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.

ASTRIA REGIONAL MEDICAL CENTER 110 SOUTH NINTH AVE YAKIMA, WA 98902 Oct. 13, 2016
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
.
Based on observation and review of hospital policy and procedures, hospital staff members failed to remove outdated patient care supplies from active storage areas.

Failure to remove outdated patient care supplies could lead to infection from compromised packaging or reduced efficacy of expired products.

Findings:

1. The hospital policy titled,"Infection Control Same Day Surgery/Operating Room/Post Anesthesia Care Unit "(Policy #IC-0001.2.1; Revised 4/13) stated in part, "H. Shelf Life. . . 4. . . .The expiration dates and sterility guarantee on products purchased sterile from outside manufacturers will be honored according to packaging instructions."
.
2. On 10/11/2016 at 10:15 AM, Surveyor #2 toured operating room suite #4 and the endoscopy suite. In suite #4, two packages of rosebud Wisksorb dressings had an expiration date of 8/2016 and 7 culture tubes had an expiration date of 7/2015. In the endoscopy suite, the surveyor observed 2 vials of Octylbond glue (glue used to bond wounds) with expiration dates of 9/2015 and 9/2014. Additionally, in the respiratory therapy cart located in the endoscopy suite , Surveyor #2 found 3 outdated nasopharyngeal airways with expiration dates of: 7/2015, 8/2016 and 9/2016.
.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
.
Based on observation and review of hospital policy and procedures, hospital staff failed to wear surgical attire in a manner that covered all head hair.
.
Failure to wear surgical caps in a manner that covers all head hair can lead to contamination of the sterile field.
.
Findings:
.
1. The hospital's policy titled, "Attire in the Operating Room (Policy# OR-701-002; Reviewed 01/14) stated in part, " . . . All head and facial hair is to be covered while in the restricted areas of the surgical suite."
.
2. On 10/12/2016 at 9:15 AM, Surveyor #2 observed a surgical procedure performed on Patient #1. Surveyor #2 noted the surgeon (Staff Member #1), a surgical technician (Staff Member #2) and the circulating nurse (Staff Member #3) wore surgical caps that did not completely contain their hair.
.
VIOLATION: INFECTION CONTROL Tag No: A0747
.
Based on observation, interview, and document review, the hospital failed to develop and implement an effective infection prevention and control program.

Failure to develop and implement an effective infection prevention and control program puts patients, staff and visitors at risk of illness from communicable diseases.

Findings:

Failure to ensure staff members' compliance with hand hygiene policies

Failure to maintain compliance with manufacturer's instructions for reprocessing semi-critical devices

Failure to follow hospital policy for use of personal protective equipment when assisting patients in isolation.

Failure to maintain hospital ice and water dispensers according to the manufacturer's instructions for use to ensure a sanitary product.

Due to the scope and severity of deficiencies cited under 42 CFR 482.42, the Condition of Participation for Infection Control was NOT MET.
.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
.
Item #1- Reprocessing of Duodenoscopes

Based on observation, interview and document review, hospital staff members failed to follow the manufacturer's instructions for use when reprocessing duodenoscopes.

Failure to follow the manufacturer's instructions for reprocessing duodenoscopes puts patients at risk of illness from inadequately cleaned and disinfected semi-critical devices.

Findings:

1. The Manufacturer's document for the reprocessing of the Olympus EVIS EXERA II TJF Type Q180V Endoscope (last revision date: March 2015) contained the following warning under Chapter 5: Reprocessing the Endoscope (and related reprocessing accessories),"The TJF-Q180V endoscope has a forceps elevator. The surface and surrounding area of the forceps elevator, such as the groove, guidewire locking groove, and forceps elevator recess, have a complex shape. Reprocess these parts carefully following the procedure described in Chapter 5.
Insufficient reprocessing may pose an infection control risk to patient and/or operators."

2. On 8/1/2016, an Olympus Endoscopy Support Technician conducted an in-service/competency evaluation of "On Track Reprocessing" of the TJFQ180V Endosocope for hospital staff members. Page 11, under the heading "Manual Cleaning", Steps 25 through 27 of the competency task list indicated that all staff members had successfully demonstrated the use of a 30 cubic centimeter(cc) syringe in the flushing of the interior of the forceps elevator, and that staff had repeated the steps as indicated in Step 28. Three central sterile staff members (Staff Members #6, #7, and #8) and the hospital infection preventionist (Staff Member #9) had attendance signatures on the competency document.

