HospitalInspections.org

References:
WAC 246-320-131 Governance.
The governing authority must: (1) Establish and review governing authority policies including requirements for: (e) Reporting adverse events and conducting root cause analyses according to RCW 70.56.020...

WAC 246-320-146 Adverse health events and incident reporting system. Hospitals must: (1) Notify the department whenever any of the following adverse events as defined by the National Quality Forum, Serious Reportable Events in Health Care occur ...

WAC 246-320-146 Adverse health events and incident reporting system. (4) As part of the root cause analysis, include the following information: (a) The number of patients, registered nurses, licensed practical nurses, and unlicensed assistive personnel present in the relevant patient care unit at the time the reported adverse event occurred; (b) The number of nursing personnel present at the time of the adverse event who have been supplied by temporary staffing agencies, including traveling nurses; and (c) The number of nursing personnel, if any, on the patient care unit working beyond their regularly scheduled number of hours or shifts at the time of the event and the number of consecutive hours worked by each such nursing personnel at the time of the adverse event ...

Based on interview and record review, the facility failed to establish a policy for reporting adverse events in accordance with current State regulation.

Failure to do so places patients at risk for recurrent adverse events related to failure to identify and thoroughly investigate such events, and potentially resulted in failure to submit information to the state to track and analyze in an effort to prevent similar recurrences.

Findings:

Per surveyor request, VS#1 provided the policy titled "Adverse Reporting", revised 8/10. Review of the policy revealed that the eight adverse events listed as reportable were those specified in the former state licensing rules, which had been revised in 2009. Stapled to the policy, but not referenced by the policy, were two other lists of reportable adverse events. One of the lists was incomplete; the second was accurate.

Review of the policy revealed that it did not address the inclusion of the required patient statistics and staffing data in the root cause analysis specified in WAC 246-320-146 (4).

These findings were confirmed by staff VS#1.



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Based on record review, the hospital failed to ensure that all personnel had required licensure or certification.

Failure to ensure that personnel have required licensure or certification risks provision of patient care by unqualified personnel.

Findings include:

During a tour of the hospital on 09/15/10, the technologist operating the mobile MRI unit stated that he did not have Washington State Certification as a Radiologic Technologist. He stated that he was not aware that state certification was required.

Based on observation and interview the facility failed to provide certain patient care supplies for emergency care and treatment of patients.

Failure to do so places patients at risk for delays in treatment and the potential for inaccurate laboratory test results.

Findings:

During tour of the patient care unit on 9/14/10 the surveyor inspected the contents of the emergency OB cart. The cart contained tubes used for drawing blood specimens. Four of the tubes had an expiration date of 6/10. Four others had expired in 8/10.

While touring the patient care unit on 9/14/10 the surveyor reviewed the items contained in the emergency crash cart. A laryngoscope, used for emergency patient intubation in respiratory arrest, was missing it's handle/power pack and therefore non-functional. The cart also contained blood draw tubes. Two had an expiration date of 6/10, and four had expired in 8/10.

The above observations were confirmed by Staff VS#1.



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Based on observation, the hospital failed to maintain the premises in a manner that would ensure the safety of patients, by failing to provide an indirect drain for two food preparation sinks.

Failure to provide an indirect drain for food preparation sinks risks backflow of sewage into the sinks, potentially contaminating patient food.

Findings include:

During a tour of the hospital on 09/15/10, it was observed that two sinks in the kitchen were hard-plumbed into the hospital sewer line. Kitchen food service personnel confirmed that these sinks were used for food preparation.

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 include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 09/16/10.

Based on observation, interview, and record review, the facility failed to follow hospital policies for medication management, based on requirements of the state Hospital Licensing rules, WAC 246-320, and state Pharmacy rules, WAC 246-873.

Failure to do so places patients at risk for medication errors, improper dosing of medications, and receiving drugs of questionable quality.

Findings:

Reference:
WAC 246-320-226 Patient care services. Hospitals must: (3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (b) Reliable method for personal identification of each patient ...

On 9/14/10 the surveyor interviewed Patient #1, admitted 9/13/10, and whose record revealed that s/he had orders for approximately 20 medications. When asked, the patient reported that when staff brought medications to him/her they did not check the patient's wristband to ensure they had the correct patient, nor did they ask the patient for his/her name and birth date. Per Staff VS#1 these were the preferred methods per hospital policy for verifying a patient's identity prior to administering medications.

On 9/14/10 the surveyor interviewed Patient #3, and asked how the staff verified his/her identity prior to giving medications. The patient stated the staff did not ask his/her name or birth date, and showed the surveyor that s/he did not have a wristband.

