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.

WESTERN STATE HOSPITAL 9601 STEILACOOM BLVD SW TACOMA, WA 98498 March 6, 2015
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation and interview, medications stored in the East Campus Medical Clinic were not secured.

Failure to secure medications, drugs and biologicals risks diversion, theft, and/or tampering, which endangers staff and patients.

Findings:

1. On 3/3/2015 at 12:00 PM, Surveyor #6 observed the following injectable medications located in an unsecured cabinet in the Orthopedics patient exam room:

a. Xylocaine 1% vial with epinephrine
b. Xylocaine 2% vial
c. Kenalog 40 milligrams per milliliter vial

2. On 3/5/2015 at 3:15 PM, Surveyor #6 entered the Medical Clinic with an escort. The entry doors to the outside hallway were unsecured to the content of the entire clinic, including the medications noted above. No staff members were present in the clinic. During that time period, the clinic space was accessible to inpatients with grounds passes and other staff members.

3. Surveyor #6 requested a policy and procedure regarding medication security, but the policy was not provided.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide evidence that staff monitored patients placed in seclusion or restraints according to hospital policy for 4 of 4 patients reviewed (Patient #1, #2, #3, and #4).

Failure to do so placed these patients at risk of injury or other decline in status.

Findings:

1. The hospital's policy and procedure entitled "Utilization of Seclusion/Restraint" (No policy number; Revised 1/2015) read in part : "Meet physical, emotional and safety needs of patient... Steps... B. Perform 15-minute assessments and observations of patient needs, care interventions and observed patient behavior(s). Monitor: a. For signs of injury. b. and support patient's nutrition and hydration. c. Circulation, range of motion, and skin integrity. d. Vital signs. e. and support hygiene and elimination. f. Physical, psychological, and comfort status. g. Readiness for release from seclusion/restraint."

2. On 3/5/2015 between 10:30 AM and 3:00 PM, review of the records of 4 patients who had been placed in seclusion or restraints during their hospital stay revealed the following:

a. Patient #1's records indicated s/he was placed in seclusion on 2/12/2015 at 3:25 PM. The monitoring flowsheet directed staff to initial each parameter at 15 minute intervals. There was no documentation in the patient record to indicate staff members completed patient monitoring as outlined in the hospital's policy.

b. Patient #2's records indicated s/he was placed in restraints on 12/15/2014 at 1:00 PM. The monitoring flowsheet directed staff to initial each parameter at 15 minute intervals. There was no documentation in the patient record to indicate staff members completed patient monitoring as outlined in the hospital's policy.

c. Patient #3's record indicated s/he was placed in restraints on 2/25/2015 at 4:30 PM. The monitoring flowsheet directed staff to initial each parameter at 15 minute intervals. There was no documentation in the patient record to indicate staff members completed patient monitoring as outlined in the hospital's policy.

d. Patient #4's record indicated s/he was placed in seclusion on 1/18/2015 at 3:25 PM. The monitoring flowsheet directed staff to initial each parameter at 15 minute intervals. There was no documentation in the patient record to indicate staff members completed patient monitoring as outlined in the hospital's policy.

3. The Director of the Psychiatric Treatment and Recovery Center(South/Center) (Staff Member #1) confirmed these observations at the time of the record reviews.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patients placed in seclusion or restraints received a face-to-face assessment within one hour by a physician, registered nurse, or physician assistant for 4 of 4 patients reviewed (Patient #1, #2, #3, and #4).

Failure to do so placed these patients at risk of injury or other decline in status.

Findings:

1. Review of the records of Patient #2 revealed the patient had been placed in restraints on 12/15/2014 at 1:00 PM. There was no documentation in the patient's record that a face-to-face assessment of the patient by a physician, registered nurse, or physician assistant within one hour as specified by regulation.

2. On 3/4/2015 at 1:30 PM, the Director of the Psychiatric Treatment and Recovery Center(South/Center) (Staff Member #1) confirmed this finding.
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VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on interview, the hospital failed to develop a process for evaluation of the quality of care provided by hospital patient care contractors.

Failure to determine whether patient care contractors meet all Medicare Conditions of Participation and standards risks provision of ineffective and unsafe healthcare to patients.

Findings:

During an interview with Surveyor #5 on 3/4/2015 at 9:00 AM, the hospital's Director of Quality (Staff Member #27) stated that patient care contacts and contractors are managed through Consolidated Business Services, Incorporated, a Washington State government-controlled entity.

During an interview with Surveyor #5 on 3/6/2015 at 9:00 AM, the hospital's Chief Executive Officer (Staff Member #28) stated that there is no process for evaluation of patient care contractor performance through the hospital's quality program.

Cross Reference: Tag A308
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VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide evidence that the patient or the patient's representative were informed of their legal rights for 3 of 9 patients reviewed (Patients #6, #8, and #9).

Failure to do so prevents the patient from being able to exercise those rights.

Findings:

1. The hospital's policies and procedures entitled "Admission Assessment Process" (No policy number; Revised 8/2013) and "Involuntary Patient Rights" (Policy #WSH 1-29; Revised 7/2001) instructed nursing staff members to inform patients of their rights verbally and in writing at the time of admission.

2. During an interview with Surveyor #8 on 3/5/2015 at 3:30 PM, the Director of the Psychiatric Treatment and Recovery Center (South/Center) (Staff Member #1) confirmed that all patients admitted to the hospital are "involuntary" patients, and that the "Involuntary Patient Rights" policy applies to all patients. The director stated that documentation of presenting rights to patients would be found in the admission progress note.

3. During the review of medical records for Patients #6, #8, and #9, Surveyor #8 found no documentation in the record to indicate that patients had been informed of their rights.
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VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on observation, the hospital failed to maintain evidence of competencies in the dietary department for 5 of 12 staff members reviewed (Staff Members #13, #14, #18, #19, #20)

Failure to maintain food handler certification places patient at an increase risk of a contracting a foodborne illness.

Findings:

1. On 3/3/2015 at 10:00 AM, Surveyor #3 found 2 out of 4 staff members had expired food handler cards on the Habilitative Mental Health unit (Staff Members #13; #14).

2. On 3/4/2015 at 3:00 PM, Surveyor #1 found 2 out of 5 staff members had expired food handler cards on the E7 unit (Staff Members #18; #19).

3. On 3/6/2015 at 10:00 AM, Surveyor #1 found 1 out of 3 staff members had expired food handler cards on the S3 unit (Staff Member #20).
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VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on interview, record review, and review of policies and procedures, the hospital failed to follow its policy regarding documentation of patient advance directives in the medical record for 7 of 7 patient records reviewed (Patients #10, #11, #12, #13, #14, #15, #16).

Failure to obtain direction for life-sustaining treatment could result in resuscitating a patient and/or prolonging the patient's life against the patient's wishes.

Findings:

1. The hospital's policy and procedure entitled "Do Not Resuscitate (DNR) Order" (Revised 6/2012) read in part: "The need for DNR status will be established upon admission, reviewed, and reordered at least annually, or when the patient's clinical status warrants, or the patient's or surrogate's desires related to life sustaining treatments change... The POLST (Physician Orders for Life Sustaining Treatment) form must be reviewed and re-signed at least annually or whenever requested by the patient, surrogate decision maker; or when there is a significant change in the patient's physical status ... Physician documentation will include the DNR order, progress note indicating rationale, DNR discussion with the patient's family or surrogate, and discussion with other treatment team members and consultation with the Bioethics Subcommittee if initiated."

