The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SKAGIT VALLEY HOSPITAL 1415 KINCAID STREET MOUNT VERNON, WA 98274 July 23, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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ITEM #1 - HAND HYGIENE (HH)

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff members performed hand hygiene according to hospital's policy and accepted standards of care.

Failure to perform effective hand hygiene puts patients at risk for infections.

Findings:

1. Facility policy titled "Hand Hygiene" revised 12/10/2012 read in part: "All staff are required to wash or sanitize their hands before and after patient contact, performing patient related procedures, and at other appropriate times, such as: 4.a. Before direct contact with patients; d. After contact with a patient's intact skin... g. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; h. After removing gloves..."

Facility policy titled "Infection Prevention and Practices: Surgical Services" revised 3/27/2015 stated in part: "8. OR scrub personnel will complete the appropriate hand scrub/wash prior to each surgical procedure: e. Alcohol based product may be used after the first surgical scrub of the day per manufacturer recommendations. f. Allow hands and forearms to dry thoroughly before donning sterile gloves."

Manufacturer's instructions for use of the product used in the facility, Surgicept, dated 2011, stated in part: "Rub hands until dry. Allow to dry before donning gloves."

2. The following observatons were made during the course of the survey:


a. While observing a medication administration episode on 7/21/2015 between 9:45 - 10:10 AM Surveyor #3 observed a Registered Nurse (Staff Member #8) remove gloves that were used during patient contact, and not perform HH afterwards.

b. While observing a medication administration episode on 7/21/2015 between 10:30 - 10:45 AM Surveyor #3 observed a Registered Nurse (Staff Member #9) enter a patient room, and prepare and administer medications without first performing hand hygiene.

3. While observing preparations for a surgical procedure on 7/22/2015 between 9:30 AM - 12:00 PM Surveyor #3 observed the following:

a. The Surgical Technician (Staff Member #10), who used surgical gel for the procedure, entered the room waving their hands to dry them, rather than rubbing thier hand until dry, per manufacturer's instructions.

b. The Circulating Nurse (Staff Member #11) picked up an item from the floor and did not perform HH prior to contacting the patient to attach the pulse oximeter or the cautery grounding pad.

c. The Surgeon (Staff Member #12) entered the operating room to assist in positioning the patient and equipment, but did not perform HH before donning gloves.

ITEM #2 - CROSS CONTAMINATION

Based on observation and interview the facility failed to prevent contamination of product before patient care.

Failure to follow manufacturer's instructions for use places patients at risk for nosocomial infections.

Findings:

1. Facility policy titled "Blood Glucose by Accu Chek Blood Meter", revised 8/11/2014, read in part: "12. ...obtain a sample - cleanse the patient's finger with an alcohol wipe and allow the finger surface to dry prior to using the lancet."

a. During observation of a medication administration episode for a patient who was in contact precaution isolation, on 7/21/2015 between 9:45 - 10:10 AM Surveyor #3 observed a Registered Nurse (Staff Member #8) reach under his/her protective gown with contaminated gloves to access items in the pocket of his/her clothing.

b. During observation of a medication administration episode on 7/21/2015 between 10:30 - 10:45 AM Surveyor #3 observed a Registered Nurse (Staff Member #9) drop an intravenous saline flush, and not discard it, but proceed to use it.

c. During observation of a blood sugar check on 7/21/2015 at 1:45 PM Surveyor #3 observed a Registered Nurse (Staff Member #13) perform the fingerstick without first disinfecting the finger.

d. During observation of preparation for a surgical procedure on 7/22/2015 between 9:30 AM - 12:00 PM Surveyor #3 observed the Anesthesiologist (Staff Member #14) examining the patient. S/he did not clean the stethoscope either before or after using it to examine the patient.

ITEM #3 - SURGICAL ATTIRE

Based on observation and review of policies and procedures, the hospital failed to ensure surgical staff properly followed the hospital's policy for surgical attire to prevent cross contamination of the sterile field or procedure site.

Failure to adhere to proper surgical attire practices puts patients at risk for cross contamination of surgical or procedural sites.

Findings:

1. Facility policy titled "Traffic Patterns in the OR" revised 10/21/2013 read in part: "3. The restricted area includes areas where operative and invasive procedures may be performed. Surgical attire and hair coverings are required."

2. While observing preparations for a surgical procedure on 7/22/2015 between 9:30 AM - 12:00 PM Surveyor #3 observed the Anesthesiologist (Staff Member #14) enter the operating room and perform patient care tasks without his/her hair being completely covered.




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ITEM #4 - VENTILATION

Based on observation, the hospital failed to ensure air pressure relationships are consistent with industry standards for ventilation.

Failure to ensure proper air pressure relationships puts patients, staff, and visitors of the facility at risk from infections and/or diseases.

Reference: 2010 Guidelines for Design and Construction of Health Care Facilities.

Findings:

1. On 7/21/2015 at 10:35 AM, Surveyor #1 used a lightweight paper strip to determine the airflow between the soiled utility room and the adjacent patient care corridor in the basement. The airflow was positive to the corridor rather than negative as required by industry standard. The environmental services manager (Staff Member #1) acknowledged this finding at the time of the observation.

2. On 7/21/2015 at 10:40 AM, Surveyor #1 used a lightweight paper strip to determine the airflow between the soiled linen room and the adjacent patient care corridor in the basement. The airflow was positive to the corridor rather than negative as required by industry standard. The environmental services manager acknowledged this finding at the time of the observation.

