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Based on observation and interview, the critical access hospital failed to ensure that patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.

Failure to properly maintain supplies places the patients at risk for delays in treatment, infection, and potential infections.

Findings:

1. On 2/9/2016 at 7:45 AM, Surveyor #3 and the Chief Nursing Officer (Staff Member #2) inspected the supply storage area on the medical surgical unit and found the following:

a. Two Becton Dickinson (BD)green-capped blood vacutainers with an expiration date of 1/2016

b. One BD blue-capped blood vacutainer with an expiration date of 12/2015.

c. Three packages of providone -iodine swabsticks, with an expired date of 10/2015, three with an expitation date of 5/2015 and 2 packages with an expiration date of 7/2015.

d. One package of tincture of benzoin swab sticks with an expiration date of 12/2015.

e. Seven 16 gauge 1 1/4 inch intravenous catheters with an expiration date of 2/2015.

f. One Monoject 1 ml safety syringe with an expiration date of 7/2015.

2. On 2/9/2016 at 10:00 AM during an inspection of the emergency department, Surveyor #1 found the following:

a. Four packages of 20 gauge 3.5 inch spinal needles with an expiration date of 3/2015.

b. Three 32 french thoracic catheters (straight) with an expiration date of 1/2016.

c. Four 20 french thoracic catheters (straight) with an expiration date of 12/2015.

3. On 2/9/2015 at 10:45, Surveyor #1 interviewed the emergency department manager (Staff Member #7) who stated the safety committee was responsible for completion of monthly checks of outdated or expired patient care supplies.
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Based on observation, interview, and document review, the critical access hospital failed to ensure compliance with the state ' s certificate of need program (CON) for number of authorized swing beds.

Failure to adhere to the state CON program risks patient safety and quality care for the community.

Findings:

1. On 2/9/2016 during an inspection and count of the hospital ' s beds, Surveyor #3 and the Chief Nursing Officer (CNO) (Staff Member #2) observed 14 patients in swing bed status.

2. On 2/11/2016 at 8:30 AM, Surveyor #1 and #3 interviewed the CNO and other members of the hospital administration about the swing bed program. The facility acknowledged that on average there were 11 patients in the chemical dependency program and 3 patients from the medical-surgical unit on swing bed status. A review of the hospital census for 2/9/2016 and 2/10/2016 indicated there were 14 patients in swing beds.

3. On 2/11/2016 at 8:30 AM, Surveyor #1 and #3 reviewed the 2014 Critical Access Hospital annual program evaluations. For calendar year ending December 31, 2014, " The number of patients admitted to the Primary Care Unit Swing Bed status was 77 " and " The Sanctuary Addiction Recovery patients admitted to the swing bed rehab program was 168 " . Similar findings were reported in the draft 2015 Critical Access Hospital annual program with 68 patients admitted to the primary care services swing bed status and 168 patients admitted to the sanctuary addiction recovery swing bed rehab program respectively.

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Based on document review and interview, the critical access hospital failed to have documentation indicating which patient care equipment has a preventive maintenance frequency based on an alternative maintenance schedule and which equipment has a preventive maintenance frequency based on the manufacturer.

Failure to identify the maintenance schedules for all patient care equipment puts patients at risk from unreliable or malfunctioning equipment.

Findings:

On 2/10/2016 between 9:30 and 10:30 AM, Surveyor #2 interviewed the Director of Plant Services (Staff Member #3) about the maintenance program for patient care equipment. Staff Member #3 indicated that the hospital used a contracted bio-medical service to maintain patient care equipment that was not otherwise under a vendor contract.

Surveyor #2 reviewed the inventory list and asked if the facility could identify which items the contractor maintained according to the manufacturer's schedule and which items they maintained under an alternative maintenance agreement. Staff Member #3 called the contractor who reported the current software did not allow for identification of those items maintained under an alternative maintenance agreement.

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Based on observation, the critical access hospital failed to secure anesthesia drugs in their surgical services department.

Failure to secure medications puts patients at risk from contaminated pharmaceuticals.

Findings:

On 2/11/2016 between 8:40 and 9:15 AM, Surveyor #2 observed a member of the housekeeping staff (Staff Member #4) as s/he cleaned operating room #2. During the observation, the surveyor identified three vials of anesthesia reversal agents (atropine, flumazenil and naloxone) unsecured and left on top of the anesthesia cart while Staff Member #4 cleaned the room. Neither a registered nurse nor an anesthesia provider were present in the room during the between-case cleaning and the items remained on the cart once the housekeeping staff member left the room.
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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY inspection reports.