2. On 3/3/2015 and 3/4/2015, Surveyor #2 inspected the emergency equipment carts and DNR patient lists located on those carts in the Center for Forensic Services. A subsequent review of patients on that list revealed the following omissions in the patient's medical record:

a. The records of Patient #10 did not have a written DNR order, and the accompanying POLST form was last signed on 1/14/2013.

b. The records of Patients #11, #12, and #13 did not have a written DNR order.

3. On 3/3/2015 at 10:00 AM following the record review, Surveyor #2 interviewed Staff Member #9, who confirmed the absence of a written DNR physician order in the above records.

4. Surveyor #2 identified similar findings in the medical records of Patients #14, #15, and #16.
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VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on review of facility documents, the hospital failed to ensure that patients were notified of their right to have a family member or representative and the patient's physician promptly notified of the patient's admission to the hospital.

Failure to do so risks patient harm by neglect of social, psychological or physical needs.

Findings:

1. On 3/5/2015 at 3:30 PM, Surveyor #8 requested a copy of the patient rights given to patients on admission. This was supplied in the form of the "Patient Handbook Western State Hospital" (Dated 10/2014) by the Director of the Psychiatric Treatment and Recovery Center (South/Center) (Staff Member #1). The handbook listed the "Basic Rights" of a patient admitted to the facility.

2. This document did not list the right to have the patient's family or representative and personal physician promptly notified of the patient's admission. This was acknowledged by Staff Member #1 at the time of the review.
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VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, and document review, it was determined that the hospital failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body.

Failure to meet minimum physical environment and quality program requirements resulted in an unsafe healthcare environment.

Findings:

Due to the scope and severity of deficiencies detailed under 42 CFR 482.21 Condition of Participation for Physical Plant and Environment; and under 42 CFR 482.41 Condition of Participation for Quality Assessment and Performance Improvement, the Condition of Participation for Governing Body was NOT MET.

Cross-Reference: Tags A263; A700
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Based on interview, document review and medical record review, it was determined that the hospital failed to meet the Condition of Participation for Governing Body. The Governing Body failed to implement systems and processes to address patient safety while waiting for the ability to transfer a forensics patient to the forensics unit. Refer to Tag # 0115.

Findings include:
Western State leadership to include the Nurse Executive and Medical Director were immediately aware of the incident between two patients and three employees that resulted in injuries on November 25, 2014. The facility policy on Administrative Incident Reporting states "the supervisor will initiate appropriate actions to ensure the immediate health and safety of the persons involved". At the time of this investigation, no internal investigation of the events leading up to the incident, the incident or post incident activities was performed. This was confirmed by the Nurse Executive and South Building Manager on December 16, 2014.

Western State leadership was aware that Patient #2 no longer met the criteria for the placement on the current assigned ward and that the recommendation was to transfer Patient #2 to the forensic unit. Employees working and assigned to the forensic unit require specialized training to provide safe and effective care to that patient population. Based on all interviews conducted on December 16 and 18, 2014, as well as chart review, Patient #2 was not placed on direct observation, staffing assignments were not adjusted and the facility did not provide staff with specialized training to care for a patient meeting forensic unit criteria.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview, review of hospital policies and procedures, and review of hospital personnel files, the hospital failed to ensure that staff received ongoing training that included competencies involving the use of physical restraints, as demonstrated by 2 of 6 licensed nursing personnel reviewed (Staff Members #13, #14).

Failure to receive periodic education and training on the use of physical restraints puts patients at risk for loss of freedom, privacy, and dignity as well as physical harm from improper or incorrect use of restraints.

Findings:

1. The hospital's policy and procedure entitled "Competency Assessment of Nursing Personnel" (Revised 1/2012) under "annual update "read in part: "Supervisor and employee must demonstrate that competency is assessed biennially or as required when there are significant changes in responsibilities (i.e., transfer, promotion, newly assigned duties)." The policy included a nursing competency verification checklist that was to be completed to verify the nurse's competence in application of restraints.

2. On 3/6/2015, Surveyor #2 reviewed the human resource files of six licensed nursing personnel. Staff Members #13 and #14 did not have documentation to indicate completion of the nursing competency verification checklist within the past twelve months as required by policy.

3. On 3/6/2015 at 11:00 AM, during an interview with Surveyor #2, an RN4 Nurse Manager at the Center for Forensic Services (Staff Member #15) confirmed the above findings.
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VIOLATION: QAPI Tag No: A0263
Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop a hospital-wide quality assessment and performance improvement (QAPI) plan to monitor, evaluate, and improve the quality of patient care services through systematic data collection and analysis.

Failure to systematically collect and analyze hospital-wide performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. The hospital failed to develop, implement, and maintain a hospital-wide, integrated QAPI program that included evaluation of patient care contractors.

Cross Reference: Tags A283, A308, A309, A398

2. The hospital failed to develop and implement an effective QAPI program that included the following:

a. Systems for ensuring the patient care environment is free from safety hazards, including plans for implementing a fire watch due to impaired fire suppression systems; and installation of tamper-resistant electrical receptacles in patient care areas;

b. Systems for ensuring that patient care supplies were within the manufacturer's expiration dates; and

c. Systems for minimizing infection risks.

Cross Reference: Tag A700, A701, A710 (Fire/Life Safety Statement of Deficiencies), A724, and A749.

Due to the scope and severity of deficiencies detailed under 42 CFR 482.41, Condition of Participation for Physical Plant and Environment; and for other condition-level deficiencies under 42 CFR 482.21, the Condition of Participation at 42 CFR 482.21, Quality Assurance and Performance Improvement, was NOT MET.
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VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop and implement action plans to improve hospital performance related to discharge planning

Failure to develop, implement, and monitor action plans for improving hospital performance reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. During an interview with Surveyor #5 on 3/4/2015 at 9:00 AM, the hospital's Director of Quality (Staff Member #27) revealed that the hospital's Quality Council monitored eight major clinical indicators. Review of the most current data for two sub-indicators that measured the completion and transmission of the patient's plan for care to the receiving facility after discharge revealed that the hospital had not met its goal for these indicators from the third quarter of 2012 through second quarter 2014.

2. The interview and subsequent quality documentation review revealed the hospital had not developed a written plan for improvement that included action items, timelines for implementation, and identification of individuals responsible for plan implementation.
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VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on interview and review of the medical staff bylaws, the hospital failed to designate a medical staff member as "Medical Director" as directed by hospital policy.

Failure to designate a physician as " Medical Director " risks a disorganized medical staff and uncoordinated medical care for patients.

Findings:

1. In review of facility document titled, "Western State Hospital Medical Staff Bylaws 2014" on page 7 it described the Medical Director responsibilities once appointed by the "CEO" with the approval of the "Governing Body" to assist in the "discharge of duties and responsibilities" related clinical and professional services of the Hospital and to serve "... at meetings of the Medical Staff and Medical Staff Executive Committee". The facility patient capacity at that time was for provision of medical service to 827 inpatients.

The bylaws further defined Medical Director responsibilities in the following areas: physician
"Temporary Privileges" (page 35); interface with the "Chief of Medical Staff" ... in "all matters concerning the medical care within the Hospital" (page 39); as a member of the Medical Staff Executive Committee (page 47) and the "Utilization Management Committee" (page 51); medical staff "Summary Suspension" of membership and clinical privileges (page 60-61); "Physician Health" (page 73); "Rules and Regulations Related to Clinical Care" (page 81) and "Rules and Regulations Related to the Medical Record" (page 82-83).