3. On 10/11/2016 at 2:00 PM, Surveyor #1 observed Staff Member #6 as s/he performed the reprocessing of a duodenoscope. During the course of the observation, the surveyor noted that at no point in the procedure, did the staff member employ a 30 cc syringe to perform the flushing of the recessed forceps elevator. When the surveyor asked the staff member about the need to use a syringe to flush the elevator forceps, the staff member indicated that s/he used the "scope buddy" (an electric endoscope flushing device) to flush the forceps elevator forceps.

4. On 10/12/2016 at 10:36 AM, Surveyor #1 called the Olympus Technical Assistance line and spoke with a member of the Olympus technical support team (Staff Member #10). The staff member indicated that the reprocessing instructions as written in the Olympus document was the only validated method for cleaning the Model TJFQ180V as approved by the U.S. Food and Drug Administration.



Item #2- Use of Personal Protective Equipment

.
Based on observation and document review, hospital staff failed to maintain compliance with national guidelines for use of personal protective equipment (PPE) when assisting patients in isolation.

Failure to comply with national guidelines for staff use of PPE when assisting patients in isolation puts staff, visitors and patients at risk from communicable diseases.

Reference: CDC. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. III B1. Contact Precautions.

Findings:

1. The hospital approved signs posted on the outside of patient room 423, indicated the patient was in both Droplet and Contact Enteric Isolation (WA State Hospital Association standardized sign). The signage for Contact Enteric isolation indicated that visitors and staff should don gown and gloves prior to entering the patient's room.

2. On 10/11/2016 at 9:45 AM, Surveyor #1 observed a registered nurse (Staff Member #4) as s/he exited room 423, where s/he attended to a patient that was in both Droplet and Contact Enteric isolation. The surveyor observed that the nurse had donned both gloves and a mask, but failed to don a gown prior to providing care to the patient.



Item #3- Maintaining Ice and Water Dispensing Machines


Based on interview and document review, the hospital failed to maintain compliance with the manufacturer's instructions for routine maintenance of ice and water dispensing machines.

Failure to maintain ice and water dispensing machines puts patients, staff and visitors at risk of illness due to machine contamination.

Findings:

1. The manufacturer's instructions for the Follett Symphony Plus 25 & 50 Series ice and water dispenser stated under the section "Preventive Maintenance", "Periodic cleaning of Follett's icemaker system is required to ensure peak performance and delivery of clean sanitiary ice" The instructions indicated that the condenser required monthly cleaning and the evaporator required semi-annual cleaning.

2. On 10/12/2016 at 11:30 AM, Surveyor #1 reviewed the hospital's "Ice Machine Repair Log". The log contained no entries after 04/15/2015.

3. At the time of the log review, the surveyor interviewed the interim facilities supervisor (Staff Member #5) who confirmed that ice machines only received maintenance/repair when staff members called in to report a problem, and they were not currently maintained on a schedule as required by the manufacturer.


Item #4- Hand Hygiene

Based on observation and review of hospital policy and procedure, the hospital failed to ensure that staff members performed hand hygiene after contact with potentially contaminated items in the patient care area.
.
Failure to perform hand hygiene after potential contamination can lead to the spread of harmful microorganisms to patients and staff.
.
Findings:
.
1. The hospital ' s policy titled,"Hand Hygiene" (Policy # HMA-IC-0003.3; Revised 2/14) stated," . . . Healthcare workers shall wash their hands with soap and water or an alcohol based hand rub when hands are not visibly soiled as follows: . . .After contact with a source this is likely contaminated with microorganisms, . . .After touching objects in the patient's immediate area, (i.e., any environmental surfaces). . . "

2. On 10/12/2016 at 9:30 AM, Surveyor #2 observed a circulating nurse (Staff Member #3) pick up an item of paper waste from the operating room floor without performing hand hygiene. The same staff member answered the operating room phone and did not perform hand hygiene after touching the receiver.
.