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Based on record review and review of hospital policies and procedures, the critical access hospital failed to ensure staff members followed its policy when caring for patients placed in restraints as demonstrated by 2 of 3 patients reviewed (Patient #4, #5).
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Failure to follow policies and procedures for restraining patients risk physical and psychological harm, loss of dignity, and violation of patient rights.
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Findings:
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1. The hospital's policy and procedure "Restraints Policy (CAH)" (Reviewed 9/11/2015) under the section "Procedure" read in part: "If less restrictive interventions are ineffective, and patient or others are at imminent risk of harm, LIP orders restraints, to include type of restraints, rationale for restraints and planned duration (to a maximum of 24 hours)".
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2. A review of the records of two patients who were restrained revealed the following:
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a. Patient #4 was a 31-year-old patient brought in to the emergency department by ambulance for abdominal pain and vomiting on 5/9/2015. A hospital staff member placed the patient in soft wrist restraints at 4:10 AM for demonstrated "self-destructive behavior including imminent risk of harm to self that requires restraints". Surveyor #1 found no documentation that a provider order for restraints was written as required by policy. Patient #4 was monitored appropriately and released from restraints at 5:10 AM.
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b. Patient #5 was a 16-year-old patient seen in the emergency department on 8/11/2015 for acute alcohol intoxication. A hospital staff member placed the patient in four point soft restraints (both arms and legs secured to the stretcher) for violent behavior at 6:43 PM. Surveyor #1 found no documentation that a provider order for restraints was written as required by policy.





35594

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Based on observation and review of hospital policies and procedures, the critical access hospital failed to ensure all drug storage areas were inspected to prevent administration of outdated or unusable medications.
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Failure to assure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk of receiving medications with compromised integrity or stability.
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Findings:
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1. The hospital's policy and procedure titled "Patient Care Unit Inspections Policy" (Reviewed 1/26/2016) read in part: "It is the policy of LCCH that the pharmacy department will conduct a monthly inspection of all patient care units or other areas of the Hospital where medications are dispensed, administered, or stored. . .When each unit is inspected, the Pharmacy Technician or designated individual will review the following during the LCCH Pharmaceutical Floor Stock Inspection Record: . . .Outdated floor stock medications removed and returned to Pharmacy. . .Outdated items routinely returned to pharmacy".
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2. The hospital's policy and procedure titled "Medication Samples Outpatient Behavioral Health Clinic" (Reviewed 4/27/2015) read in part: "Medication samples will be checked monthly for dating on or before the 1st of each month. Surplus, outdated, or damaged drug samples shall be disposed of by either returning the samples to the manufacturer, or returning the drug samples to the Pharmacy Department for destruction."
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3. On 2/9/2016 at 10:00 AM in the emergency department, Surveyor #1 found three unit dose 30-milliliter containers of mineral oil with an expiration date of 10/2014.
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4. One 2/10/2016 at 1:30 PM during an inspection of the specialty clinic, Surveyor #1 found four boxes of drug samples each containing seven tablets of the medication mirabegron 50mg with an expiration date of 10/2015. The pharmacy director (Staff Member #8) removed the items at the time of observation.
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PART 1:

Item #1- High-level disinfection

Based on observation and interview, the critical access hospital failed to ensure that staff members followed manufacturer's instructions for use of chemical test strips designed to test the efficacy of high-level disinfection of trans-vaginal probes used in diagnostic imaging.

Failure to properly test equipment for high-level disinfection efficacy puts patients at risk of infection from improperly disinfected equipment.

Findings:

On 2/9/2016 at 2:30 PM, Surveyor #2 toured the diagnostic imaging department. During the review, the surveyor observed an open bottle of chemical test strips used to determine the efficacy of the Metricide disinfectant. The bottle was not marked with the opening date or discard date as required by the manufacturer.

Item #2- Operating Room Cleaning

Based on observation and interview, the critical access hospital failed to maintain cleanliness in the surgical services department.

Failure to properly clean areas in the surgical services department puts patients at risk of infection from communicable diseases.

Findings:

1. Hospital policy titled "Wet Mopping Policy (CAH)" (Rev. 10/13/2014) under the section titled "Contents" "Room mopping" stated in part: "Note: Be sure to mop in corners and doorways."

2. Hospital policy titled "Operating Room Cleaning (CAH)" (Rev 6/26/2015) stated in part under "Procedure: Wash with cleaning solution, all fixtures and surfaces".

3. On 2/11/2016 between 8:40 and 9:15 AM, Surveyor #2 observed a member of the housekeeping staff (Staff Member #4) while s/he completed a between case cleaning of operating room (OR) #2. The surveyor observed items of debris and accumulated dust in the corners of the hallway, exterior to the OR suites. Inside OR #2, the surveyor observed accumulated dust on the air vent located directly behind the OR door. As Staff Member #4 cleaned items in the room, the surveyor observed that the staff member cleaned some but not all of the equipment cords in the room and at one point draped unclean cords over the top of the anesthesia cart without cleaning them at any point in the process. The surveyor also observed the staff member did not pull items away from the wall to mop behind equipment. The surveyor asked if the cleaning process differed for a terminal cleaning (end of day) versus a between-case cleaning, and the staff member indicated that items were wetted more, since they had more time to dry at the end of the day.