2. On 3/5/2015 at 2:00 PM Surveyor #6 interviewed the hospital's Supervising Physician for Medical Services (Staff Member #34). The physician stated that both s/he and the Supervising Psychiatrist reported to the hospital's Medical Director, but that there had been no one serving in that capacity since 2/27/2015. Staff Member #34 denied knowledge of interim coverage plans before or during the vacancy period.

3. In review of the attendance sheets for the month of February 2015 of the weekly Transfer Committee Meeting, Surveyor #6 noted that there was no record of physician attendance among the expected group attendees.

4. On 3/6/2015 at 10:30 AM, Surveyor #6 interviewed the Assistant Nurse Executive (Staff Member #43). The nurse indicated that the previous Medical Director represented the facility physicians at the weekly Transfer Committee Meeting. The purpose of the meeting was to prioritize patient placement relative to admissions, transfers and discharges. Planning for transfers focused on the need to re-locate patients to other patient care units (under a different team of care providers) for disruptive and dangerous behavioral issues, including assaults to other patients (and staff members).
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VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop a hospital-wide plan to monitor, evaluate, and improve the quality of patient care services through routine data collection and analysis.

Failure to monitor quality of care and the care environment in all hospital services and departments limited the hospital's ability to identify problems and formulate action plans. This reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. During the survey, Surveyor #5 interviewed the hospital's Director of Quality Management (Staff Member #27) and the lead worker in the Clinical Risk Management department (Staff Member #29). The surveyor also reviewed the hospital's medical staff bylaws and portions of the 2014-2015 meeting minutes for the Quality Council, Medical Staff Executive Committee, Governing Body Committee, and Patient Care Committee. The interviews and document review revealed the following:

a. The medical staff bylaws and Medical Executive Committee meeting minutes indicated that data related to medication errors, mortality and morbidity, hospital-associated infections, and other clinical care performance data (i.e. laboratory and radiology data) were reported to hospital's Medical Executive Committee and Patient Care Committee. Data regarding these topics were monitored and analyzed by individual subcommittees and departments who developed quality improvement action plans.

Review of Quality Council meeting minutes and an interview with the hospital's Director of Quality Management (Staff Member #27) on 3/5/2015 at 9:00 AM revealed that these data and action plans were not reported to the hospital's quality management department, Quality Council, Executive Leadership Team, or Governing Body.

b. Review of the Quality Council meeting minutes and interview revealed that raw data related to hospital associated infections were reported to but not analyzed by the Quality Council. An interview with the hospital's Director of Quality Management (Staff Member #27) on 3/5/2015 at 9:00 AM revealed that analysis and action was performed by the infection control unit and reported to the Patient Care Committee.

c. An interview with the lead worker in the Clinical Risk Management department (Staff Member #29) on 3/5/2015 at 10:00 AM and review of quality documentation revealed that events reported through the hospital's Administrative Incident Reporting System (AROI), including injuries due to patient to patient assaults and patient to staff assaults that did not result in workers compensation claims, were counted and analyzed individually. Numbers of assaults were graphed and trended but not systematically analyzed by the hospital's quality program to determine patterns and contributing factors, such as patient assaults related to improper patient transfers to other wards and staffing variances.

d. During an interview with Surveyor #5 on 3/4/2015 at 9:00 AM, the hospital's Director of Quality (Staff Member #27) stated that Patient care contractors are managed through Consolidated Business Services, Incorporated, a Washington State-controlled entity.

During an interview with Surveyor #5 on 3/6/2015 at 9:00 AM, the hospital's Chief Executive Officer (Staff Member #28) stated that there is no process for evaluation of patient care contractor performance through the hospital's quality program.

Cross Reference: Tag A083

2. Other observations and interviews during the survey confirmed that the hospital did not monitor the quality of all hospital services. This was demonstrated by findings of an unsafe and unsanitary patient care environment.

Cross Reference: A701, A710, A724, and A749.
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VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and review of the hospital's quality plan, the hospital failed to develop, implement, and maintain a quality assessment and performance improvement (QAPI) plan that reflected current hospital practice, and to revise the plan as needed.

Failure to develop, implement, and maintain a QAPI plan limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. On 3/3/2015 at 8:30 AM, Surveyor #5 requested a copy of the hospital's quality plan. Review of this plan revealed the following:

The plan stated that the "Clinical Services Coordination Committee" reviewed clinical reports from all areas of the hospital, determined appropriate recommendations, and provided feedback and monitoring where indicated.

2. During an interview with Surveyor #5 on 3/6/2015 at 9:00 AM, the hospital's CEO (Staff Member #28) and quality director (Staff Member #27) revealed that this committee no longer exists. The WSH Committee Structure algorithm in the 2013-2015 quality plan did not reflect a current reporting structure. The interview revealed that the the quality plan that was presented as "current" was obsolete.

3. Further review of the hospital's quality program revealed that the hospital had no systematic reporting structure to convey information regarding hospital-wide quality measures and action plans to the quality management department, Quality Council, Executive Leadership Team, and Governing Body.
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VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on interview and document review, the hospital failed to demonstrate that the clinical performance of non-employee nursing staff was evaluated by nursing services.

Failure to evaluate the performance of non-employee nursing staff risks provision of ineffective and unsafe healthcare to patients.

Findings:

1. On 3/3/2015 at 9:45 AM Surveyor #6 interviewed Staff Member #32 who worked as a scheduling coordinator for the Staffing Office. S/he was responsible for scheduling temporary vacancies with coverage by non-permanent ("on-call") staff throughout the facility. The total number of non-permanent staff members was greater than 80 persons. Staff member types included, but were not limited to, Registered Nurse, Licensed Practical Nurse, Mental Health Technicians and Psychiatric Security Attendants. The latter two staff member types were required per job description to be certified and/or registered nursing assistants. When asked if there was an evaluation process for on-call staff members, s/he stated that there was not a process.

2. On 3/5/2015 at 12:00 PM the nurse manager of the nurse staffing pool (Staff Member #33) verified this finding.
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VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and review of policies and procedures, the hospital failed to ensure facility staff completed the patient's treatment plan according to policy, as demonstrated by 2 of 8 patients reviewed (Patients #17, #18).

Failure to complete the treatment plan places patients at risk for delayed treatment and services.

Findings:

1. The hospital's policy and procedure titled "Medical Records Procedures - Ward Monthly Assessment (WSH 23-16)" (Revised 5/2013) read "Upon admission, the following treatment plans are due: Diagnostic Plans for Forensic Eval due within 7 calendar days. . . Transfer Review within 2 weeks of transfer to another ward."

2. On 3/3/2015 at 10:30 AM in clinical unit F-1, an open medical record review revealed Patient #17 was transferred to clinical unit F-1 on 12/30/2014. The record indicated that the patient's treatment plan was developed and placed into the patient's medical record on 1/21/2015, 21 days after transfer.

3. On 3/3/2015 at 1:00 PM in clinical unit F-6, an open medical record review revealed Patient #18 was transferred to clinical unit F-6 on 2/11/2015. The record indicated that the patient's treatment plan was developed and placed into the patient's medical record on 2/27/2015, 16 days after transfer.
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VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, interview, and review of medication storage area temperature logs, the hospital failed to maintain drug storage areas within an acceptable temperature range.

Failure to maintain medications under proper conditions of sanitation, temperature, light, moisture, and ventilation puts patients at risk for receiving medications with compromised sterility, integrity, or stability.

