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Based on observation and staff interview, it was determined the hospital failed to ensure physicians and nursing staff followed effective infection control practices, including hand hygiene. This directly affected 2 of 6 patients (#18 and #19) whose care was observed, and had the potential to affect all patients. This had the potential to result in patients acquiring healthcare associated infections. Findings include:

The CDC weekly Morbidity and Mortality Report and Recommendation, dated 10/25/02, included a "Guideline for Hand Hygiene in Health-Care Settings." The guideline included, but was not limited to, the following recommendations for hand hygiene:
- before having direct contact with patients
- after contact with a patient's intact skin
- after contact with body fluids, mucous membranes, nonintact skin and wound dressings
- after contact with inanimate objects (including medical equipment)

This guideline was not followed. Examples include:

1. Patient #19 was a 59 year old female admitted to the hospital on 10/24/15, for sepsis (a life threatening complication of an infection) and osteomyelitis (infection in a bone) related to a diabetic foot ulcer on her left lateral foot. She had additional wounds on her right and left heels. Additional diagnoses included insulin dependent DM, CHF and kidney failure.

On 10/27/15 at 9:30 AM, the CWOCN was observed as she assessed Patient #19's foot wounds. She cleansed her hands with gel and applied gloves prior to touching the patient. The right heel wound was open to air. She removed the dressings from the left lateral foot and left heel. The dressings were noted to contain drainage from the wounds. The CWOCN placed the moist dressings on the overbed table, on top of a paper wrapper from a dressing supply. The wrapper was not large enough to contain the dressings, which touched the surface of the overbed table. Patient #19's overbed table was used for meals, grooming and other patient activities.

After cleansing Patient #19's right and left foot wounds, the CWOCN picked up a camera and small mirror with her contaminated gloves. She used the mirror to observe the wounds on Patient #19's heels, and used the camera to photograph the 3 wounds. She then placed the camera and mirror on the bedside table, without a barrier between the table and the contaminated mirror and camera.

After applying clean dressings to Patient #19's foot wounds, the CWOCN disposed of the contaminated dressings in the waste basket. She picked up the mirror and camera from the bedside table and put them in a basin on her cart in the hallway. She did not clean Patient #19's bedside table.

During an interview on 10/27/15 at 9:55 AM, the CWOCN stated she typically used sanitizing wipes to clean any surface she used during her wound care, before and after providing the care. She confirmed she did not sanitize Patient #19's overbed table prior to providing care, or after placing contaminated dressings and supplies on it.

The CWOCN did not disinfect Patient #19's bedside table after it was contaminated.

2. Patient #18 was a 60 year old male, admitted to the hospital on 10/19/15, for infected wounds on both feet. Additional diagnoses included hepatitis B and C, seizure disorder, and COPD.

On 10/27/15 at 8:45 AM, an RN was observed administering medications to Patient #18. Upon entering his room, the RN cleansed her hands with gel and applied gloves. While she was removing his pills from the packaging, Patient #18 asked her to retrieve his bed control device from the floor, where he had dropped it. The RN picked the device up from the floor and handed it to him. She assisted him to reposition in bed by lowering the head of his bed, using a pad under his trunk area to pull him up in the bed, then raising his siderail. After repositioning him, she removed the rest of his pills from the packaging, placed them in a small cup and handed the cup to Patient #18, so he could swallow his pills. The RN did not cleanse her hands or change gloves after retrieving the device from the floor, and having direct contact with his skin and bed linens.

During an interview on 10/27 at 10:10 AM, the RN confirmed she did not cleanse her hands after touching the patient, his bed linens and an item that was on the floor.

The RN failed to perform hand hygiene after contact with inanimate objects and patient's skin.

3. A tour of the facility was conducted on 10/26/15 beginning at 10:00 AM. While in the ICU a staff member was observed entering a patient's room without performing hand hygiene prior to entering. Additionally, another staff member was observed walking around the unit with gloves on after leaving another patient's room.

