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14701 179TH AVE SE

MONROE, WA 98272

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

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Based on observation, interview and review of hospital policies and procedures, the hospital failed to provide appropriate telemetry alarm monitoring on their medical surgical unit.

Failure to provide appropriate telemetry alarm monitoring could lead to missed or delayed detection of cardiac dysrhythmias and death.

Findings:

1. The hospital's policy and procedure entitled "Cardiac Monitoring - Telemetry Protocol" (ID # 900.11) (Approved 5/12/2014) read in part as follows: "PURPOSE: To outline the management of telemetry monitoring for the early detection of cardiac dysrhythmias in the Adult MSTU patient population. EXPECTED OUTCOMES: 2. Alarms are managed immediately and are tailored to each patient's specific needs ...ALARM SET UP & REVIEW: ...Alarms are attended to immediately..."

2. On 4/27/2015 at 12:00 PM, Surveyor #5 reviewed an electronic medical record at the nurses' station on the medical/surgical/telemetry unit (MSTU). During the record review, the surveyor noticed the main telemetry monitor on the desk. The monitor displayed three patients' cardiac rhythms. One patient's (Patient #1) heart rate displayed 130 beats per minute (bpm) and the telemetry monitor screen blinked a "red" bell next to the bpm. No sound was audible from the telemetry monitor.

3. An interview on 4/28/2015 at 8:45 AM, with the MSTU charge nurse (Staff Member #8) detailed the portable telemetry monitoring system. At the start of cardiac monitoring, hospital staff manually enter each patient's room number, age, and sex into the monitor. Heart rate and alarm type/limits are set for each patient at the main terminal in the unit. Surveyor #5 asked the charge nurse to demonstrate the alarm volume. The alarm button was pushed and the volume of the alarm was barely audible. The charge nurse showed the surveyor "slave" monitors hanging in the hallway and demonstrated that the two monitors are for visual only; no audible alarms. The surveyor asked the charge nurse who is responsible for attending a patient's telemetry alarm and the nurse stated that the patient's primary nurse is responsible. No staff member sits in front of the main telemetry monitor.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0166

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Based on observation, interview and review of hospital policies and procedures, the hospital failed to ensure hospital staff members documented in each patient's plan of care changes due to restraint episodes in two of four medical records reviewed (Patients #2 and #3).

Failure to document restraint episodes in each patient's plan of care could lead to inappropriate restraint use, missed attempt at a least restrictive measure, adverse outcome, and death.

Findings:

1. The hospital's policy and procedure entitled "Restraints" (ID #3.10) (Approved May 2012) read in part: "SCOPE: All hospital employees and medical staff involved with restraints at EvergreenHealth Monroe [EHM]. POLICY: 4. A modification to the patient's written plan of care is completed if the patient restraints are applied ... RN Monitoring and Reassessing Patient: 5. Changes necessary in the Plan of Care due to the restraint episode ...Observed and documented: Every 2 hours by an RN."

2. Review of the records of 4 patients placed in restraints during their hospital stay revealed the following:

a. Patient #2 was a 94-year-old patient who was admitted to the hospital's acute care unit on 12/13/2014 for treatment of septic shock secondary to pneumonia. On 12/14/2014 at 11:00 AM, the patient became confused, impulsive, and attempted to remove a medical device. Nursing staff applied soft wrist restraints on 12/13/2014 at 11:15 AM and removed them three hours later.

The patient's record included documentation of nursing assessments during restraint use. The record did not include a modification to the patient's written plan of care as directed by hospital policy and procedure.

b. Patient #3 was a 49-year-old patient who was admitted to the hospital's medical/surgical unit on 12/7/2014 for treatment of acute renal failure secondary to dehydration. On 12/16/2014 at 5:00 AM, the patient became confused, impulsive, and attempted to pull out his/her indwelling catheter. Nursing staff applied soft wrist restraints on 12/16/2014 at 5:00 AM. The patient's record did not include a modification to the patient's written plan of care.