Findings:

1. The hospital's policy and procedure titled "Monthly Medication Room Inspections" (Revised 1/2015) read in part: "Standards for Drug Depot and Medication Areas: Criteria and standards for all drug depot and medication areas are listed on the ward inspection record form and in MP 80:11." The medication area inspection record lists: "1b. Logs maintained and within appropriate temperature range ... Yes (or) No."

2. On 3/3/2015 during an inspection of the WN1 medication room Surveyor #5 reviewed the "Medication Storage Area Temperature Log" and found the readings in the storage area had exceeded the maximum allowable temperature of 79 degrees Fahrenheit (F) for 69 out of the previous 72 days.

3. On 3/5/2015 at 10:00 AM, Surveyor #2 interviewed the Assistant Director of Pharmacy (Staff Member #7) who confirmed a room temperature of 80 degrees F or greater may affect a medication's stability. A follow-up interview with the pharmacy service office assistant (Staff Member #8) confirmed that changes made to the temperature log form on 12/19/2014 reflected a lower temperature range of 68 to 79 degrees F. The temperature log form posted in the WN1 medication room was outdated.
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VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to provide a safe and secure environment for patients.

Failure to maintain a safe and secure environment risked serious injury or death for patients, staff, and visitors in the hospital.

Findings:

Western State Hospital cares for patients with

The hospital failed to maintain a safe and secure patient care environment that included the following:

1. Systems for ensuring the patient care environment is free from safety hazards, including plans for implementing a fire watch due to impaired fire suppression systems; and installation of tamper-resistant electrical receptacles in patient care areas;

2. Systems for ensuring that patient care supplies were within the manufacturer's expiration dates; and

3. Systems for minimizing infection risks.

Cross Reference: Tag A700, A701, A710 (Fire/Life Safety Statement of Deficiencies), A724, and A749.

Due to the scope and severity of deficiencies identified during the survey, the Condition of Participation for Physical Plant and Environment was NOT MET.
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VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, interview, and record review, the hospital failed to provide an environment that was conducive to the safety of its psychiatric patient population.

Failure to provide a safe environment placed patients at risk of harm to self and or others in the facility.

Findings:

ITEM #1 - ELECTRICAL SAFETY

Reference: National Association of Psychiatric Health Systems, "Design Guide for the Built Environment of Behavioral Health Facilities", edition 6.2, April, 2014.
Under "Construction and Materials Considerations", Level 4a. Patient Rooms (page 37):

"It is strongly recommended that all electrical outlets inpatient rooms and patient toilet rooms be hospital grade, tamper-resistant type. It is also preferred that they be GFCI receptacles to greatly reduce the risk of patients being able to harm themselves by tampering with the receptacles."

Findings:

1. During the survey, Surveyors #1 and #4 observed the following:

a. On 3/5/2015 at 11:25 AM, Surveyor #1 noted that patient sleeping room #139 on Unit E3 lacked a tamper resistant electrical receptacle to prevent electrical shock to the patient and to prevent fires to the facility.

b. On 3/5/2015 at 9:35 AM, Surveyor #4 noted that in room 19 on Unit F3 a power tap was plugged into the wall receptacle. This arrangement eliminates tamper resistance of the electrical circuit thereby allowing for both an electrical and fire risk.

c. On 3/5/2015 at 10:05 AM, Surveyor #4 noted that room 6 on Unit F3 lacked a tamper resistant electrical receptacle.

d. On 3/5/2015 at 10:30 AM, Surveyor #4 noted that in room 22 on Unit F7 a power tap was plugged into a tamper resistant electrical receptacle. This arrangement eliminates tamper resistance of the electrical circuit thereby allowing for both an electrical and fire risk.

e. On 3/5/2015 at 10:40 AM, Surveyor #4 noted that in room 15 on Unit F3 a power tap was plugged into the wall receptacle. This arrangement eliminates tamper resistance of the electrical circuit thereby allowing for both an electrical and/or fire risk.

f. On 3/5/2015 between the hours of 3:00 and 3:30 PM Surveyors #1 and #4 toured Units F1, F5 and F8 to determine if day areas of the units were outfitted with tamper resistant electrical receptacles. Units F5 and F8 lacked tamper resistant receptacles in their respective day areas. The surveyors observed that room 7 on unit F8 lacked tamper resistant receptacles.

2. Interviews and record review during the survey revealed several incidents of patients inserting items into electrical outlets, causing the outlets to arc so patients could light their cigarettes. Not installing tamper-resistant electrical receptacles placed the patient population at high risk for injury from fire.


ITEM #2 - LIGATURE HAZARD

On 3/5/2015 between the hours of 1:30 and 2:30 PM, Surveyor #1 observed a hand-held shower attachment in the shower room of Unit S7. Both the design and location of the attachment posed a ligature risk to suicidal psychiatric patients.


ITEM #3 - SECURE ENVIRONMENT

On 3/5/2015 at 10:10 AM, Surveyor #4 observed an unlocked pass-through between the utility room and the shower room on Unit F3. The unsecured pass-through allowed patients access to the secured area.
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VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and policy review, the hospital failed to ensure that patient care supplies did not exceed the manufacturer's designated expiration date.

Failure to ensure patient care supplies do not exceed their expiration dates risks patient harm due to unsafe and unusable equipment.

Findings:

1. The hospital policy titled "Chapter 8, Nursing Units-Infection Control Policy" (Approved June, 2013) under Section III D. "Medical Supplies" states in part: "All medical supplies shall be checked on at least a monthly basis for outdates and compromises to packaging."

2. During the course of the survey, Surveyors #2, #3 and #8 made the following observations:

a. On 3/3/2015 at 10:35 AM, Surveyor #3 identified a bottle of saline (used for irrigation) with an expiration date ending in 2012.

b. On 3/3/2015 at 3:25 PM in the F-3 exam room, Surveyor #2 identified the following items:

1) Three urinary drainage bags with an expiration date of 4/2014.

2) Two 16F urethral catheters with an expiration date of 5/2005.

3) One 22F urethral catheter with an expiration date of 5/2010.

4) Seven 16F urethral catheters, one with an expiration date of 8/2012, one with an expiration date of 12/2012 and five with an expiration date of 5/2014.

5) One urethral catheter with an expiration date of 12/2014.

c. On 3/4/2015 Surveyor #2 identified the following items:

1) At 9:30 AM in the F-4 exam room, one urinary drainage bag with an expiration date of 4/2014.

2) At 1:00 PM, in the F-6 exam room:

(a) One box of exam gloves with an expiration date of 9/2014.

(b) Two female catheter kits, one with an expiration date of 4/2014 and one with an expiration date of 10/2014.

(c) Four 16F urethral catheters with an expiration date of 1/2013 and three 14F urethral catheters with an expiration date of 5/2013.

3) At 2:45 PM in the F-7 exam room:

(a) One suture kit with an expiration date of 9/2013.

(b) One female catheter kit with an expiration date of 10/2014.

(c) Two 12F urethral catheters with an expiration date of 9/2014.

(d) Two boxes of exam gloves, one with an expiration date of 5/2012, and one with an expiration date of 10/2014.

d. On 3/4/2015, in the C-7 exam room, Surveyor #3 identified a sterile-wrapped "suture removal kit" with an expiration date ending in 2013.

e. On 3/5/2015, Surveyor #8 identified the following items:

1) At 1:30 PM in the S-3 medication room:

(a) Nine IV start catheters, three with an expiration date of 10/2011, five with an expiration date of 10/2012 and one with an expiration date of 12/2012.

