could not be located:

a. Patient #1 was a 21 year old patient who had severe pregnancy-related vomiting. A PICC line was inserted on 2/5/2015 for treatment with intravenous hydration.

b. Patient #2 was a 91 years old patient who had a urinary tract infection. A PICC line was inserted on 3/31/2015 for treatment with intravenous antibiotics.