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Based on interview and document review, the facility failed to inform patients of the right to have a family member or representative and physician notified of his/her admission.

Failure to inform patients of this right places them at risk of not being able to exercise this specific right, and potentially delay or inhibit their care.

Findings:

Surveyor #3 requested and reviewed the list of Patient Rights given to patients. The list did not include the above-described right to have family or representative of choice, and personal physician notified of the patient's admission. This was confirmed by the Senior Vice President (Staff Member #9) on 2/6/2014 at approximately 10:00AM.



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Based on medical record review, the hospital failed to ensure that orders were received for all episodes of physical restraint for 1 of 4 records reviewed for restraints (Patient #2)

Failure to ensure that physician orders are obtained places patients at risk of harm related to the potential of being restrained without physician knowledge.

Findings:

1. Per record review by Surveyor #2, Patient #2 was placed into physical restraints on 2/2/2014. A review of the monitoring documentation showed the patient was "released from restraints" on 2/3/2014 at 8:00 AM. The record showed that the patient remained out of restraints until after 8:00 PM (12 hours). After being placed back into restraints, no evidence of a new physician order was found in the record.

2. Patient #2 was in physical restraints on 2/4/2014 at 12:00 AM and was "released" sometime between 12:00 AM and 6:00 AM. After being placed back into restraints, no evidence of a new physician order was found in the record.

3. Patient #2 was released from physical restraints on 2/4/2014 from 8:00 AM until 10:00 PM. At this time restraints were re-applied and subsequently removed at 12:00 AM on 2/5/2014. No evidence of a new physician order was found in the record.



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Based on review of provider training documents, the hospital failed to ensure that documentation existed to show providers had a working knowledge of hospital policy regarding the use of restraint or seclusion for 4 of 4 credential files reviewed for restraint documentation (Staff member #1, #2, #3, #4).

Failure to have adequate knowledge of restraint usage places patients at risk of harm related to the potential misuse of physical restraints.

Findings:

Per review of provider credential training documentation by Surveyor #2, no evidence was found that physicians (Staff members #1, #2, #3 and #4) had received training regarding the hospital policy and procedure concerning patient restraints.



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Based on medical record review, the hospital failed to ensure that a physician documented a face-to-face evaluation of a physically restrained patient, as required by law, for 1 of 4 records reviewed for restraints (Patient #7)

Failure to ensure that the physician evaluation is accomplished places patients at risk of harm related to the potential of being restrained without physician assessment.

Findings:

Per record review by Surveyor #2, Patient #7 was seen in the Emergency Department (ED) on 12/9/2013 and subsequently placed into physical restraints. A review of the ED documentation did not provide evidence that a face-to-face evaluation, using the required criteria, was accomplished within one hour of the patient being restrained.



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Item #1 - Failure to Monitor Dialysis Care Performed by a Contractor

Based on administrative staff interview and medical record review, the hospital Quality Program failed to adequately monitor dialysis care provided by a contractor for 3 of 3 records reviewed for dialysis (Patients #1, #3, #4).

Failure to monitor the effectiveness and safety of services and quality of care places patients at risk of harm related to care being provided in an inconsistent and un-standardized manner.

Findings:

1. Per record review by Surveyor #2, Patient #1 received hemodialysis on 1/30/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR [Blood Flow Rate] as tolerated". Neither the Chief Nursing Officer (Staff Member #6), nor the dialysis service contractor could provide any documentation describing how dialysis staff were to operationalize this order in a standard and consistent manner between all dialysis staff providing care for the patient. No documentation was received from the hospital or dialysis service contractor showing that dialysis staff had received any training or education regarding how staff were to operationalize this order.

2. An additional example of the above was noted on 1/31/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR as tolerated".

3. An additional example of the above was noted in the record of Patient #3 on 2/2/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR as tolerated".

4. An additional example of the above was noted in the record of Patient #4 on 1/30/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR as tolerated".

5. An additional example of the above was noted in the record of Patient #3 on 2/2/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR as tolerated".