(b) Five Packages of 2" X 2" gauze with an expiration date of 6/2012.

(c) Four IV tubing extension sets, three with an expiration date of 12/2013 and one with an expiration date of 9/2014.

(d) A hospital- assembled suture set including all items for suturing a wound with an expiration date of 8/2014.

(e) A manufactured suture removal set with an expiration date of 7/2010.

2) At 1:50 PM, in the S-3 treatment room:

(a) A bottle of Hibiclens, a skin prep solution, with an expiration date of 12/2014.

(b) A bottle of hydrogen peroxide, with an expiration date of 8/2012.

(c) A culture swab/tube, with an expiration date of 2/2013.

f. On 3/6/2015, at 9:50 AM in the C-3 treatment room, Surveyor #8 identified four bladder catheterization kits, one with an expiration date of 8/2014 and three with an expiration date of 10/2014.
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
ITEM #1 - SURVEILLANCE AND CONTROL OF METHICILLIN-RESISTANT STAPH AUREUS

Based on interview and review of hospital reporting documents, the hospital failed to develop a system for notifying the hospital's infection prevention program of patients who tested positive for methicillin-resistant staph aureus (MRSA).

Failure to have such a system risks transmission of MRSA to staff members and other patients through use of improper infection control procedures.

Findings:

1. Review of a hospital reporting document dated 3/5/2015 entitled "Medical Nurse Consultant Updates" revealed that 14 patients on the hospital campus had tested positive (+) for MRSA.

2. On 3/5/2015 at 2:00 PM, during an interview with Surveyor #5, infection prevention program staff members (Staff Members #30 and #31) indicated they were not aware of the MRSA (+) patients identified in the "Medical Nurse Consultant Updates" document. The infection prevention program staff members had not determined if those patients should be cared for using contact precautions.


ITEM #2 - SURVEILLANCE AND ACTION FOLLOWING STAFF EXPOSURE TO BLOOD AND BODY FLUIDS

Based on interview and review of quality documentation, the hospital failed to refer a staff member (Staff Member #36) to the occupational health nurse for follow-up after exposure to human saliva.

Failure to refer staff members for care and treatment following exposure to blood and body fluids puts staff at risk of infection.

Findings:

1. In review of facility policy titled, "3.2.9 Management of Hospital Personnel Exposed to Blood or Other Potentially Infectious Materials" it defined "Other Potentially Infectious Materials (OPIM)" as coming from several sources, including but not limited to saliva and blood. The policy stated that the facility was responsible for timely post-exposure medical evaluation and for follow-up of exposure incidents. It provided detail about different levels of responsibility including the supervisor's responsibility to report the incident to the Infection Control/Employee Health Office (including during after-hours) and completion of specific forms. The supervisor was also responsible for identifying source data, i.e. pertinent medical data from OPIM source individual(s).

2. On 3/4/2015 at 4:00 PM, Surveyor #6 interviewed a RN 2 (Staff Member #36) on the S-8 unit. S/he disclosed that s/he was assaulted by Patient #19 on 2/26/2015 at 5:30 PM. The patient was being treated for schizoaffective disorder with methamphetamine dependence and other medical problems.

During the assault Staff Member #36 sustained injuries that included a bite to the right elbow with enough force to break the skin (causing bleeding) in 2 locations, a 2 inch scratch to the left side of the forehead an a puncture to the left middle finger from a key.

The RN reported the incident to her/his supervisor, then s/he completed an "Administrative Report of the Incident" form, a security incident report form and then went to seek medical care at an outside facility per policy.

When Surveyor #6 asked staff member #36 if s/he had been contacted by hospital employee health staff or if any source medical data had been obtained from the assailant, the RN responded the no facility staff had spoken with her/him about the assault subsequent to its occurrence.

3. On 3/5/2015 at 10:00 AM Surveyor #6 conducted a follow-up interview with the Director of Infection Control and Employee Health (Staff Member #37). S/he confirmed that his/her department was not aware of the OPIM assault incident. When asked to rate the level of risk from the patient bite to staff member's arm, s/he stated that the risk was unknown so it would have to be treated as a high-risk event. At that time in review of the "Western State Hospital Bloodborne Pathogens Exposure Packet" the director noted that it was the supervisor's duty to identify the exposure, report the incident to Employee Health and provide an exposure packet to the nurse.

4. Upon review of the "Administrative Report of Incidents" completed the day of the incident, there were three RN3 (supervisor) signatures on the form, including one at 8:00 PM with a check in a box on the form that stated "Supervisor Closure Recommended." Subsequently on 2/27/2015 an "x" was placed in the box on the form for "2nd Line Supervisor/Manager Closure Recommended" and it was signed by the RN4.


ITEM #3- CLEANING PATIENT CARE EQUIPMENT AND ENVIRONMENT

Based upon review of policy and procedure, staff interview and observation, the hospital failed to ensure that staff properly cleaned equipment and environmental spaces after being used to care for patients.

Failure to properly clean equipment and environmental surfaces puts patients at risk for harm from infectious disease, including extended hospital stays, increased healthcare costs, and death.

Findings:

ITEM #3A - CLEANING AND DISINFECTION OF GLUCOMETERS

1. The hospital's policy and procedure entitled "Precision XceedPro", on page 11 of 14 and under the section titled "Care and Cleaning of equipment", read in part: "The meter is to be cleaned when visibly dirty and in between use for each patient."

2. On 3/4/2015 at 11:15 AM on the E2 unit, Surveyor #1 observed a registered nurse (Staff Member #21) test a patient's blood glucose using a glucometer. The nurse did not clean the glucometer with a disinfectant wipe before or after use.


ITEM #3B - STERILIZATION OF DENTAL EQUIPMENT

On 3/3/2015 during a tour of the central sterile processing department between the hours of 1:30 PM and 2:30 PM Surveyor #1 interviewed the manager of the central sterile processing department (Staff Member #22). At the time of the interview, Surveyor #1 observed a container of dental care instruments sitting on a counter. Surveyor #1 asked the central sterile processing manager to identify the instruments. The manager stated she/he could not identify the instruments.

The manager stated that central processing staff members batched and sterilized the dental equipment with other hospital instruments. Surveyor #1 asked for the manufacturer's instructions for sterilization of each piece of dental instruments to ensure that the instruments were being processed according to manufacturer's directions. The central sterile processing manager could not provide manufacturer's instructions for sterilization of the item.


ITEM #3C - CLEANING PATIENT ROOMS AND SHOWER AREAS

1. On 3/4/2015 at 3:45 PM, in ward F-4, Surveyor #4 observed personal hygiene items (bar soap and shampoo cup) and a soiled towel left in shower stall #3.

2. On 3/5/2015 at 9:45 AM Surveyor #4 noted that bedding in Room 14 on Ward F3 was both bloody and soiled with human waste.

3. On 3/5/2015, at 11:05 AM, Surveyor #4 observed body hair on tub surfaces as well as hair and soap residue on the drain screen in the Unit F7 bathtub, indicating patient care staff had not cleaned the tub after patient use.


ITEM #3D - USE OF DISINFECTANTS

1. The hospital's policy and procedure entitled "Environmental Services Standard Operating Procedures", on page 7 of 59 under the section titled "Restroom Cleaning Procedures", read in part: "Thoroughly clean all surfaces of sink and fixtures with a clean cloth saturated with clean germicidal detergent solution." For all other departmental sinks, the procedure read in part: "...use the scouring cream, rinse well, and clean with the disinfectant solution".