ITEM #5 - PERSONAL PROTECTIVE EQUIPMENT

Based on observation, interview, and document review, the hospital failed to implement policies and procedures designed to prevent exposure to infectious agents during the processing of medical equipment.

Failure to wear personal protective equipment during the processing of medical equipment puts patients and staff of the facility at risk from infections and/or diseases.

Findings:

1. The hospital's policy and procedure titled "Endoscopy Immersible Scopes, Cleaning, Maintenance and Storage" (Revised: 4/21/2015) read in part: "Equipment: 1. Cover Gown, 2. Gloves, 3. Shoe Covers, 4. Protective Eye-wear/Face Shield, 5. Mask".

2. On 7/22/2015 at 9:35 AM, Surveyor #1 observed an echocardiographer (Staff Member #2) cleaning a transesophageal echocardiography endoscope. During the cleaning process, the staff member did not wear a gown, protective eye-wear, or a face shield. The echocardiographer and the environmental services manager acknowledged this finding at the time of the observation.

Based on observation certain staff of the facility failed to properly put on or remove personal protective equipment.

Failure to put on or take off personal protective equipment per recommended practice puts patients, staff and visitors of the facility at risk of infection.

Reference: The Centers for Disease Control and Prevention bulletin titled "Example of Safe Donning and Removal of Personal Protective Equipment", dated 3/2010, stated in part: "GOWN: Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back."

Findings:

On 7/21/2015 between 9:45 - 10:45 AM Surveyor #3 observed two episodes of medication administration in rooms of patients who were in contact precaution isolation. During the observation, two Registered Nurses (Staff Members #8 and #9) donned gowns as part of their PPE. However, the gowns were too small to completely cover their clothing in the back, placing them at risk for contaminating their clothing.

ITEM #6 - MDRO PROCESS

Based on observation, interview, medical record review and review of hospital policies and procedures, the hospital failed to ensure that patient care staff members followed infection prevention procedures and provided a healthcare environment that minimizes the risk of transmission of infections and communicable diseases.

Failure to do so places the patients at risk for harm from infectious diseases, including extended hospital stays, increased healthcare costs, and death.

Findings:

1. The hospital's policy and procedure titled "Methicillin Resistant Staphylococcus Aureus (MRSA) (Revised 1/28/2015) read in part, "Patients with known history of MRSA colonization ... shall be placed in Contact Isolation precautions .....Document initiation and discontinuation of Contact Isolation."

2. On 7/17/2015 at 11:36 PM, Patient #1 was a [AGE] year old patient admitted with complaints of chest pain and has a history of recurrent angina, diabetes, and end stage renal disease. The hospital's infection prevention nurse (Staff Member #3) reported that the patient tested positive for MRSA colonization April of 2015.

3. On 7/22/2015 at 10:48 AM, Surveyor #2 started to walk into Patient #1's room when the following observations were made:

a. On 7/22/2015 at 11:09 AM in the Medical Unit, Surveyor #2 interviewed a registered nurse (Staff Member #4) assigned to care for Patient #1 who had the contact isolation cart at the door and isolation garments/supplies hung on the patient door. However, there was no "Contact Isolation" sign posted and supplies were turned away to prevent access.

Staff Member #4 communicated that s/he did not receive information/report of isolation details for patient #1. The nurse added that the patient was to be transferred to a skilled nursing facility later that day.

Upon review of the patient's chart, Staff Member #4 and Surveyor #2 found no order for initiation or discontinuation of isolation precautions. Staff Member #4 found an order in the patient's electronic record for MRSA testing dated 7/20/2015. The lab report stated, "Results pending" with completion due 7/23/2015.

Patient #1 reported to Surveyor #2 that s/he received dialysis in the afternoon of 7/21/2015 and patient care staff did not wear gowns or gloves.

The hospital's Quality Director (Staff Member #5) reported a positive result for MRSA for Patient #1 during this hospital visit.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
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Based on medical record review and review of hospital policies and procedures, the hospital failed to ensure staff members responsible for the hospitals discharge planning process, provided applicable patients with a list of Medicare-participating Home Health Agencies (HHA) or skilled nursing facilities (SNF) for whom their discharge plan indicated home health or post-hospital extended care services, in 4 of 5 records reviewed (Patients #2, #3, #4 and #5.)

Failure to provide patients with a Medicare-participating HHA or SNF provider list can lead to patients' limited choice of post-hospital providers and inappropriate post-hospital care.

Findings:

1. The hospital's policy and procedure entitled "Discharge Planning Assessment: Case Management" (ID # ) (Revised 5/5/2014) read in part as follows: "Case Management Discharge Responsibilities ...4. Provides a Medicare accredited list of facilities, or patient verbalizes choice, and then discusses the patient's choice for SNF, if recommended by Provider and/or therapies, with patient and/or next of kin, and facilitates contacting these facilities through the Utilization Management Specialist or Case Management Assistant."

2. Surveyor #4 reviewed patient records with the hospital's Director of Care Management (Staff Member #6); and the Social Worker Transitional Care Manager (Staff Member #7) of 5 patients that required post- hospital home health services or post hospital extended care services. Staff Member #9 could not provide evidence in the medical record for Patient's #2, #3, #4 or #5 that they received or were provided a list of Medicare-participating HHA or SNF as required.