3. During the medical record review on 4/29/2015 at 10:30 AM, the hospital's Medical/Surgical/Telemetry Manager (Staff Member #9) confirmed the missing documentation.
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DATA COLLECTION & ANALYSIS

Tag No.: A0273

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Based on interview and review of the hospital's quality program, the hospital failed to systematically aggregate and analyze quality indicators related to restraint usage.

Failure to systematically collect and analyze hospital wide performance data limits the hospital's ability to identify problems and formulate effective interventions reducing the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

On 4/29/2015 at 9:30 AM, Surveyor #2 reviewed the hospital's quality program and interviewed the regulatory compliance officer (Staff Member #2), and quality manager (Staff Member #11) about the hospital's process for data collection and analysis of restraint usage. The review revealed staff members responsible for the quality program did not analyze and report aggregate data for patterns and trends instead used a line listing methodology to track restraint usage on an individual basis.

ORDERS FOR DRUGS AND BIOLOGICALS

Tag No.: A0409

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Based on record review and review of hospital policy and procedure, the hospital failed to ensure staff members documented the blood transfusion procedure according to policy for 3 of 3 patients reviewed (Patients #4, #5 and #6).

Failure to follow the blood transfusion procedure according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings:

1. The hospitals policy and procedure titled "Administration of Blood Products" (Approved 1/12/2015) read in part: "Informed consent will be obtained prior to blood administration ... Infusion rates per physicians orders, not to exceed 4 hours/unit of blood product ... Baseline vital signs ...Pre transfusion within 30 minutes prior to blood administration, at 15 min after initiation, at 60 minutes, then hourly and following conclusions of the transfusions " .

2. On 4/29/2015 at 3:30 PM, Surveyors #2 and #4 reviewed the records of three patients who received blood transfusions during their hospital stay and observed the following:

a. There was no physician signature on the consent form for blood transfusion and no infusion rate prescribed in the medical record for Patient #4. Additionally, nursing staff did not document vital signs for blood transfusion as required by policy, omitting the second hour of administration. The record did contain a final set of vital signs entered upon completion of the transfusion, 89 minutes after the last recording.


b. There was no consent form for blood transfusion and no infusion rate prescribed in the medical record for Patient #5.

c. The physician order for Patient #6 did not include an infusion rate. Nursing staff caring for Patient #6 did not document vital signs for the first fifteen-minute block of time, upon initiation of blood administration, as required by policy.
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FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

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Based on observation and interview, the hospital failed to maintain supplies in order to provide an acceptable level of safety and quality for patients in their medical/surgical/telemetry unit (MSTU).

Failure to maintain supplies could lead to outdated, contaminated, or deteriorated supplies stored in carts and available for patient use.

Findings:

1. On 4/27/2015 at 11:30 AM, Surveyor #5 entered the clean supply room on the (MSTU) and observed a 5-drawer supply cart. The MSTU manager (Staff Member #9) indicated this is the "wound care" cart and that wound clinic staff maintain the supplies. There was no supply/inventory checklist available for this cart. In drawer #1, there were two tubes of 5gm of Hypergel ointment, with an expiration date of 10/2013. The manager confirmed the expiration date and removed both tubes from the cart.

2. An interview with the hospital's materials Manager (Staff member #10) on 4/29/2015 at 8:50 AM revealed that the materials staff only inventories and maintains supplies on each hospital unit's supply room shelves that are labeled with materials "par" level labels. The department is not responsible for maintaining supply carts.
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INFECTION CONTROL PROGRAM

Tag No.: A0749

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Item #1 - Food Services- Compliance with the Washington State Retail Food Code

Based on observation and interview the hospital failed to provide dietary services in a manner consistent with the Washington State Retail Food Code (Washington Administrative Code 246-215).

Failure to maintain acceptable standards of practice for food service puts patients at risk of food borne illness.

Findings:

1. On 4/28/2015 at 10:45 AM Surveyor #1 observed a food colander placed in a two-compartment sink that served as both a food preparation sink and a utility sink. At the time of the surveyor's initial observation, staff placed the food colander into the right hand compartment for the rinsing of pasta (elbow macaroni). Subsequent to this observation, dietary staff moved the colander into the left hand sink compartment that contained a dirty utensil (knife). Discussion with the food service manager (Staff Member #12) revealed that there was no policy for cleaning and sanitizing the sink between use as a food preparation sink and use as a utility sink.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart C - Numbers and Capacities, 04325(3) Equipment - Designated food preparation sinks.