6. Per record review, Patient #1 received hemodialysis on 1/31/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "K+ [Potassium bath] as tolerated". Neither the hospital nor the dialysis service contractor could provide any documentation describing how dialysis staff were to operationalize this order in a standard and consistent manner between all dialysis staff providing care for the patient.

7. Dialysis staff showed the Surveyor a sheet of paper with several reminders and helpful hints for dialysis staff which included a chart of potassium bath solutions associated with particular patient blood potassium levels. However, no documentation was received from the hospital or dialysis service contractor showing that a protocol for converting blood potassium levels to dialysis care was provided as described in the physician order. No evidence that dialysis staff had received any training or education regarding how staff were to operationalize this order was provided.

8. An additional example of the above for Patient #1 was noted on 2/3/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "K per Protocol".

9. Per record review, Patient #3 received hemodialysis on 2/2/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "300 ml/hr clotting". The order did not include the type of intravenous fluid to be used. A review of the flow sheet form did not provide evidence that the fluids had been given to the patient, nor documentation that the order was followed as written.


Item #2 - Failure to Follow Parameters of Dialysis Contract

Based on medical record review and review of the dialysis service supplier contract with the hospital, the Quality program failed to ensure that the parameters of service contracts were followed for 2 of 3 records reviewed for dialysis services (Patients #1, #4).

Failure to monitor the credential privileging and contractor services places patients at risk for harm of care received from non-designated providers.

Findings:

1. Per record review by Surveyor #2, on 1/30/2014 Patient #1 received hemodialysis, based on orders from a Physician Assistant-Certified (PA-C) (Staff Member #5). A review of the contract between the dialysis supplier and the hospital revealed that the contract specified that dialysis orders could only be written by a medical doctor or a licensed independent practitioner. Since a PA-C is not allowed, by the contract, to write dialysis orders for hospital patients, the dialysis should not have been completed by the contractor licensed nurse without clarification of the order.

2. An additional example of the above was noted in the record of Patient #4 on 1/30/2014.



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Item #1 - Privileges Granted Not Congruent with Contracted Services Agreement

Based on provider credential file review and contractor agreement, the hospital failed to ensure that provider credentials for privileges were reviewed to ensure that privileges extended to the provision of care through a contracted patient-care service were appropriate for 1 of 10 credentialing files reviewed (Staff #5).

Failure to monitor the credential privileging and contractor services places patients at risk of harm related to care being provided by non-designated providers.

Findings:

Per review by Surveyor #2 of a Physician Assistant-Certified (Staff Member #5) credentialing file on 2/6/2014, the provider had been given privileges to write orders for hospital patients. The file did not contain evidence that this provider was also privileged to write dialysis orders for dialysis contractor services, regardless of the contract language.


Reference: Tag A-0273




17188


Item #2 - Privileges Not Delineated for Registered Nurse First Assistant (RNFA)

Based on document review the facility failed to assure that privileges granted were clear and complete, listing the specific privileges or limitations for that category of practitioner for 1 of 10 credentialing files reviewed (Staff #29).

Failure to delineate and completely list the specific privileges or limitations for a category of practitioner puts patients at risk of being treated in an inappropriate manner or by an unqualified individual.

Findings:

On 2/6/2014, at approximately 2:00 PM while reviewing the medical staff credentialing processes Surveyor #1 asked for and received the privileges granted for an RNFA (Staff Member #29). Upon reviewing the written document "RN First Assist Clinical Privileges and Procedures" it was noted that the document did not list specific privileges or limitations for this category of practitioner. As written it served as a job description that only listed the desired attributes of the individual holding the position.



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Based on medical record review, and administrative staff interview, the Director of Nursing (Staff Member #6) failed to adequately monitor non-employee nursing personnel providing hemodialysis care to hospital patients for 3 of 3 records reviewed for dialysis (Patient #1, #3, #4).

Failure to monitor the care provided by non-employee personnel places patients at risk of harm related to care being provided in an inconsistent and un-standardized manner.