4. On 10/27/15 beginning at 11:00 AM, the ICU staff were gathered around the nurses' station to conduct an interdisciplinary huddle to discuss patients. The interdisciplinary huddle included the Medical Director, RNs, Respiratory Therapist, Case Managers, Dietician, Speech Therapist, and Occupational Therapist.

The Medical Director was going through the patients charts as they were being discussed. He was observed licking his index finger to flip through the pages of the charts. The Medical Director did not wash or cleanse his hands during the time of the interdisciplinary meeting.

5. During the same meeting in the ICU, an RN walked into the nurses' station carrying 2 folders, a glucometer, and a vial of test strips for checking blood sugar levels. The RN dropped the vial of test strips on the floor, picked them up, and proceeded into a patient's room. The RN did not clean the vial of strips or perform hand hygiene after picking the vial up from the floor or prior to entering the patient's room.

During an interview on 10/27/15 at 4:30 PM, the Infection Control Officer stated the Infection Control Program followed CDC guidelines. She confirmed the CDC guidelines for hand hygiene were not followed by staff members.

The facility staff failed to adhere to the Infection Control Program guidelines for hand hygiene.



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Based on record review, policy review, and staff interview, it was determined the hospital failed to provide thorough discharge planning evaluations when appropriate. This had the potential to result in patients being discharged without the knowledge and ability to meet their post-hospitalization needs. This directly affected 1 of 3 patients (Patient #16) whose records were reviewed and who were discharged to their home. It also had the potential to affect all patients. Findings include:

The hospital's policy PC 160, "Discharge Planning," revised 2/2015, stated "Discharge planning is a systematic coordinated program that is designed to bring about a timely discharge of a patient from a hospital to the next appropriate level of care or return to their normal living situation. It is a process that begins upon the patient's admission to the hospital." Additionally, it stated "Every patient will have discharge planning from admission that will take into consideration clinical, social, insurance/financial, and physical factors."

During an interview on 10/27/15 at 3:45 PM, the Director of Case Management stated discharge planning was performed by the hospital's Case Managers. She stated discharge planning was documented on the Case Management evaluation, completed 1-2 days after admission.

Patient #16 was a 34 year old male admitted to the hospital on 10/02/15, for osteomyelitis (infection of the bone) in his lumbar spine. Additional diagnoses included history of IV drug abuse, anemia, depression and anxiety. He was discharged from the hospital on 10/09/15.

Patient #16's record included a "Case Management Evaluation," signed by a Case Manager, and dated 10/06/15, 4 days after his admission. The evaluation stated "Pt [patient] came from working in oil fields [sic] of North Dakota. He has no permanent living arrangements in Spokane. Sister [name] will assist."

Patient #16's record included a "Team Conference Update" dated 10/06/15, and signed by the Case Manager. The section of the document titled "Needs at discharge" stated TBD (to be determined). It did not address his needs at discharge or his ability to meet his needs.

Case Management notes dated 10/07/15, and 10/08/15, did not include information related to discharge planning.

During an interview on 10/29/15 at 8:20 AM, the Case Manager confirmed Patient #16's Case Management evaluation was late. She was unable to explain why it was late. She stated she was a part-time employee, and the evaluation was on her schedule to be completed when she reported for work on 10/06/15. Additionally, the Case Manager confirmed the Case Management documentation did not address Patient #16's post-hospital needs or his ability to meet his needs.

Patient #16's discharge planning was not completed per the hospital's policy. Additionally, it did not address his needs for post-hospital services or his ability to obtain them.

Based on record review, policy review, and staff interview, it was determined the hospital failed to thoroughly document pertinent information related to discharge planning. This had the potential to result in unmet patient needs related to discharge. This directly affected 1 of 3 patients (Patient #16) whose records were reviewed and who were discharged to their home. It also had the potential to affect all patients. Findings include:

The hospital's policy PC 165, "Case Management and Social Services," effective 02/2006, stated "1. Documentation of the social data will occur in the medical record per policy. 2. Any significant communications between referral agencies, payer sources, and patient/care givers(s) will be documented."

