HospitalInspections.org

.

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 CODE inspection reports.

.
Based on interview and record review, the critical access hospital failed to ensure hospital staff members followed hospital policies and procedures related to the use of physical restraints for 1 of 4 patient records reviewed (Patient #7).

Failure to follow policies and procedures related to the use of physical restraints put patients at risk for injury or death, as well as leaving patients in restraints longer then deemed necessary.


Findings:

1. The hospital's policy and procedure titled "Restraint and Seclusion Policy" (Policy: 964.00, Approved 10/2014), read in part: "NON-VIOLENT OR NON-SELF DESTRUCTIVE RESTRAINT 11. Obtaining a Time-Limited Provider Order. Any use of a restraint must be initiated by a physician (or licensed independent designee) as specified by WA state and the organization. The order must include the type and duration of the restraint. The non-violent or non-self destructive restraint may be ordered for up to a 24-hour period ...RENEWAL OF ORDERS 16. Continued use of restraint beyond the first 24 hours requires a new order ..."

2. On 5/27/2015 at 2:00 PM, Surveyor #3 reviewed closed medical records for patients (non-violent behavior, non-self-destructive) who had been placed in restraints. Patient #7's record revealed a 61-year-old patient who had been admitted to the hospital's critical care unit on 3/19/2015 for treatment of hyponatremia (low blood sodium level), low back pain, failure to thrive, and alcohol withdrawal. The patient was placed in soft limb restraints on 3/20/2015 at 4:37 PM for agitation, combativeness and pulling out his/her intravenous infusion. The patient's record revealed that he/she remained in restraints for 12 days. The patient's medical record did not include evidence that the patient's provider renewed the restraint order for 24-hour period starting on 3/30/2015. The patient remained in restraints during that time.

.

.
Based on interview and review of hospitals documents, the critical access hospital failed to review and update patient care policies on an annual basis as required.

Failure to review and update patient care policies can result in unsafe and inappropriate care to patients.

Findings:

1. On 5/27/2015 at 9:30 AM, Surveyor #3 reviewed nine surgical services and eighteen swing- bed patient care policies. The policies' review dates ranged from 5/2008 to 3/2014. Of the twenty-seven patient care polices, six surgical polices and eighteen swing-bed patient care policies were overdue for annual review.

2. On 5/27/2015 at 1:00 PM, Surveyor #3 interviewed the hospital's Associate Vice President for Patient Care Services (Staff Member #4) who confirmed the patient care policies are overdue for review.

.
Item #1- Potentially Hazardous Foods

Based on observation, the critical access hospital failed to maintain the temperature of potentially hazardous foods in a manner that reduces the risk for bacterial growth or contamination.

Failure to properly maintain cold holding temperatures for potentially hazardous food puts staff, patients and visitors at risk of food-borne illness.

Findings:

On 5/27/2015 at 9:50 AM, Surveyor #1 used a thin-stemmed thermometer to assess the temperature of the items in the "Cornerstone Cafe" refrigerated case. The following potentially hazardous foods had an internal temperature >41 degrees Fahrenheit:

a. Cesar salad with chicken: 46 degrees Fahrenheit

b. Pasta salad: 45 degrees Fahrenheit

Surveyor #1 placed the thin-stemmed thermometer on the display case shelf to assess the ambient air in the vicinity of the identified items. The temperature fluctuated between 42 and 47 degrees Fahrenheit during the course of the assessment. Dietary staff members removed the items from service, and maintenance staff members repaired the unit during the survey.

Reference: Washington State Retail Food Code, WAC 246-215-03525 (1) (b)

Item #2- Isolation Precautions

Based on observation and policy review, the critcal access hospital failed to ensure that medical staff members maintained compliance with hospital policy for contact isolation (multi-drug resistant S. aureus (MRSA)).

Failure to comply with hospital policies for controlling exposure to multi-drug resistant organisms (MDROs) puts staff and other patients at risk of exposure to infectious diseases.

Findings:

1. Hospital Policy #153.00 titled "Infection Control Standard" stated in part: "Content: The following minimum elements of infection prevention and control apply to all areas...
Health Care Workers: 8. Will adhere to transmission based, i.e. Airborne Respirator, Airborne Contact, Droplet, Contact Enteric and Contact Precautions as posted."

2. On 5/27/2015 beginning at 2:35 PM, Surveyor #1 observed a member of the Environmental Services Department (EVS) perform a terminal cleaning of operating room (OR) suite #2, following a surgical procedure for a patient in contact isolation for MRSA.
Prior to the arrival of EVS, OR staff members posted a contact isolation sign on the outside of the OR door. The sign indicated that staff members should done personal protective equipment (PPE) including gown and gloves. The EVS staff member donned a protective gown and gloves prior to entering the room.
During the course of the observation, a Certified Registered Nurse Anesthetist (CRNA) (Staff Member #7) entered the room without donning a protective gown or gloves, and proceeded to gather personal items from the vicinity of the anesthesia cart used in the procedure. Without wiping down the items, Staff Member #7 exited the room, only to re-enter a few minutes later, touch additional items in the vicinity of the anesthesia cart, including a chair that the EVS staff member had not yet disinfected, and then exited the room a final time.