Findings:

1. Per record review by Surveyor #2, Patient #1 received hemodialysis on 1/30/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "BFR [Blood Flow Rate] as tolerated". Neither the hospital, nor the dialysis service contractor could provide any documentation describing how dialysis staff were to operationalize this order in a standard and consistent manner between all dialysis staff providing care for the patient.

2. Per record review, Patient #1 received hemodialysis on 1/31/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "K+ [Potassium bath] as tolerated". Neither the hospital nor the dialysis service contractor could provide any documentation describing how dialysis staff were to operationalize this order in a standard and consistent manner between all dialysis staff providing care for the patient.

3. Per record review, Patient #3 received hemodialysis on 2/2/2014. A review of the "Acute Hemodialysis Flow Sheet" form showed an order that read "300 ml/hr clotting". The order did not include the type of intravenous fluid to be used. A review of the flow sheet form did not provide evidence that the fluids had been given to the patient, nor documentation that the order was followed as written.

4. Per interview with the Chief Nursing Officer (Staff Member #6) on 2/5/2014, there was no documentation of quality assurance activities on non-employee dialysis service contractors.

Reference: Tag A-0273



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Based on observation and interview, the facility failed to ensure that drugs were administered according to accepted standards of practice and facility policy.

Failure to do so places patients at risk of adverse effects, including infection, related to observed clinical practices.

Findings:

1. Reference: "APIC position paper: Safe injection, infusion, and medication vial practices in health care", dated 2010, reads in part: "Dinfect IV ports and vial stoppers by wiping and using friction with a sterile 70% isopropyl alcohol, ethyl/ethanol alcohol, iodophor, or other approved antiseptic swab. Allow the port to dry before accessing."

2. On 2/5/2014 beginning approximately 10:50 AM Surveyor #3 observed a post-anesthesia (PACU) registered nurse (RN) (Staff Member #8) administering medications to a recovering patient. On two occasions the RN did not disinfect the rubber stopper of the medication vial prior to drawing up the sterile medication for injection. The RN also injected medications into an aseptic intravenous access line without first disinfecting the injection port. The surveyor observed the RN fail to disinfect the port prior to injection a total of 5 times. The Assistant Administrator, Surgery (Staff Member #7) confirmed on 2/5/2014 at approximately 11:00 AM that these practices were not compliant with facility policy or expected standard of practice.



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Based on observation the facility failed to assure that dietary services were provided in a manner that would meet recognized food service standards. More specifically, the Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC).

Failure on the part of the facility to assure that food service standards are met puts patients, staff and visitors of the facility at risk of food borne infection and/or illness.

Findings:

1. On 2/5/2014, between the hours of 9:00 AM and 12:00 PM, Surveyor #1 checked both cold and hot holding temperatures in the cafeteria service area. Improper cold holding was noted for sliced tomatoes that were being held at 44.3 degrees Fahrenheit (F). Improper hot holding was noted for breakfast sausage that was being held at 131 degrees F.

(Reference: Section 03525 Temperature and time control--Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16) (1) (a) and (b).

2. On 2/5/2014, between the hours of 9:00 AM and 12:00 PM, Surveyor #1 observed Kitchen Staff (Staff Member #32) enter a refrigeration unit to retrieve cheese for a sandwich that a customer had requested be prepared using a different type of bun. The staff person was wearing gloves when entering the refrigerator but didn't change gloves before handling the new bun and cheese, which are ready to eat items.

(Reference: Section 0330 Preventing contamination from equipment, utensils, and linens--Food contact with equipment and utensils (2009 FDA Food Code 2-304.11); and (Reference: Section 03342 Preventing contamination from equipment, utensils, and linens--Gloves, use limitation (2009 FDA Food Code 3-304.15) (1)

3. On 2/5/2014, between the hours of 9:00 AM and 12:00 PM, Surveyor #1 observed Kitchen Staff (Staff Member #33) entering a refrigerator while wearing gloves. Upon leaving the refrigerator the staff person was stopped from handling ready to eat food (lettuce) because s/he had not changed gloves.