On 9/15/10 the surveyor shadowed Staff VS#3 while s/he administered medications to five long term patients. The surveyor had been told by Staff VS#1 that pictures were available for identification, since most had some degree of cognitive impairment. S/he stated that the patient ' s name band would function as the second identifier, per hospital policy.

Staff VS#3 was not observed to access a photograph for any of the five patients to whom s/he administered medications. None of the patients had name bands.

The above findings were verified by Staff VS#1.


Reference:
WAC 246-873-080 Drug procurement, distribution and control. (6) Medication orders. Drugs are to be dispensed and administered only upon orders of authorized practitioners...

On 9/15/10 the surveyor observed an endoscopy procedure. The patient was brought into the endoscopy room, and prepped by a registered nurse and a procedure tech, including attaching vital sign monitoring equipment and positioning the patient. The physician (Staff VS#6) was notified that the patient was ready and entered the room. The RN (Staff VS#5) advised the physician that the patient had not yet received any sedating medication. The physician told the RN to administer the medication, but did not specify which drug(s) to use or dosages to give.

The RN proceeded to draw up and administer doses of two medications - versed (a sedative) and fentanyl (an analgesic) through the patient's IV line. At no time during the procedure did the physician give any medication orders to the RN. The physician, when queried about this practice, stated that the staff who assisted with endoscopy had done "thousands" of these procedures, and knew what to do, so he never told them what drugs or dosages to use, unless specifically questioned in an unusual situation.

Staff VS#1 had told the surveyor on 9/14/10 that the facility did approximately three endoscopy procedures a week, and that Staff VS#6 was the only physician who performed them. On 9/15/10 Staff VS#1 stated that hospital policy requires a valid practitioner's order to administer medications.

Reference:
WAC 246-873-080 Drug procurement, distribution and control.
(7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations. (h) Controlled substances, Schedule II and III, which are floor stocked, in any hospital patient or nursing service area shall be checked by actual count at the change of each shift by two authorized persons licensed to administer drugs.

During tour of the emergency department on 9/14/10 the medication storage area was inspected. "Take home" medications were stocked in the area - medications given to patients to tide them over before they can get a prescription filled. Some of these medications were controlled substances. The procedure used for counting them at change of shift consisted of counting the number of bottles present, not the actual number of tablets. The bottles were not sealed in a manner that would ensure the number dispensed into the bottles were either present or there would be evidence if some had been removed. Staff VS#1 and VS#7 acknowledged that this procedure was inadequate to ensure accurate tracking of these drugs.

Reference:
WAC 246-873-090 Administration of drugs.
(3) Patient's drugs. The hospital shall develop written policies and procedures for the administration of drugs brought into the hospital by or for patients. (a) Drugs brought into the hospital by or for the patient shall be administered only when there is a written order by a practitioner. Prior to use, such drugs shall be identified and examined by the pharmacist to ensure acceptable quality for use in the hospital.

On 9/14/10 the surveyor interviewed Patient #1, who had been admitted the day before with a diagnosis of pneumonia. S/he stated that s/he had brought all routine medications from home to ensure that they would be available. Review of the patient ' s record revealed multiple diagnoses, and physician orders for approximately 20 medications. Interview with Staff VS#1 revealed that it was not the facility ' s practice to ensure that medications brought from home were identified and examined by a pharmacist prior to administering them to patients.

Reference:
WAC 246-873-090 Administration of drugs. (2) Administration. Drugs shall be administered only by appropriately licensed personnel in accordance with state and federal laws and regulations governing such acts and in accordance with medical staff approved hospital policy.

During survey of the OB room and patient care unit, the surveyor found the expired medications available for use in carts that were supplied for emergency situations. Staff VS#1 stated that hospital policy gave staff and Pharmacy the responsibility for checking these supplies on at least a monthly basis for the purpose of ensuring the needed medications were present and not expired.

The OB cart contained the following:
? Lidocaine (for treating heart arrhythmias) - one expired 3/1/10, the other expired 9/1/10
? Naloxone (for treating over-sedation) - two vials expired 7/10
? Oxytocin (for inducing labor and for preventing uterine bleeding after delivery) - three vials expired 5/10
? Betadine (a skin disinfectant) - one bottle expired 4/10

The cupboard in the OB room contained 6 six-packs of Enfamil water (for hydration of newborns) expired 8/1/10

The crash cart on the patient care unit contained heparin vials (a blood thinner) expired 8/10. The pediatric box on the crash cart contained 3 vials of epinephrine (used in cardiac and other emergencies) which expired 8/1/10.

Staff VS#1 confirmed the above findings.



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Based on observation and interview, the facility failed to develop, implement, and maintain policies and procedures for specific infection prevention issues.