.
Based on record review and interview, the critical access hospital failed to ensure the hospital staff was educated and trained in epidural catheter removal procedures.
.
Failure to educate hospital staff regarding epidural catheter removal places patients at risk for physical harm and injury.
.
Findings:
.
1. On 5/26/2015 at 11:00 AM, Surveyor #2 reviewed the electronic medical record of Patient #4 in the Family Birth Center and noted an annotation in the labor record that on 5/24/2015 at 11:30 PM, the registered nurse (Staff Member #2) removed the epidural catheter with the tip intact.
.
2. On 5/27/2015 at 1:00 PM, Surveyor #2 interviewed the nurse manager of the Family Birth Center (Staff Member #3) and discussed staff training in removing an epidural catheter. S/he stated that the anesthesia department provided the training. The Family Birth Center nurse manager (Staff Member #3) confirmed there was no documentation in the registered nurse's (Staff Member #2) competency/training file to indicate that s/he had received training on removing epidural catheters.
.

.
Based on observation and review of hospital policies and procedures, the critical access hospital failed to implement procedures for allergy identification for 3 of 4 patients (Patients #4, #5, #6).

Failure to implement procedures for allergy identification places patients at risk for medication errors.

.
Findings:
.
1. The hospital's policy and procedure titled "Allergy Identification and Prevention Policy" (Revised 3/2013) read,"Place allergy band on patient, if allergies present".
.
2. On 5/26/2015 at 11:00 AM, during an interview with Patient #4, Surveyor #2 observed that the patient was not wearing a red allergy armband as required by hospital policy. Patient #4 has allergies to sulfa (antibiotic) and hydrocodone (narcotic analgesic) documented in the hospital's electronic medical record.
.
3. On 5/27/2015 at 9:50 AM, during an interview with Patient #5, Surveyor #2 observed that the patient was not wearing a red allergy armband as required by hospital policy. Patient #5 has an allergy to statin medications (lowers cholesterol) documented in the hospital's electronic medical record.
.
4. On 5/27/2015 at 9:50 AM, Surveyor #2 requested the nurse manager of Acute Care Services (Staff Member #1) check for the presence of an allergy band on Patient #6. S/he confirmed that Patient #6 was not wearing a red allergy band as required by hospital policy. Patient #6 has an allergy to Phenergan (antiemetic) documented in the hospital's electronic medical record.

.
Based on record review and review of hospital policy and procedures, the critical access hospital failed to ensure hospital staff members completed and documented pain reassessments after each pain management intervention for 3 of 4 surgical patients reviewed (Patient #1, #2, #3).
.
Failure to reassess for pain places patients at risk for inconsistent, inadequate, or delayed relief of pain.
.
Findings:
.
1. The hospital's policy and procedure titled "Pain Management Policy" (Revised 4/2013) read in part: "Assessment before and reassessment within 1 hour after any pain interventions " .
.
2. On 5/27/2015 beginning at 1:00 PM, review of three surgical patient records revealed the following:
.
a. Patient #1 was a 79-year-old patient who was admitted on 2/25/2015 for right femoral neck fracture. The patient received vicodin (a narcotic medication for pain) on six occasions (2/25/2015 at 11:52 PM; 2/26/2015 at 4:35 AM; 2/26/2015 at 5:04 PM; 2/26/2015 at 9:12 PM; and 2/27/2015 at 1:31 AM and 4:50 AM) with no evidence of a reassessment for pain following medication administration.

.
b. Review of the medical records of Patients #2 and #3 revealed similar findings.
.

.
Based on interview and review of hospital documents, the critical access hospital failed to provide "swing bed" residents with a complete list of their patient rights upon admission to swing bed status as required.

Failure to notify residents of their rights can result in residents not capable of making informed decisions concerning their medical care and failure to formulate advance directives.

Findings:

1. On 5/26/2015 at 11:45 AM, an interview between Surveyor #3 and the hospital's social worker (Staff Member #5), revealed a hospital document labeled "Transitional Care Patient Right and Responsibilities." The staff member said residents review and sign the form upon admission to swing-bed status. The patient receives a copy and one is placed in their medical record. The hospital document contains required components except:

a. §483.10(b)(4) The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph 8 of this section.

b. §483.10(j) Access and Visitation Rights (1) The resident has the right and the facility must provide immediate access to any resident by the following: (vii) Subject to the resident s right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and (viii) Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.

2. On 5/28/2015 at 9:00 AM, an interview with the hospital's accreditation manager (Staff Member #6) confirmed the missing components of swing-bed patient rights.

.