(Reference: Section 0330 Preventing contamination from equipment, utensils, and linens--Food contact with equipment and utensils (2009 FDA Food Code 2-304.11); and (Reference: Section 03342 Preventing contamination from equipment, utensils, and linens--Gloves, use limitation (2009 FDA Food Code 3-304.15) (1)

4. On 2/5/2014, between the hours of 9:00 AM and 12:00 PM, Surveyor #1 noted that a handwash sink at the service line was also being used as a utility sink.

(Reference: Section 05270 Operation and maintenance -- Using a handwashing sink (2009 FDA Food Code 5-205.11) (2)



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Based on observation the facility failed to provide proper ventilation so as to assure the maintenance of asepsis.

Failure on the part of the facility to maintain asepsis puts patients at risk of infection.

Findings:

On 2/6/2014 at approximately 9:00 AM Surveyor #1 performed a check of air movement in/out of the "Old Core" of the surgical suite. Using a light strip of tissue held to the slightly cracked open door of the Old Core it was noted that air flow was from the corridor into the Old Core.

Subsequent to this finding the air movement was reversed so that air moved from the core into the corridor.



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18001


Based on observation, interview, and document review the facility infection prevention system failed to prevent breaches of infection control policy, related to breaches in hand hygiene, disinfection, prevention of cross contamination, personal protective equipment use, and environmental cleaning.

Failure to prevent these breaches places patients at risk of potential exposure to pathogenic organisms, resulting in infection, debility, extended hospital stays, increased cost of care, and death.


Item #1: Hand Hygiene

Findings:

1. Reference: Facility policy #5605 titled "Hand Hygiene" reviewed by facility on 10/23/2013 read in part:
"HAND ANTISEPSIS: Use an alcohol-based hand rub for routine decontamination if hands are not visibly soiled:
a. Before and after patient contact.
b. After removing gloves.
c. After contact with contaminated equipment or environmental surfaces.
d. Apply product to palm of one hand and rub hands together covering all surfaces of hands and fingers, until hands are dry."

2. During tour of post anesthesia care unit (PACU) on 2/5/2014 at approximately 10:50 AM Surveyor #3 made observations of the PACU registered nurse (RN) (Staff Member #8) caring for a patient. The RN, wore the same pair of gloves, without removing and performing hand hygiene (HH), repeatedly going from direct patient contact to accessing clean patient care supplies, medications, documenting in the medical record, and performing other tasks. During approximately 15 minutes of observation of this RN, s/he did not once remove contaminated gloves, perform HH, or don fresh gloves.

3. While observing preparations for and the initiation of a surgical procedure on 2/5/2014 beginning approximately 11:50 AM Surveyor #3 observed the Certified Registered Nurse Anesthetist (CRNA) (Staff Member #10) perform HH. Rather than rubbing hands/fingers together until the alcohol based hand rub was dry, on three occasions the CRNA waved them around to dry them.

4. On 2/5/2014 during observations at approximately 3:50 PM in the Cardiac Cath Lab, Surveyor #3 observed an RN (Staff Member #11) lift the lid of a hamper containing contaminated trash with bare hands, and without subsequently performing HH, donned gloves and handed off sterile patient care supplies to another staff member.

5. During the same time frame noted in #4, Surveyor #3 observed that a Cardiovascular Tech (Staff Member #12) also lifted the trash hamper lid, without subsequently performing HH before returning to patient care.


Item #2: Disinfection

Findings:

1. Reference: Facility policy #8461-56 titled Environmental Services reviewed by facility 6/4/2013 indicated, according to the equipment sanitation chart on page 3 that portable computers (WOWs) were to be sanitized daily, at discharge, and by clinical/respiratory therapy staff after use when taken into the patient room.

2. During tour of the 4th floor Surgical/Orthopedics unit on 2/4/2014 approximately 10:30 AM Surveyor #3 observed a WOW parked in the hallway. The wrist pad adjacent to the keyboard had deteriorated, with holes and pitting, to the point where it would not be possible to clean and sanitize it effectively. This was confirmed by Peer Review/Quality staff (Staff Member #13).