Item #3- Cleaning of Cloth Restraints

Based on interview and document review, the critical access hospital failed to ensure that staff members used appropriate cleaning products for patient restraints used in the emergency room.

Failure to use appropriate cleaning products for non-critical items puts patients and staff at risk from infections or exposure to toxic substances.

Findings:

1. The instructions for use for the "Posey Secure Mitt" produced by the Posey Company, 5635 Peck Road, Arcadia CA, stated in part, under "Laundering Instructions (if applicable): These products, other than foam products can be machine washed under CDC guidelines for material soiled with blood or bodily fluid."

2. On 2/9/2016 at 10:45 AM in the emergency room, Surveyor #1 interviewed a registered nurse (Staff Member #5) about cleaning of restraints. Staff Member #5 stated that once restraints are removed from a patient, they are disinfected with a cleaner labeled "Virex" (a quaternary ammonium disinfectant designed to clean, disinfect and deodorize hard, non-porous environmental surfaces) and returned to a storage container.
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3. On 2/9/2016 at 2:00 PM in the emergency room, Surveyor #1 interviewed a certified nursing assistant (Staff Member #7) about how restraints are cleaned. Staff Member #6 stated staff members cleaned restraints with a disinfectant called "Virex" and returned to a storage container.


35594

PART 2:

Item # 1 Surgical Masks

Based on observation, interview and review of hospital policies and procedures, the critical access hospital failed to ensure staff members followed hospital policy for infection control.

Failure to follow policies and procedures puts patients and staff at risk of infection.
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Findings:

On 2/10/2016 at 9:25 AM, Surveyor #3 and Chief Nursing Officer (CNO) (Staff Member #2) observed a surgical procedure for Patient #2. During the surgical procedure, the Certified Registered Nurse Anesthetist (CRNA) (Staff Member #1) was positioned behind the patients sterile drape. Two monitor/anesthesia carts on either side of the CRNA. Surveyor #3 observed the CRNA pick up a cup from behind the laptop, removed his /her mask, and drink from the cup. The CRNA slid their mask back on their face covering both the mouth and nose. Staff Member #1 repeated drinking from a cup at 9:27 AM and again at 9:29 AM.

Item #2 Hand Hygiene

Based on Based on observation, interview and review of hospital policies and procedures the Critical Access Hospital failed to ensure staff members performed hand hygiene according to hospital policy.

Failure to perform proper hand hygiene can put patients at risk for health care associated infections.

Findings:

1. On 2/10/2016 at 9:25 AM, Surveyor #3 and Chief Nursing Officer (CNO) (Staff Member #2) observed a surgical procedure for Patient #2. During the surgical procedure, Surveyor #3 observed no hand hygiene being preformed by the CRNA, Staff Member #1 after changing the patients IV bag, or after delivering IV medication to the patient.

2. On 2/10/2016 at 10:30 AM, Surveyor #3 observed an absence of hand sanitizers on or attached to the anesthesia carts. One hand sanitizing station found attached to the wall behind the anesthesia carts.

Item #3 Beverage in sterile operating room

WAC 296-823-14035 Prohibits food, drink, and other personal activities in the work area.

On 2/10/2016 at 9:25 AM, Surveyor #3 observed Staff Member #1 drink from a cup 3 times during the sterile procedure for Patient #2.

Item #4 Sanitary environment; back-pack on Operating Room floor.

1. Hospital policy titled "Surgical Attire" (Rev. 8/2014) read in part "Fanny packs, briefcases, and backpacks are not permitted in semi-restricted or restricted areas of the perioperative suite."

2. On 2/10/2016 at 10:30 AM, Surveyor #3 observed a black colored back-pack on the floor at the base of the anesthesia cart in the operating room.
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Based on record review and review of hospital policy and procedures, the critical access hospital failed to ensure properly obtained informed consents for 3 of 3 surgical charts reviewed (Patients #1, #2, and #3).

Failure to do informed consent places patients at risk for sirgical errors.

Findings:

1. The hospital's policy and procedure titled "Consent to Treatment" (Rev. 8/22/2014) read in part "a properly executed informed consent form contains ...Signature of patient or legal guardians; Date and Time consent is obtained."

2. On 2/10/2016 at 8:00 AM, Surveyor #3 reviewed the surgical chart for patient #1. The consent was signed and dated however the time was not recorded as required by hospital policy.

3. On 2/10/2016 at 2:00 PM, Surveyor #3 reviewed the surgical chart for patient #3 and noted similar findings to Patient #1.

4. On 2/10/2016 at 9:30 AM, in the operating room, Surveyor #3 reviewed the surgical chart for Patient #2 The record contained a consent written in spanish, that was signed without a date or time of signature noted.