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Based on record review and interview the facility failed to provide documentation the surgical staff had received their annual training covering a fire in the operating room (OR) and malignant hyperthermia (a response to anesthesia that can lead to death if not treated quickly). The failure to ensure employees were continuously trained in OR fire and malignant hyperthermia (MH) emergencies placed patients at increased risk for harm or death. Findings:

Record review on 2/3-4/14 revealed no documentation of recent OR drills for fire and MH.

During an interview on 2/5/14 at 1:50 pm, Registered Nurse (RN) #3 confirmed the last OR drill, specifically for fire, was completed 5/25/12 and the last MH drill was completed 7/12/12.

Policy review on 2/3-6/14 of "Fire Prevention, Fire Risk Assessment and Fire Response in the OR", dated 10/29/13, revealed "...Education and Training: Participation in OR fire drills quarterly with knowledge of roles and demonstration of tasks."

Review on 2/10/14 of Malignant Hyperthermia Association of the United States (MHAUS) website (mhasu.org) revealed, "Healthcare Professionals are encouraged to keep MH training current in order to rapidly recognize and diagnose the disorder..."



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Based on observation and interview the facility failed to ensure they had sufficient amounts of potable water to use in an emergency. This deficient practice increased the risk for patients, staff, and visitors of water shortages during a facility emergency. Findings:

Observation during a facility walk-through on 2/4/14 from 12:00 - 2:00 pm revealed 19 cases of 16 ounce bottles of water with 24 bottles in each case (for a total of 57 gallons).

During the walk-through, the Biomedical Engineer confirmed the 19 cases of water represented the facility's emergency water supply and it would not be enough water in the event of a disaster to provide for patients, staff, and visitors.

During an interview on 2/5/14 at 11:55 am, the Chief Nursing Officer confirmed the facility had identified the potable water available was not sufficient for the patients and staff in the event of a disaster.

Review on 2/11/14 of the Federal Emergency Management Agency website (ready.gov), revealed "To determine your water needs, take the following into account: One gallon of water per person per day, for drinking and sanitation...Children, nursing mothers and sick people may need more water...A medical emergency might require additional water...Keep at least a three-day supply of water per person."



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Based on observation, interview, and record review the facility failed to ensure:

1) Hand sanitizers were not expired;
2) Patient care items were not stored under the sinks;
3) Review of the infection control policies and procedures were completed annually;
4) The staff were able to identify which specific scopes were used during patient procedures;

and the facility failed to ensure

5) 2 providers, Physician #1 and certified registered nurse anesthetist (CRNA) #1, had current tuberculosis (TB) screening.

Findings:

Random observations of the facility from 2/3-6/14 revealed the following:

HAND SANITIZERS

Observations in the facility 2/3-6/14 revealed: Avagard D in Radiology with an expiration date of 2010; Purell hand sanitizers in Outpatient Specialty Clinic exam rooms #1 and 2 with an expiration date of 9/2012; and a 1 liter refill bag of Purell in the Outpatient Specialty Clinic procedure room with an expiration date of 10/2010.

During an interview on 2/5/14 at 3:55 pm, the Chief Nursing Officer (CNO) confirmed the expired hand sanitizers were currently in use and should have been discarded.


STORAGE OF PATIENT CARE SUPPLIES UNDER SINKS


Specialty Clinic Procedure Room


1 - opened box of small purple nitrite gloves;
1 - box of "Hazard Bags";
1 - gallon jar of Vinegar;
1 - Kin Care gentle hand wash;
1 - liter refill bag of Purell; and
Red biohazard bags lying loose on the shelf.



Mountainside Outpatient Clinic Exam Room #1

3 - opened paper towel rolls;
1 - baby and 1 adult CPR mannequin; and
1 - large opened cardboard box that contained rolled towels and was touching the pipes under the sink.


Mountainside Outpatient Clinic Exam Room #3

7 - opened paper towel rolls;
1 - roll of paper for patient exam table; and
1 - container of Super Sani Cloth.

Review on 2/4/14 of "Infection Prevention and Control Committee (ICC) Meeting Tuesday, July 30, 2013 Quarter 3" revealed, "...Lab - Under the sinks: Old equipment, towels, boxes, unlabelled containers under the sinks...Oceanside Physical Therapy - Under the sinks: old equipments, towels, dishes under the sinks. Only cleaning supplies can be stored under the sink."