Item #3: Potential Contamination

Findings:

1. Reference: Facility policy #5200 titled Isolation Precautions reviewed by facility 1/26/2014 includes the following minimum directives for Standard Precautions (page 3): "Patient Care Equipment: Handle in a manner that prevents transfer of micro-organisms to others and the environment... Reusable equipment will be cleaned and disinfected/sterilized prior to use by another patient..."

2. During tour of the 4th floor Surgical/Orthopedics unit on 2/4/2014 at approximately 10:30 AM Surveyor #3 observed that a clean item (moisturizing skin cream) was observed in the medication room on the edge of the hand wash sink, subjecting it to contamination. Evidence of splatter from previous hand washing was apparent on the skin creas and surrounding areas.

3. On 2/4/2014 at 2:00 PM Surveyor #1 noted that a cardboard box of intravenous fluids was being stored on the floor of Storage Room #4473. Subsequent to this finding the Director of Supply Chain (Staff Member #28) stated that this practice is not permitted (cardboard shipping containers are not to be taken to patient care areas of the facility).

4. While observing preparations for a surgical procedure on 2/5/2014 at 10:30 AM Surveyor #3 observed an anesthesiologist (Staff Member #14) examine a patient with a stethoscope. S/he did not disinfect the stethoscope before or after using it to examine the patient.

5. During the above observations at approximately 12:15 PM a bladder catheter was inserted into the patient and attached to a collection bag which immediately began to fill. On two occasions, while a number of staff members were positioning the patient and equipment, the urine collection bag was lifted above the level of the patient's bladder. These actions resulted in backflow of urine from the collection bag and back into the bladder.

6. In the peri-operative area on 2/5/2014 at approximately 10:40 AM Surveyor #3 reviewed the difficult intubation cart, stored in an alcove near a door to the unit. Assorted airways and bite blocks were stored openly atop the cart without protection from contamination. Similar findings were noted on 2/5/2014 between 1:45 - 3:00 PM in the anesthesia room of the birthing center and on the anesthesia cart in the C-section room. In the C-section room Surveyor #3 also observed a laryngoscope blade (an item used to assist placing a breathing device into a patient's breathing tube) sitting on top of the cart covered only by a towel.

7. While washing hands in the birthing center staff restroom on 2/5/2014 at about 3:15 PM Surveyor #3 observed that the paper towel dispenser was approximately 6" above the water-splattered counter surrounding the sink. The surveyor tried several times to obtain a paper towel for drying hands that did not become contaminated from contact with the contaminated counter.

Item #4 - Personal Protective Equipment Use

Findings:

1. On 2/4/2014 at approximately 1:30 PM Surveyor #1 observed a registered nurse (Staff Member #30) donning his/her personal protective equipment (PPE) in the wrong order outside room 5507, which was posted for both contact and droplet precautions. The staff person was observed putting on gloves prior to donning a protective gown. The observed order of donning PPE did not follow the Centers for Disease Control (CDC) "Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings", dated 3/2010. This Guidance document outlines that the gown is to be donned first; then any indicated mask, respirator, or face shield, and gloves donned last.

2. On 2/7/2014 at approximately 10:45 AM Surveyor #1 observed a tech (Staff Member #31) cleaning an endoscope while not wearing goggles as is required per facility policy titled "Cleaning, High Level Disinfection, and Reprocessing of GI Endoscopes" Number GI-8.

Item #5 - Environmental Cleaning

1. On 2/4/2014 at approximately 1:45 PM Surveyor #1 noted two chairs in the corridor of the 3rd floor tower near room 3333. One of the chairs exhibited wear and a tear making it uncleanable.

2. On 2/6/2014 at approximately 11:00 AM Surveyor #1 toured the Caesarian-Section Operating Room (OR) and noted a heavy accumulation of dust on ventilation air diffusers and high horizontal surfaces (i.e. upper door frame). It was also noted that portions of wall surfaces were not smooth and cleanable due to damage.



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