During an interview on 10/27/15 at 3:45 PM, the Director of Case Management stated discharge planning was performed by the hospital's Case Managers. She stated the discharge planning was documented on the Case Management evaluation, and Case Management notes.

Patient #16 was a 34 year old male admitted to the hospital on 10/02/15, for osteomyelitis (infection of the bone) in his lumbar spine. Additional diagnoses included history of IV drug abuse, anemia, depression and anxiety. He was discharged from the hospital on 10/09/15.

Patient #16's record included a "Team Conference Update" dated 10/06/15, and signed by the Case Manager. The section of the document titled "Needs at discharge" stated TBD (to be determined). It did not document his needs at discharge or his ability to meet his needs.

Case Management notes dated 10/07/15, and 10/08/15, did not include information related to discharge planning.

Patient #16's record included a nurse's note, dated 10/09/15, the day of his discharge. The note included an entry at 10:00 AM, signed by the RN. It stated "pt [patient] will be discharging today d/t [due to] insurance...Showing anxiety about paying for visit & future procedures." Patient #16's Case Management notes did not document information related to insurance or his anxiety related to financial issues.

During an interview on 10/29/15 at 8:20 AM, Patient #16's Case Manager stated on 10/09/15, she was informed Patient #16's medical insurance expired on 9/29/15. She stated the insurance company called him to inform him his insurance had expired. She confirmed she did not document this information in his medical record.

Patient #16's medical record did not include documentation of information pertinent to discharge planning and affecting his post hospital needs.

Based on record review, policy review, and staff interview, it was determined the hospital failed to reassess discharge plans when appropriate. This had the potential to result in patients being discharged without the knowledge and ability to meet their post-hospitalization needs. This directly affected 1 of 3 patients (Patient #16) whose records were reviewed and who were discharged to their home, and had the potential to affect all patients. Findings include:

The hospital's policy PC 160, "Discharge Planning," revised 2/2015, stated "Depending upon the patient's meeting his/her treatment goals, and/or if change in the patient's condition or available support occurs these plans may be changed and modified."

Patient #16 was a 34 year old male admitted to the hospital on 10/02/15, for osteomyelitis (infection of the bone) in his lumbar spine. Additional diagnoses included history of IV drug abuse, anemia, depression and anxiety. He was discharged from the hospital on 10/09/15.

Patient #16's record included a nurse's note, dated 10/09/15, the day of his discharge. The note included an entry at 10:00 AM, signed by the RN. It stated "pt [patient] will be discharging today d/t [due to] insurance...Showing anxiety about paying for visit & future procedures." Patient #16's Case Management notes did not document information related to insurance or his anxiety related to financial issues.

During an interview on 10/29/15 at 8:20 AM, Patient #16's Case Manager stated at the time of his admission, it was determined he had medical insurance. However, on 10/09/15, when she called the insurance company to obtain authorization for a test, she was informed Patient #16's medical insurance expired on 9/29/15. She stated the insurance company called him to inform him his insurance had expired. She stated on 10/09/15, Patient #16 requested to be discharged.

Patient #16's discharge instructions contained a list of 13 medications to be taken after discharge, including Fluconazole, used to treat the fungal infection in his spine. Additionally, it included instructions to obtain an MRI and laboratory tests, and to schedule appointments with an infectious disease physician, a neurosurgeon and his primary care physician.

Patient #16's medical record did not include a reassessment of his discharge plan due to the change in his financial status that impacted his ability to obtain necessary health care following his discharge. There was no documentation of efforts made to obtain financial assistance, or to connect him to resources in the community to assist him in meeting his post hospital needs, including obtaining necessary tests, medications, and follow-up care as prescribed by his physician.

During an interview on 10/29/15 at 8:20 AM, the Case Manager confirmed Patient #16's discharge plan was not reassessed or updated related to the change in his financial situation affecting his ability to obtain necessary services after discharge. She confirmed she did not connect Patient #16 with resources to assist him following hospital discharge.

Patient #16's discharge plan was not reassessed and updated to address the change in his ability to obtain necessary health care following his discharge.