During an interview on 2/5/14 at 11:35 am, the Clinical Manager - Mountainside Outpatient Clinic confirmed, "I know nothing should be stored under the sinks."

During an interview on 2/6/14 at 11:10 am, the CNO confirmed the items stored under the sinks throughout the facility should be removed and that the problem had been identified by the facility during Infection Control walking rounds.


ANNUAL REVIEW OF POLICIES AND PROCEDURES


Record review on 2/4/14 of "Departmental Policy & Procedure [P & P] Manuals...Infection Control & Employee Health...Annual Review Required", the last date the P & P manuals had been reviewed was 12/5/12.

Review on 2/4/14 of "Infection Control Program", dated 6/2007, revealed "...all policies and procedures will be reviewed annually by the Infection Control Committee and by the hospital Policy and Procedure review Committee..."

During an interview on 2/6/14 at 11:10 am, the Stand-in Infection Preventionist (IP) confirmed the annual review of the Infection Control policies and procedures had not been completed.


IDENTIFICATION OF SCOPES USED DURING PATIENT CARE


Review on 2/4/14 of the log of scope cleaning provided by the Operating Room Tech, revealed no patient or scope specific information that could be used to identify which scope was used in each patient procedure.

During an interview on 2/4/14 at 9:15 am the Operating Room Tech confirmed, using the current facility processing of scopes, you would not be able to identify which scope was used for each patient procedure in the event of a post procedure complication such as an infection.

During an interview on 2/6/14 at 11:10 am, the Stand-in IP confirmed the IP should have been monitoring the identification of the scopes used for each patient procedure.


ANNUAL TB SCREENING


Review of medical staff credentialing on 2/6/14 revealed, Physician #1's last annual TB screening was dated 9/9/2012 and CRNA #1's was dated 11/23/12.

During an interview on 2/6/14 at 8:50 am, Health Information Management Manager confirmed both Physician #1 and CRNA #1 did not have current annual TB screening documented in their records.

During an interview on 2/6/14 at 11:10 am, both the CNO and the Stand-in IP confirmed Physician #1 and CRNA #1 did not have current annual TB screening, but should due to their contact with facility patients.



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Based on record review and interview the facility failed to ensure 1 patient (#16) out of 19 patients whose medical records were reviewed for advanced directives had documented evidence that information on advanced directives was given. This failed practice placed the patient at risk for receiving unwanted care in the event of cardiopulmonary arrest (the sudden, unexpected loss of heart function, breathing and consciousness). Findings:

Record review from 2/4-6/14 revealed Patient #16 was admitted on 10/28/13 through the emergency department and then to observation with diagnosis that included suicide attempt.

Record review from 2/4-6/14 revealed Patient #16's "Nursing Admission Assessment " , dated 10/28/13, revealed yes or no check boxes for: having a living will; advanced directives pamphlet given; organ/tissue donor; and enrolled in comfort one program. All the boxes had been left blank for advance directive options.

During an interview on 2/6/14 at 9:30 am, the Director of Nursing was asked if Patient #16 had been given information on advanced directives. She said it wasn't documented that Patient #16 received any information.

Review of the policy "Admission of a Patient", last revised 5/2005, revealed "...Advanced Directives information packet and guidelines will be reviewed. It will be documented that the packet was given or declined on the Nursing Admission Assessment Form ..."

Review of the policy "Advanced Directives/Self-Determination", last revised 2/05, revealed "...patients will be asked if they have Advanced Directives ..."





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Based on observation, interview and policy review, the facility failed to ensure equipment used for patients' care had received annual preventative maintenance (PM) for safety and quality. Findings:

Random observations of the facility, from 2/3-6/14, revealed numerous pieces of equipment, which were used for patients' care, had PM stickers which were outdated or had no sticker indicating when their last PM monitoring was completed. The equipment was found in the following areas:

Pre-operative/post-operative;

Laboratory;

Mountainside Outpatient Clinic;

Mountainside Specialty Clinic procedure room;

Acute cares clean utility room;

Emergency room;

Rehabilitation department; and

Obstetrics unit.

During an interview, on 2/5/14, at 9:50 am, the Biomedical Engineer was asked if hospital equipment had a preventative maintenance date that was not current did that mean the equipment was outdated and should have been checked. The Biomedical Engineer confirmed the equipment would be out of date and would need a preventative maintenance check.