Failure to do so places patients, staff, and visitors at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.
Findings:

I.
On 9/14/10 during tour of the patient care unit, the surveyor observed two uncovered trays of dishes and water pitchers on the counter of the clean utility/nutrition room. Staff VS#1 stated they were delivered by the kitchen for patient use. The trays were situated directly adjacent to the handwashing sink, which subjected them to splatter and contamination when the sink was used. This was confirmed by Staff VS#1.

II.
During tour of the patient care unit on 9/14/10 the surveyor observed dust and debris on some computer keyboards in various areas of the unit. Staff VS#1 stated that there was no policy and procedure in place which outlined the frequency and method for cleaning and sanitizing the keyboards and peripherals.

III.
On 9/14/10 during survey of the OB room, the surveyor inspected the OB cart, which contained medications and patient care supplies. Dust and other types of debris was found in the cart ' s drawers. This observation was confirmed by Staff VS#1.

IV.
During survey of staff activities related to Endoscopy procedures on 9/15/10 the surveyor observed a staff member measuring a patient's vital signs. The staff member brought the vital signs machine into the patient room, attached several items to the patient, then detached them and removed the machine from the room. The machine was stored in the hall awaiting use with another patient. The machine was not cleaned or sanitized either prior to or after use. This was confirmed by Staff VS#1.

V.
On 9/15/10 Surveyor #14866 observed Staff PS#1 cleaning a patient room marked with a "contact precautions" sign. At approximately 9:25AM PS#1 left the room without removing his/her personal protective equipment (gown and gloves) and without performing hand hygiene. S/he walked down the unit corridor to a housekeeping cart, and pulled the cart back to the door of the room s/he was cleaning. S/he then went back into the contact precautions room and continued cleaning. Another housekeeper then accessed the contaminated cart.

VI.
On 9/15/10 the surveyor observed Staff VS#3 administer medications to five patients. On numerous occasions hand hygiene was not performed when indicated.

Staff VS#3 gave medications to four patients who were eating breakfast in the dining area. S/he did not perform hand hygiene before preparing the first patient's medications. S/he repeatedly took a patient's pulse, assisted with medications, and handled soiled medication cups and drinking glasses. Following each sequence of activities s/he did not perform hand hygiene before returning to the medication cart, handling a key ring, using a computer keyboard, and obtaining more medications. S/he did not perform hand hygiene prior to approaching the next patient.

Staff VS#3 went to a patient's room to replace a medicated patch. S/he did not perform hand hygiene before donning gloves. S/he assisted another staff member to re-position the patient, during which time the gloves came in contact with a soiled under-pad. Using the same soiled gloves s/he handled a multi-use container of spray medication designed to help the medicated patch adhere to the patient ' s skin. S/he also used the gloved hands to open a package and remove the patch. S/he later used a bare hand to flush a toilet, but did not perform hand hygiene before continuing medication administration tasks.

On 9/15/10 the surveyor observed Staff VS#4 performing an IV start. Staff VS#4 did not perform hand hygiene after removing gloves following the procedure.



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Findings:

Based on interview and record review, the facility failed to implement a system to plan and document care through development of an individualized patient plan of care.

Failure to do so places patients at risk of inadequate care and neglect of basic needs.

Findings:

Per record review on 9/14/10, Patient #1 presented for care in the hospital emergency room on 9/13/10. The patient's chief complaints were pain and shortness of breath. S/he was placed in observation status, diagnosed with pneumonia, and admitted as an inpatient. The record revealed other diagnoses including chronic obstructive lung disease, gastric reflux and ulcer, pulmonary hypertension, sleep apnea, chronic back pain, and morbid obesity.

The care plan written while the patient was in observation status documented only one problem - pain. The care plan written upon the patient's admission also addressed only one issue - respiratory problems. None of the patient's other physical, or potential emotional or social needs were addressed. There was no evidence that a process had been undertaken to devise a care plan based on assessments which had been performed.

The above was confirmed by Staff VS#1. S/he stated that the lack of a comprehensive care plan was common for patients who were not there long-term (i.e. swing bed patients).



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Based on interview and review of performance improvement documentation, the hospital failed to systematically assess medication errors for patterns and trends.

Failure to systematically assess medication errors limits the hospital's ability to prevent future errors and reduce risk of patient harm.

Findings include:

During review of performance improvement data and an interview on 09/16/10, it was found that the hospital did not systematically analyze aggregate data on medication errors to determine if the errors had a common cause or if certain types of errors were increasing in number and frequency. A line list of medication errors through late 2009 was available, but not for 2010. There was no method for using analysis of errors to discover major patterns and trends that could lead to action plans to improve medication delivery systems and prevent recurrence of errors.