2. On 3/4/2015 at 10:15 AM, Surveyor #1 observed daily cleaning of a patient's room. During the cleaning procedure, the custodian (Staff Member #23) applied a scouring cream cleanser to the sink and faucet handles. The custodian then scrubbed and rinsed the sink. The custodian did not use the approved disinfectant or germicide as stated in the policy when cleaning the sink in the patient's room.


ITEM #3E- CLEANING SINKS IN MEDICATION ROOMS

1. On 3/3/2015 at 3:00 PM, Surveyor #6 inspected the medication room on the E-2 unit. The sink located there was soiled and covered on the inside and on the border with a dull film. A large metal spoon (1 foot long) used for stirring patient beverages had been placed within a few inches of the soiled sink on the counter.

2. On 3/4/2015 at 11:45 Surveyor #6 observed that sinks located in the Unit E-7 medication room and nurses' station were both soiled. The medication room sink was covered on the inside and on the border with a dull film. The surveyor also observed a pink-colored residue lining the faucet handles. A large metal spoon (1 foot long) had been placed on the counter within a few inches of the sink.

3. On 3/4/2015 at 12:15 Surveyor #6 interviewed a custodian (Staff Member #38) about her/his responsibilities for cleaning the sink in the medication room and the nurses' station. S/he stated the sinks were cleaned twice a week and 2-3 times a week, respectively, with a mild soft scrub (Day Mark) and then with an antimicrobial agent (Ecolab 2.0). When asked further about the frequency for cleaning, s/he stated that it was difficult to gain access to the medication room because it was locked and the nurses did not want disruption of the sink cleaning during medication administration.

4. On 3/6/2015 at 8:55 AM, Surveyor #6 interviewed the Director of Environmental Services (Staff Member #39) and asked whether there was a procedure that directed staff about cleaning sinks located in the medication rooms and nurses' station. S/he stated that one did not exist to direct staff on product use and frequency and that the cleaning should be done "as often as needed".


ITEM 3F - CLEANING EXAMINATION TABLES

1. A hospital document entitled "Chapter 8 Nursing Units - Infection Control Policy", on page 5, item 4, contained information about cleaning equipment. It stated that "Medical equipment (e.g. geri-chairs, broda-chairs ...) shall be cleaned with a hospital approved cleaner/disinfectant between patients and whenever soiled".

2. On 3/4/2015 at 1:45 PM Surveyor #6 observed a Medical Nurse Consultant (Staff Member #40) provide wound care to Patient #20. Hospital staff members did not clean the exam table after the patient exited the exam room.

3. On 3/5/2015 at 4:00 PM Surveyor #6 observed a licensed practical nurse (Staff Member #41) administer an inhaled breathing treatment to Patient #22 in the C-7 treatment room. Hospital staff members did not clean the chair after the patient exited the exam room

4. On 3/4/2015 at 1:45 PM Surveyor #6 interviewed Staff Member #40 about her/his practice of cleaning the exam room table between patient use. S/he stated s/he was not aware of any procedure for cleaning the exam room table between patient use.


ITEM #3G - CLEANING FOOD REFRIGERATORS

Based on observation, the hospital failed to maintain patient refrigerators in activity rooms to prevent excessive food spills and contamination.

Failure to maintain refrigerators used for patient-owned foods, puts the patient food at risk of contamination from other food items.

Findings:

On 3/3/2015 at 1:20 PM, Surveyor #3 observed spilled liquid throughout the shelving of the patient refrigerator in room 211 of ward C-5. A staff nurse (Staff Member #13) accompanying the surveyor at the time of the observation, confirmed this finding.


ITEM #4 - GLOVING AND HAND HYGIENE

Based on observation and review of hospital policies and procedures, four hospital staff members did not comply with the hospital's gloving and hand hygiene policy.

Failure to perform hand hygiene when required puts patients and staff at risk of infection.

Findings:

1. The hospital's policy and procedure entitled, "Western State Hospital 2.3.6 Standard Precautions " (Revised 5/3/2013), under section "IV. Protocol B. Glove Use", read in part: "Change gloves and wash hands between patients, between procedures on the same patient, and after touching contaminated items."

2. On 3/4/2015 at 11:10 AM, Surveyor #1 observed a registered nurse (Staff Member #21) preparing to test a patient's blood glucose. The staff member donned clean gloves, then touched his/her hair with the gloves and proceeded with patient care without changing the gloves.

3. On 3/3/2015 between 9:30 - 10:30 AM, Surveyor #8 observed a Registered Nurse (Staff Member #4) repeatedly take a used tissue from his/her pocket, wipe his/her nose, then replace it in his/her pocket. The nurse did not perform hand hygiene after each episode. This was confirmed by the nurse at the time of the observation.

4. On 3/5/2015 at 9:25 AM, Surveyor #8 observed a Registered Nurse (Staff Member #5) pick an item up from the floor, then did not perform hand hygiene prior to touching multiple surfaces in the patient dining room on S7. This was confirmed by the the Director of the Psychiatric Treatment and Recovery Center (South/Center) (Staff Member #1).

5. On 3/5/2015 at 11:00 AM Surveyor #8 observed a Treatment Nurse (Staff Member #6) perform a blood glucose test. Twice during the procedure s/he removed gloves and put on new ones. Neither time did s/he perform hand hygiene after removing the contaminated gloves.


ITEM #5- PREVENTION OF CONTAMINATION OF PATIENT CARE ITEMS

Based on observation and policy review, the hospital failed to store patient care supplies in such a way as to protect them from contamination

Failure to maintain supplies in a clean environment puts patients at risk from use and exposure to contaminated items.

Findings:

1. The policy titled "Chapter 8, Nursing Units-Infection Control Policy" (Approved June, 2013) under Section III D. "Medical Supplies" states in part: "Do not store medical supplies under sinks, near water sources or under direct light sources."

2. On 3/3/2015 at 10:35 AM, Surveyor #3 observed patient care items stored under a hand sink in the Habilitative Mental Health (HMH) treatment room. A member of the environmental services staff (Staff Member #16) removed the items at the time of the observation.

3. On 3/4/2015 at 2:15 PM Surveyor #8 observed patient care items stored under a sink in the Medication Room on C7. These included boxes of gloves and paper towels. At the time of the observation, the Medication Nurse (Staff Member #2) confirmed the finding.

4. On 3/4/2015 at 3:30 PM, Surveyor #8 observed paper towels stored under the sink in the Medication Room on C8. One package had evidence of water damage. At the time of the observation, the Registered Nurse (Staff Member #3) confirmed the finding.

5. On 3/5/2015 at 9:15 AM Surveyor #8 observed patient care items stored under a sink in the Treatment Room on S7. These included a basin for soaking a patient's feet and 10 plastic storage boxes for storing patient care items. At the time of the observation, the Director of the Psychiatric Treatment and Recovery Center (South/Center - Staff Member #1) confirmed the finding.


ITEM #6 - N95 RESPIRATOR FIT TESTING

Based on interview and review of hospital policies and procedures, the hospital failed to implement its N95 face mask fit testing program.

Failure to test for proper fit of N95 face masks risks transmission of airborne diseases to patient care staff members.

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

Findings:

On 3/6/2015 at 9:00 AM, Surveyor #1 interviewed the physical plant technician (Staff Member #24), the staff member identified as being responsible for the hospital's respiratory protection program. During the interview, the staff member confirmed the respiratory protection program should fit testing of patient care staff members who wore N95 face masks when caring for patients with airborne infections.

