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 Dec. 1, 2016
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
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Based on document review and interview, the hospital failed to follow its credentialing policy for privileging practitioners for 1 of 10 credentialing files reviewed.

Failure to have the governing body approve membership to the hospital's medical staff puts patients at risk of sub-standard care.

Findings:

1. On 11/29/2016 between 2:00 and 3:00 PM, Surveyor #1 reviewed credentialing files for 10 hospital practitioners. The credentialing file for the hospital's Director of Rehabilitation (Staff Member #22) showed no evidence that the governing body had reviewed the staff member's file for the purpose of granting current privileges. Governing body minutes from March 2016 indicated that the physician's re-appointment packet was not submitted for approval, but was to be submitted for the following meeting. There was no other documentation in subsequent meeting minutes to indicate the governing body reviewed and approved the physician's privileges.

2. During the review, the manager for Medical Staff Services (Staff Member #23) confirmed that the packet had been signed off by the Medical Executive Committee, but never forwarded to the governing board.

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VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
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Based on review of medical records, the hospital failed to include written copies of Patient's Advance Directives in patient records.
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Failure to include patient's Advance Directives may lead to poor patient care and failure to follow patient's wishes.
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Findings:
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1. On 11/20/2016 between 2:00 and 4:00 PM, Surveyor #2 reviewed medical records of former patients with a quality coordinator (Staff Member #5). The surveyor found no documentation to indicate that hospital staff had discussed advanced directives or offered information about advanced directives to 3 of 5 patients and/or their representatives (Patients #15, #16, #19). The staff member confirmed this finding at the time of the review.

2. On 12/1/2016 between 9:00 and 11:30 AM, Surveyor #4 reviewed medical records of former patients with a quality coordinator (Staff Member #5). The surveyor found no documentation to indicate that hospital staff had discussed advanced directives or offered information about advanced directives to 5 of 8 patients and/or their representatives (Patients #5, #6, #7, #8, and #9). The staff member confirmed this finding at the time of the review.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
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Based on review of medical records and interview, the hospital failed to ensure that a licensed provider wrote an order for restraints for a patient in the emergency department.

Failure of a provider to write an order for the use of restraints could lead to poor documentation and monitoring for patient's condition.
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Findings:
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1. The hospital policy and procedure titled, "Restraint and Seclusion" (Policy # ADMIN 039P; Effective 5/14) stated in part, "I. Documentation. Each episode of restraint is documented in the patient's medical record consistent with policies and procedures. . .v. Written orders for use."
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2. On 11/30/2016 between 2:00 and 4:00 PM, during medical record review of an emergency room visit for trauma and transfer to higher level of care for Patient #14 that occurred on 11/4/2016, Surveyor #2 observed that chart notes indicated that hospital staff placed the patient in soft restraints at 2032 (8: 32 PM). Further review of medical record revealed there was no written order documented by a provider for the placement of restraints.
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3. On 11/30/2016 at 3:30 PM, Surveyor #2 interviewed the emergency room manager (Staff Member #6) who noted that the trauma record documentation was considered the "orders" for action and care given during the visit. In discussion with Staff Member #6 and the Quality Manager (Staff Member #2) with Surveyor #2, it was acknowledged that there was not a written order signed by the provider in the record.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
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Based on observation and review of hospital policy and procedure, the hospital failed to ensure that two nurses completed narcotic counts at least once a day.
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Failure to ensure that hospital nurses complete regular narcotic counts could lead to opportunity for diversion activity, jeopardizing patient's health and safety.
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Findings:
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1. The hospital policy titled, " Controlled Substances: Floor Stock Accountability" (Policy # RX 15-05; Effective 01-2014) stated in part, "Policy 1.1 All controlled substances and drugs requiring additional inventory accountability . . .must be securely stored, inventoried, and properly wasted . . .accurately documented in compliance with federal and state laws as well as professional practice standards . . . Procedure . . . 2.2 If medications are provided in the patient care areas using an ADC (automatic dispensing cabinet), a single inventory may be made once daily with the change in shift."
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2. Per Pharmacy Hospital Standards, WAC 246.873.080 (7)(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."
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3. On 11/30/2016 at 9:45 AM, Surveyor #2 reviewed the Narcotic Count record on the Rehabilitation Unit. The record for November 2016 revealed that hospital staff failed to complete counts on 4 dates (11/3, 11/5, 11/20, 11/21). Surveyor #2 then requested the logs for narcotic counts for the months of September 2016 and October 2016. A Review of those monthly logs revealed hospital staff failed to complete counts in September on 4 dates (9/25, 9/27, 9/28, 9/29) and failed to complete counts in October on 3 dates (10/9, 10/28, 10/30).
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
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Based on observation, the hospital failed to maintain smooth, cleanable surfaces to ensure patient safety and well-being.

Failure to maintain cleanable surfaces placed patients, staff, and visitors at increased risk of exposure to pathogens.

Findings:

1. On 11/29/2016 at 10:00 AM, Surveyor #3 observed exposure to the wall cavity through an opening in the sheetrock under the counter in the Clean Utility Room of the 4th floor Acute Care Unit (ACU). The Director of Environmental Services (Staff Member #18), acknowledged that the cavity rendered the area un-cleanable. A maintenance worker (Staff Member #19) indicated the opening would be immediately patched and sealed.

2. On 11/29/2016 at 11:20 AM during a tour of the Linen and Laundry Operations, Surveyor #3 observed gouges in the sheetrock of a wall, approximately 10-inches above the floor. The Director of Environmental Services (Staff Member #18) acknowledged the gouged areas and indicated that s/he would request a work order.