Review of the facility's policy "Equipment Management Program", dated 12/10, revealed "Sitka Community Hospital (SCH) will provide a safe and effective equipment management program for patients...maintain a high level of care of fixed and portable equipment used for...care of patients through out the hospital system."




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Based on record review and interview the facility failed to monitor 2 medication refrigerator temperatures in the surgical suite (PACU) on holidays and week-ends. This deficient practice put the patients at risk of being harmed from receiving spoiled medications. Findings:

Record review on 2/4/14 of temperature logs for refrigerator #s 1 and 2 in PACU revealed no temperatures recorded on holidays and weekends.

During an interview on 2/4/14 at 10:25 am, RN #3 confirmed the 2 medication refrigerators in PACU were not monitored by staff on weekends and holidays to verify if the temperatures stayed within acceptable ranges. RN #3 further confirmed any medications stored in these refrigerators could become spoiled or ineffective by temperature fluctuations.

Review on 2/4/14 of the facility policy, "Refrigerator Temperature Monitoring", dated 6/12/09, revealed "The purpose of monitoring the refrigerator temperatures in the Surgical Suite is to ensure that temperatures stay within recommended ranges, making it appropriate for storage of medications and culture media ...Temperatures shall be checked and recorded in the log provided on each weekday by assigned O.R. staff and on the weekends & holidays by the Nursing Unit Charge Nurse."


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Based on observation, record review and interview the facility failed to ensure expired medications and biologicals stored throughout the facility were disposed of properly. As a result, patients were at potential risk for adverse effects from expired medications and biologicals being used in their care. Findings:

Random observations from 2/3-6/14 throughout the facility, revealed multiple expired medications and biologicals in the following departments:

Outpatient specialty clinic (Exam rooms 1 & 2 and Procedure room);

Emergency Department (Medication room and crash cart);

Surgical suite;

Acute patient crash cart; and

Mountainside outpatient clinic (Closets 1 & 2; Exam rooms 1, 2, 3, 6 & 10; Utility room; Medication room, including crash box).

During an interview on 2/3/14 at 1:35 pm Registered Nurse (RN) #2 confirmed the identified expired medications and biologicals in the emergency department were expired and available for use in patients' care. When questioned by the Surveyor as to who was responsible for checking the expiration date she said pharmacy checks medications in the employee areas and the nurses check the crash carts.

Review of the policy "MEDICATION DISPOSAL - OUTDATED AND RECALLED, MFHC 7.04", issued 5/11/09 revealed "The Charge Nurse (RN) will go through all clinic medications and check for outdates no less than once a month..."

Review of the policy "Inspections of Medication Storage Areas, Pharm-008", last revised June 2011, revealed "...Monthly inspection of drug supplies and storage conditions of those drugs kept in areas outside of the Pharmacy shall be made under the supervision of the Pharmacy Director. The areas to be inspected include: Emergency Room; Operating Suites and Recovery Room...Code carts at Nursing Station, E.R...checked monthly by nursing staff...During these inspections, the responsible personnel will check for: outdated drugs...Medications in the Hospital-Based Clinic/Visiting Physicians Clinic will be inspected and updated by the staff at the clinic..."

Review of the policy "Crash Carts, Pharm-015", last revised December 2003, revealed"...Each crash cart shall be checked routinely by the Charge Nurse...each shift".




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Based on record review and interview the critical access hospital failed to ensure all their policies and procedures were reviewed on an annual basis and to determine if policies and procedures needed revisions. Findings:

Review of the hospital's policies from 2/3-6/14 revealed not all the policies had been reviewed annually.

Review of "Department Policy Manual Abbreviated Review", a checklist for the policy and procedure committee to use with their policy reviews, revealed the following departments and dates their policies were reviewed:

Acute Care - March 1, 2012;

Advanced Nursing Skills - April 12, 2012;

Infection Control - June 28, 2012; and

Emergency Operations Plan - August 28, 2012.

During an interview, on 2/6/14 at 11:00 am, the Policy and Procedure Committee Chair, was asked if the hospital policies and procedures were reviewed on an annual basis. She confirmed that the required annual review of the facility policies and procedures was not up to date.