2. On 4/28/2015 at 11:15 AM, Surveyor #1 checked the cold holding temperatures of food items placed in the cafeteria's salad bar. The surveyor assessed the temperature of the items using a thin stem digital thermometer. The temperature of leaf lettuce was 48 degrees Fahrenheit, which exceeded the maximum cold-holding temperature of 41 degrees Fahrenheit. No other items in the unit exceeded the required temperature. Dietary staff members pulled the lettuce from the line for re-chilling.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 3, Subpart E - Limitation of Growth of Organisms of Public Health Concern, 03525 Temperature and time control - Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16)

3. On 4/28/2015 at 12:00 PM, Surveyor #1 noted that a serving pan of uncooked leaf spinach for salads appeared not to have been rinsed or washed. At the time of the observation, a member of the dietary staff informed the food service manager (Staff Member #12) that the spinach had not been rinsed or washed prior to placement on the salad bar. Staff indicated to the manager that the spinach packaging indicated the product was "ready to eat". Verification of the spinach's readiness for serving (i.e. ready to eat / ready to use) could not be made at the time of the finding because all packaging materials had been discarded.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 3, Subsection C - Preventing Contamination After Receiving, 03318 Preventing food and ingredient contamination - Washing fruits and vegetables (2009 FDA Food Code 3-302.15)

Item #2- Operating Room Between-Case Cleaning

Based on observation, the hospital failed to prevent or minimize the potential for cross contamination of environmental surfaces during the cleaning of an operating room.

Failure to adhere to recommended procedures for the cleaning of an operating room (i.e. cleaning from top to bottom and from clean to dirty) puts patients at risk of infection due to cross contamination.

Findings:

On 4/27/2015 at 1:45 PM, Surveyor #1 observed the turnover of operating room (OR) #2. During the turnover, the surveyor observed a member of the Environmental Services (EVS) team (Staff Member #13) while s/he cleaned and disinfected the operating room lights and booms. The staff member performed this process over the surgical table, which the staff member had already cleaned and disinfected, subjecting the environmental surfaces of the table to cross-contamination.

Item #3- Hand Hygiene


Based on observation and policy review, the hospital staff failed to comply with the hospital hand hygiene policy.

Failure on the part of the medical staff to perform hand hygiene puts patients and staff at risk of infection.

Findings:

1. Hospital Policy Identification # 5.5.24 titled "Hand Hygiene, Approval Date: 3/12/2014" stated in part: "Alcohol based hand rub or soap and water indicated when: ...After contact with medical equipment/supplies in patient areas"..." All staff will use hand-hygiene techniques ... after removing gloves ... keep nails short (1/4 inch in length). No artificial nails or extenders in high-risk areas, i.e. OR, ICU."

2. On 4/28/2015 at 9:40, Surveyor #6 observed an anesthesiologist (Staff Member #3) place a breathing device into the mouth of a surgery patient. S/he then removed his/her gloves and donned another pair of gloves, and without performing hand hygiene, returned to patient care.

3. On 4/28/2015 at 9:45 AM Surveyor #6 observed a surgeon (Staff Member #4) assisting in the adjustment of position for a surgical patient. S/he then removed his/her gloves, and without performing hand hygiene, donned another pair of gloves and returned to patient care.

4. On 4/28/2015 at 1:15 PM, Surveyor #5 interviewed a critical care nurse (Staff Member #1) regarding patient care. During the interview, the surveyor noticed the nurse wearing artificial fingernails. On 4/29/2015 at 8:30 AM, the hospital's regulatory manager (Staff Member #2) confirmed this observation.



33900

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Item #4 -Employee Health

Based on record review and review of hospital policies and procedures, the hospital failed to ensure staff members remained compliant with its respiratory protection and tuberculosis control policies and procedures.