The staff member reported that the hospital developed the program in 2010 but failed to implement it.


ITEM #7 - PREVENTION OF CONTAMINATION OF READY-TO-EAT FOODS

Based on observation, the hospital staff failed to protect ready-to-eat foods from contamination during preparation. .

Failure to implement procedures to minimize contamination of ready to eat foods puts patients at risk of food-borne illness

Findings:

On 3/4/2015 at 11:20 AM, Surveyor #3 observed a food service worker (Staff Member #17) in the C-6 lunchroom, pull a folding knife out of his/her uniform pocket and without cleaning the blade, use it to open a package of pre-sliced American cheese. The cheese was used to make patient sandwiches for the lunch service.






ITEM #8 - FOOD SERVICES - COMPLIANCE WITH WASHINGTON STATE RETAIL FOOD CODE

Based on observation, 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 3/3/2015 at 10:45 AM Surveyor #4 observed a member of the kitchen staff (Staff Member #46) processing utensils at a two compartment utility sink (Diet Line Wash Sink). The staff member used the two compartments of the sink for washing and rinsing items. The staff member then immersed the items in a bucket containing a sanitizing rinse solution. At the time of the observation the surveyor checked the concentration of the sanitizing rinse with a paper test strip and found that the bucket contained no sanitizer. The manufacturer's directions for use (DFU) for Oasis 146 quaternary ammonium compound solution calls for > 150 parts per million (PPM).

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart E, (3)(b) Equipment - Manual and mechanical warewashing equipment, chemical sanitization - Temperature, pH, concentration, and hardness (2009 FDA Food Code 4-501.114); and

Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart C, etal. Equipment - Manual warewashing, sink compartment requirements (2009 FDA Food Code 4-301.11)

2. On 3/3/2015 at 11:00 AM Surveyor #4 asked a member of the kitchen staff (Staff Member #47) to demonstrate the processing of utensils/equipment at a two compartment utility sink (Diet Kitchen Sink). Soapy water was available in a bucket located in the left hand or 1st compartment of the two compartment sink. Utensils and equipment would be washed in this compartment. The next step of the process as explained and demonstrated was rinsing the utensil or equipment under running water from the faucet. The third step or sanitizing step was accomplished by pouring a bleach solution over the utensil or equipment. Kitchen staff failed to properly wash, rinse, and sanitize items using a two compartment sink as required by code.


Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart C, etal. Equipment - Manual warewashing, sink compartment requirements (2009 FDA Food Code 4-301.11); and

Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart G, (3) Methods -Hot water and chemical (2009 FDA Food Code 4-703.11)

3. On 3/3/2015 at 11:05 AM, Surveyor #4 observed a paper cup serving as a scoop, left in a bulk container of oatmeal.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 3, Subsection C - Preventing Contamination After Receiving, (2) Preventing contamination from equipment, utensils, and linens - In-use utensils, between-use storage (2009 FDA Food Code 3-304.12)

4. On 3/3/2015 at 11:08 AM, Surveyor #4 observed utensils in the Dietary Department Kitchen stored in a dirty drawer, subjecting them to contamination.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4: Equipment, Utensils and Linens, Subpart I - Protection of Clean Items, (1) etal Storing - Equipment, utensils, linens, and single-service and single-use articles (2009 FDA Food Code 4-903.11)

5. On 3/3/2015 at 11:25 AM Surveyor #4 asked a member of the kitchen staff (Staff Member #48) to demonstrate the processing of utensils/equipment at a two compartment sink in the Cold Diet kitchen.

The staff member proceeded to wet a damp washcloth with liquid detergent, wiped the utensils with the washcloth, and then rinsed the utensils under running water, followed by immersion in sanitizer. Kitchen staff failed to properly wash, rinse, and sanitize items using a two compartment sink as required by code.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart C, etal. Equipment - Manual warewashing, sink compartment requirements (2009 FDA Food Code 4-301.11)

6. On 3/3/2015 at 11:30 AM Surveyor #4 interviewed a kitchen supervisor (Staff Member #49) regarding the need to rinse raw fruits and vegetables prior to service as a ready to eat food item. The supervisor indicated that staff members did not rinse products such as pre-chopped salad mix or shredded lettuce and shredded cabbage prior to service. A review of packaging labels indicated the pre-chopped salad mix and the shredded lettuce lacked a " Ready-to-Eat " label, and required rinsing prior to use.

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

7. On 3/3/2015 at 11:40 AM, Surveyor #4 observed a member of the kitchen staff (Staff Member #47) preparing plates for patient meals. During the preparation, the staff member applied sanitizer from a rag, to his/her gloved hands and transferred food (fish) to a plate. The surveyor observed the directions for use for the Quaternary Ammonium sanitizer indicated use on hard, non-porous food contact surfaces and requires a one-minute contact time followed by air-drying. The staff member did not follow manufacturer ' s directions for use in the application of this product.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 3, Subsection C, Preventing contamination from the premises - Food Preparation (2009 FDA Food Code 3-305.14)

8. On 3/3/2015 at 2:45 PM Surveyor #4 checked the internal temperature of the hot food holding unit using a digital thermometer. The thermometer registered 109 degrees Fahrenheit. A minimum temperature of 135 degrees is required by code.

During an interview with a kitchen supervisor (Staff Member #49) at the time of the observation, the supervisor stated that the holding unit was set at the highest temperature setting and that higher temperatures could not be achieved. The holding unit was taken out of service after the interview.

Reference: Washington State Retail Food Code, Chapter 246-215 Washington Administrative Code (WAC) Part 4, Subpart C, . Equipment - Cooling, heating, and holding capacities (2009 FDA Food Code 4-301.11)
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VIOLATION: INTEGRATION OF OUTPATIENT SERVICES Tag No: A1077
Based on interview, review of clinical documents and job description, the hospital failed to implement a system to assure that inpatients referred to the outpatient setting for specialty care were triaged systematically by patient need.

Failure to have a system that ensures timely patient referrals risks delay of patient care and deterioration of the patient's health status.

Findings:

1. On 3/5/2015 at 3:40 PM, Surveyor #6 reviewed referral files from the inpatient setting for outpatient specialty referrals at the East Campus Medical Clinic. Referrals for outpatient clinic specialist services included, but were not limited to; obstetrics and gynecology, gynecology, ophthalmology, optician, dermatology, podiatry, urology, neurology and orthopedics. Also, the clinic provided services occasionally to children from the Child Study Treatment Center.

2. At that same date and time, Surveyor #6 interviewed the RN3 charge nurse (Staff Member #35) in the Medical Clinic about the system to assure appropriate access for patients to clinic specialty services. The charge nurse stated that s/he reviewed the referral files and made a determination about urgency with the clinic's licensed practical nurse. When s/he was asked if there were any clinic policies and procedures that addressed prioritizing referrals, s/he stated that there were not any procedures related to triage or other clinic functions.

3. The hospital's position description # 953 entitled, "Charge Nurse/Medical Nurse Consultant for Clinic" under section V. outlined the duties of the clinic charge nurse. The first item listed in the 50% time category stated, "Develop and implement a system and schedule for hospitalized patients to be assessed by specialists and contract physicians. The system ensures patients are seen in a timely manner and the flow of the clinic process enables all patients to be evaluated as needed".