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Based on medical record review and interview, the facility failed to ensure 1 (#12) patient's medical record of 2 records reviewed for blood transfusion had a written and signed physician's order. Findings:

Record review from 2/4-6/14 revealed Patient #12 was admitted to the emergency department 3/6/13 with diagnoses that included multi-system trauma. The patient was given 4 units of packed red blood cells.

Review of the Patient's medical record, "PHYSICIAN NOTES/MEDICAL RECORDS", dated 3/6/13, revealed no written physician's order for the patient to receive packed red blood cells.

During an interview on 2/6/14 at 9:30 am, the Chief Nursing Officer (CNO) was asked if there should have been an order for the packed red blood cells that Patient #12 received. The CNO confirmed there should have been an order written for the blood and it would have been written on the "PHYSICIAN NOTES/MEDICAL RECORDS."

Review of the policy "PHYSICIAN ORDERS, NUR 027", last revised 10/2001, revealed "...All diagnostic and therapeutic orders are written on the physician's order sheet ..."




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Based on record review and interview, the facility failed to ensure 1 patient (#2) of 19 patients reviewed had an appropriate care plan. Findings:

Record review on 2/3-6/14 of Patient #2's medical record revealed Patient #2 was placed on observation at the facility on 1/27/14 with a sacral decubitus (bedsore) noted in both the "Nursing Admission Assessment", dated 1/27/14, and the "Physician Progress Notes", dated 1/28/14. Review of the Patient Comprehensive Plan of Care, dated 1/29/14, revealed no comprehensive plan for sacral decubitus wound care.

During an interview on 2/6/14 at 9:30 am, the Chief Nursing Officer confirmed Patient #2's Comprehensive Plan of Care should have included a plan for sacral decubitus wound care.




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Based on observation and interview the facility failed to ensure access to patients' medical records were secured and not accessible to individuals who did not need to know. Findings:

Observation during a physical plant walkthrough, on 2/4/14 from 12:00 - 2:00 pm, revealed a locked storage room with a sign on the door "For access call ext. 303 RESTRICTED ACCESS WAREHOUSE". The door was opened by the Biomedical Engineer. Observation of the storage room revealed there were 5 open shelves with patient x-rays and names clearly visible. Across from these shelves were housekeeping supplies and equipment. Further storage room observation revealed multiple other departments; surgery, biomedical, dietary, long term care decorations, and information technology (IT) were using the storage room.

During the walk through the Biomedical Engineer said the storage room housed multiple departmental items. He further said it was a concern because multiple non-clinical staff members had keys to access the storage area, even though the room was restricted.

Observation of the locked storage room on 2/6/14 at 8:30 am revealed the locked door was opened by IT staff. He said other departments used the area for storage, including his IT department. Observation in the storage room revealed numerous patient x-ray reports that were easily identifiable with patient names.

Based on policy review and interview the facility failed to have policies and procedures in place regarding inpatient and outpatient visitation rights, including any restrictions or limitations, and how the hospital staff would be trained to appropriately deal with the visitation right of the patient. Findings:

Review of the hospitals' policies and procedures from 2/3-6/14 revealed no policy or procedure on patient visitation rights.

During an interview, on 2/5/14 at 4:20 pm, the Chief Nursing Officer confirmed there was no policy and procedure on patient visitation rights.





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Based on policy review and interview the facility failed to have written policies and procedures in place regarding inpatient and outpatient visitation rights that included: 1) informing each patient of his/her visitation rights, including any clinical restriction; and 2) informing each patient of their right, subject to their consent, to have whomever they wish visit. Without these policies, patients and their visitors lacked information regarding any clinical restrictions that would contradict visits: Findings:

Review of the hospitals' policies and procedures from 2/3-6/14 revealed no policy or procedure for patient visitation.

During an interview, on 2/5/14 at 4:20 pm, the Chief Nursing Officer confirmed there was no policy on patient visitation rights.






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Based on policy review and interview the facility failed to have policies and procedures in place regarding visitation rights, including any restrictions or limitations in place and the reason for the restrictions. By not implementing these policies there was the potential for patients to have unequal and inconsistent visitation rights. Findings:

Review of the facilitys' policies and procedures from 2/3-6/14 revealed no policy or procedure that addressed patient visitation rights.

During an interview on 2/5/14 at 4:20 pm, the Chief Nursing Officer confirmed there was no policy or procedure on patient visitation rights.