Failure to comply with policies and procedures related to tuberculosis control and respiratory protection puts staff members at risk of exposure to airborne infections.

Reference: 29 CFR 1910.134 - Occupational Health and Safety Standards - Personal Protective Equipment.

Findings:

1. The hospital's policy and procedure titled "Respiratory Protection Program" (Approved 2/9/2010) read in part: "Every employee considered for inclusion in the VGH Respiratory Protection Program must participate in a medical evaluation. A determination of the employees' ability to wear a respirator while performing assigned duties shall be made prior to being assigned tasks requiring respiratory protection."
The hospital's policy and procedure titled "Baseline and Follow-Up Testing for M. Tuberculosis Infection" (Approved 3/25/2014) read in part: "Baseline testing for M. tuberculosis infection is recommended for all newly hired healthcare workers (HCWs), regardless of the risk classification of the healthcare setting and can be conducted with the TST (Tuberculin Skin Test) or BAMT. . .If either the baseline first-step TST result is positive or the first-step TST result is negative, but the second-step TST result is positive: TB disease should be excluded, and if it is excluded, then the healthcare worker should be evaluated for treatment of LTBI."

2. On 4/29/2015 at 2:30 PM, during a review of Human Resource records, Surveyor #2 identified 3 of 11 clinical staff members who did not have a fit test evaluation required for wearing an N95 respiratory mask.

3. On 4/29/2015 at 2:30 PM, during a review of Human Resource records, Surveyor #2 identified 1 of 11 hospital staff members who did not complete the hospital's TB testing procedure. The staff member's record indicated a positive TST with no evidence of follow-up evaluation to rule out a tuberculosis infection.


35197

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Item #5- Isolation Procedures

Based on observation and document review, the hospital failed to ensure infection control practices are implemented.

Failure to implement infection control practices puts patients and staff at risk for the transmission of communicable diseases.

Reference: Center for Disease Control, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007.

Findings:

1. The hospital's policy titled "Precaution Strategies: Standard, Contact, Droplet, Airborne, and Protective" (no review date) read in part: "B. Contact & Contact-Enteric Precautions...Obtain precaution cart of supplies from Central Supply. Post sign and document precautions...".

2. On 4/29/2015 at 8:47 AM, Surveyor #3 observed a registered nurse (Staff Member #15) give insulin to a patient in contact isolation. There was no sign posted at the patient's room to indicate the patient was in contact isolation during the observation.

Item #6- Cross Contamination

Based on observation, hospital staff failed to maintain patient care items in a manner to prevent cross-contamination from other items in the patient care area.

Failure to prevent cross-contamination of clean and dirty items puts patients at risk from infectious diseases.

1. Hopper, WR, MD, FAAOS and Moss, R, RN, MN, CNOR. "Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications". AORN J 91 (March 2010) 350-364, Page 354 read in part: "All items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain both their sterility and integrity."

The hospital's policy and procedure titled "Point of Care Glucose Monitoring Using the Precision XCeed Pro Glucose Monitor" (Approved 3/17/2015) read in part "Cleaning the exterior surface: monitors should be wiped down with Cavi-wipes between patients and at the end of testing."


2. On 4/28/2015 at 9:20 AM, Surveyor #6 observed the Circulating Registered Nurse (RN) (Staff Member #5) pass a medication to the Surgical Technologist (ST) (Staff Member #6) working in the sterile field. The RN picked up a non-sterile can opener and used it to remove the top of the medication vial, before pouring it into a sterile basin on the field.

4. On 4/28/2015 at 11:00 AM, Surveyor #4 observed a Registered Nurse (Staff Member #16) perform point of care testing for blood glucose on a patient in room 120. Following the test, the registered nurse used two alcohol pads to clean the exterior of the monitor instead of the hospital-approved disinfectant wipe as required by policy.

5. On 4/29/2015 at 9:30 AM, Surveyor #6 observed a registered nurse (RN) in the Infusion Area (Staff Member #7) use the top of a potentially contaminated soiled linen hamper as a work surface for performing documentation tasks in a patient record. The RN stated that this was not a best practice.



















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