The document entitled "2.1.2 Referral to Western State Hospital (WSH) Specialty Clinics and Community Practitioner/Hospitals" (Revised 4/22/2013) provided information about referring patients out of the system when specialty consultants were not available but it did not identify clinic nursing criteria for determining needs.
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VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, document review and medical record review, it was determined that the hospital failed to meet the Condition of Participation for Patient Rights. The hospital failed to assure the patient's right to receive care in a safe setting by not placing Patient #2 in the appropriate setting and/or not providing appropriately trained staff to care for the patient care needs.

Interview dates and times:
Nurse Executive - December 16, 2014 @ 0830
CEO - December 18, 2014 @ 0800
RN #1 - December 16, 2014 @ 1000
RN #2 - December 16, 2014 @ 0930
RN #3 - December 16, 2014 @ 1150
RN #4 - December 16, 2014 @ 1050
RN #5 - December 16, 2014 @ 1120
ANC #1 - December 18, 2014 @ 0900
LIP #1 - December 18, 2014 @ 1030

Findings include:

Based on interview with the facility's Nurse Executive and corroborated during interviews with RN #1, RN #2, RN #3 and LIP #1 and by document review, three employees were assaulted by Patient #1 and Patient #2 on November 25, 2014 at noon. The facility's policy on 'Transfers of Patients Within WSH' states "If a Community Program client must be placed into the CFS building due to decompensation and /or a violation of his/her CR condition, this must be completed immediately". Patient #1 was restrained at the time of the assault and secluded until transfer to the forensic unit was arranged on November 26, 2014 at 9:30 am.

Patient #2 was placed in seclusion at approximately 12:15 on November 26, 2014 but released to the open ward on November 26, 2014 at 1:30 pm. Patient #2 met criteria to be transferred to the forensic unit based on the assault of November 25, 2014 but the documentation states no beds were available for this patient. Based on interview with RN #1 on December 16, 2014, Patient #2 continued to make verbal threats of violence stating "I want all of you black bitches gone"; exhibited threatening behaviors including charging toward individuals and stopping short of actual contact; and requesting other patients to participate in injuring employees. On November 29, 2014, one patient did not agree to participate in injuring others and as a result of the refusal, Patient #2 yelled obscenities at the visitors. Patient #2 was transferred to the forensic center on December 1, 2014.

A Code Green is "initiated when additional support is needed to provide for the safety of patients and staff". The facility policy on "Code Green Response" states "the way in which clinical staff responds to a Code Green is of the highest importance". Based on interview with RN #3, s/he was off the ward and working on paperwork in another location at WSH. S/he states that the page of the Code Green came through his/her pager. S/he completed the paperwork before responding to the Code Green. When the Rapid Response code (indicating a patient/staff medical emergency) came through the pager, the paperwork completion stopped and RN #3 responded to the emergency.

On interview with LIP #1, s/he stated that the Code Green came through his/her pager but "there are so many Code Greens I do not respond to all of them" since others respond. When the Rapid Response Code came through the pager, LIP #1 responded to the emergency.

Based on interview with RN #1, LPN #1 was assigned to medication administration duties on November 25, 2014. At the time of the emergency, LPN #1 stayed in the locked medication room. RN #1 stated LPN #1 was on "light duty" secondary to being assaulted and injured by a patient earlier in 2014. The investigator confirmed from RN #3 (acting supervisor) that LPN #1 was released from "light duty" in July 2014 and was deemed to be "fit for duty". The policy on Code Green Response was not followed by RN #3, LPN #1 or LIP #1.

The facility policy on reporting serious incidents states " the supervisor shall initiate appropriate action as necessary to ensure the immediate health and safety of patients " . At the time of this complaint investigation on December 16, 2014, neither the supervisor and/or assigned leadership responsible for the S8 ward had completed a review of the incidents of November 24 and 25, 2014 and the facility had not implemented corrective or preventive measures to assure the ongoing safety of patients and employees.

During Safety Rounds on Ward S8 on November 24, 2014, staff noticed a bent paperclip and singed electrical outlet. Based on the facility policy 2.4.5 titled 'Searches', a physician order was obtained an Patient #1's room was searched. Contraband was found in Patient #1's room on November 24, 2014 to include a billiard ball, two 15 foot ropes and a paperclip. There was no review of how the contraband was obtained by Patient #1 at the time of the seizure of the items. After the assault, LIP #1 and RN #4 discovered a locked cabinet in the day room on S8 had been vandalized. No report of the incident could be found and the facility did not follow their policy on inventorying items placed in locked cabinets. A ward search was not conducted for contraband which may have been obtained from the cupboard.

On November 25, 2014, following the assault incident, Western State leadership was aware that the Patient #2 no longer met the criteria for the current assigned ward. The facility policy on transfer criteria indicated based on the assault incident, Patient #2 was to transfer to the forensic unit.

Employees working and assigned to the forensic unit require specialized training to provide safe and effective care to that patient population. Staff that care for the patient population in the forensic unit are to be competent based on successfully passing courses designated by DSHS: CFS (Center for Forensics) Security Essentials and CFS Basics. Patient #2 continued to make verbal threats of violence, exhibited threatening behaviors to patients, visitors and staff until s/he was transferred to the forensic center on December 1, 2014. Staff caring for Patient #2 during November 25, 2014 through December 1, 2014, while awaiting a bed in the forensics unit, did not have the required competencies to care for this patient's classification.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview, document review and medical record review, it was determined that the hospital failed to meet the requirement of having a RN immediately available to provide bedside care of any patient. Failure to provide a RN for the immediate delivery of care at the bedside places the patients at risk of substandard nursing oversight.

Findings include:

Every inpatient unit within the hospital-wide nursing service must have adequate numbers of RNs to be physically present and immediately availability for the bedside care of any patient. Based on interview with RN #1, RN #2, RN #3 and RN #4 on December 16 and 18, 2014, there are time periods on the nursing wards that an RN is not immediately available for patient care. On S8, one RN is scheduled for patient care. At times, no coverage is provided for the RN when s/he leaves the unit for meal breaks. This same practice was described on S6 and S7. The interviewees stated that what is" supposed to happen" is the supervisor (RN) should be available to cover for meal breaks but this does not always occur. The investigator was not able to confirm the lack of coverage with the staffing sheets since supervisor availability is not included on these documents. The lack of coverage does not allow for a RN to be immediately available for the bedside care of patients.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview, document review and medical record review, it was determined that the hospital failed to meet the standard to provide nursing staff with the required skills and competencies. Failure to provide adequately skilled and competent nurses places the patient at risk for substandard nursing care.

Findings include:

Nursing care assignments must be in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. On November 25, 2014, Patient #2 met criteria to be transferred to the forensics unit based on the facility policy. The forensics unit employees are required to complete the DSHS WSH CFS Security Essentials and Basics course in order to meet the competency requirement to care for patients assigned to the forensics unit. Patient #2 was not able to be moved to the forensics unit because a bed was not available. Staff that did not meet the competency requirements for this patient were assigned during November 25, 2014 through December 1, 2014 when the patient was physically moved to the forensics unit. This was confirmed with the Nurse Executive.

Nursing staff are required to be competent to perform during a behavioral crisis as defined by the facility procedure #253. Competency is determined by conducting Behavioral Crisis Drills at least quarterly on each ward and each shift. The completed Behavioral Crisis Drill Forms are to be retained for two quarters according to the facility policy. On review of 2014's second and third quarter crisis drills, five of the 25 units participated in the drills for 2nd quarter 2014 and only for the day shift. Documentation was completed on twelve units for night shift only during the third quarter of 2014. This was confirmed with the Nurse Executive.