HospitalInspections.org

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Based on observation and interview, hosptial staff failed to implement preventative maintenance program for medical equipment and facility equipment.


Failure to implement a preventative maintenance program places patients' safety and health at risk.

Findings:

On 3/25/2015 at 9:10 AM, Surveyor #3 interviewed the hosptial manager (Staff Member #8) about the hospital's process for ensuring all patient care equipment and facility equipment received preventive maintenance including those items with vendor contracts for maintenance. S/he kept preventative maintenance invoices for equipment maintained by vendors but could not provide an inventory list for either patient care equipment (maintained by a vendor) or equipment (maintained by the facility staff). The following equipment was found to be out of compliance for preventative maintenance:

a. Sports Art treadmill machine: unable to provide initial inspection.
b. Compat enteral feeding pump: next service due date 5/14 (past due)
c. Scotsman Ice machine: email for repairs on 1/26/2015; facility could not provide preventative maintenance information.

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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports. "

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Item #1- Proper Use of Disinfectants

Based on interview, observation and document review, the hospital failed to ensure that all environmental services staff members were knowledgeable about the manufacturer's recommendations for use of the quaternary ammonium disinfectant (Chem Kleen) used on environmental surfaces.

Failure to follow manufacturer's directions for use of disinfectants puts patients, staff and visitors at risk of exposure to infections from improperly disinfected surfaces.

Findings:

1. a On 3/25/2015 at 3:30 PM, Surveyor #2 interviewed a member of the environmental services staff (Staff Member #9) about cleaning procedures for patient rooms. The staff member stated that s/he used a disinfectant-soaked rag to wipe down surfaces, and then wiped the surfaces until dry. The manufacturer's directions for use indicated the product required a contact time of 10 minutes.

b. On 3/26/2015 at 9:30 AM, Surveyor #3 interviewed the housekeeping supervisor (Staff Member #1) about the use of the hospital's quaternary ammonium disinfectant. The staff member indicated the contact time for the product was 5 minutes, and not 10 minutes as indicated by the manufacturer's directions for use.

2. a. On 3/18/2015 at 9:15 AM Surveyor #1 observed a RN (Staff Member #10) prepare medications for administration for Patient #1. During the process the nurse placed a plastic spoon onto and off of the counter surface, including before and after obtaining applesauce (for ingestion) to be mixed in with the medications.

b. On 3/18/2015 at 10:00 AM Surveyor #1 interviewed an environmental services staff member (Staff Member #7) about cleaning the counters in the medication administration room. S/he stated that s/he wiped down the counter surfaces with a quaternary ammonium disinfectant called Chem Kleen.

c. In review fo the manufacuters instructions for Chem Kleen in food preparation areas, it stated to use the product for a desired contact time and then to wipe the surface clean of the product when used on food contact surfaces.


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Item #2- Proper Use of Chemical Test Strips

Based on observation and documentation review, facility staff failed to follow manufacturer's instructions for use (IFU) to verify efficacy of the cleaning and disinfecting process of semi-critical devices.

Failure to adhere to manufacturer's instructions for use puts patients and staff at risk for infections and communicable diseases.


Reference: Cidex OPA manufacturer's instruction for use indicates, "date the bottle of test strips when opened (expires at 90 days or the expiration date on the bottle of test strips, whichever comes first)".

Findings:

On 3/26/ 2015 at 9:00 AM, Surveyor #3 observed an opened bottle of chemical indicator test strips used to determine the efficacy of the high-level disinfecting solution used for trans-vaginal ultrasound probes in the imaging department. The open date and 90-day expiration date was not marked on the outside of the bottle as directed by the manufacturer.

Item #3- Proper Use of Ultrasound Gel
Based on observation and interview the facility failed to prevent contamination of product before patient care.

Failure to prevent contamination of product, places patients at risk for infections and communicable diseases.

Reference: FDA Guidelines, "FDA Safety Communication: Update on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" (Date Issued: June 8, 2012) , states in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings:

On 3/26/2015 at 9:15 AM during an interview with the ultrasound technician (Staff Member #11) Surveyor #3 observed a large refill container and a small squeeze bottle of "Med Choice Ultrasound Gel" in the exam room. The ultra sound technician stated in part, "that they refill the squeeze bottle with the larger container of ultrasound gel as needed and that they use the same squeeze bottle for up to 3 months before getting a new one".

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Based on observation the Critical Access Hospital failed to assure compliance with Washington State Retail Food Code (246-215 WAC).

Failure on the part of the CAH to comply with the food service codes puts patients, staff and visitors of the facility at risk of foodborne illness.

Findings:

On 3/25/2015 at 4:15 PM Surveyor #3 observed a staff personal styrofoam coffee cup in the designated area for personal drinks. The styrofoam coffee cup did not have a handle or a cover as required in the State Retail Food Code.

Ref: Washington State Retail Food Code Working Document Chapter 246-215-02400 Washington Administrative Code (WAC) Modification of 2001 FDA Food Code
Chapter 2-401.11 (B).

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Based on interview and review of policy and procedures, the facility failed to ensure that hospital policies and procedures were reviewed at least annually.

Failure to review patient care policies creates risk that staff may not have access to up-to-date references to ensure standards of patient care.

Findings:

1.In review of policy and procedure titled, "Policy Format and Compliance" (revised 12-30-2014) under item 12 it stated, "Each department manager is responsible to ensure that the policies for their department are reviewed annually."

2. On 3/16/2015 at 2:30 PM Surveyor #1 interviewed the Chief Operating Officer (Staff Member #6) about the annual review process for patient care policies and procedures. S/he stated many policies had not been reviewed in the past year.

3. In review of patient care policies and procedures, the following policies and pricedures had not been reviewed annually as required by facility policy:

a.Laboratory: "Blood Culture" 3/16/2013; "Gram Stain" 2/16/2012

b. Social Services: "Discharge Planning" 5/23/2013; "Resident Rights" 5/23/2013; "Social Services Documentation" 5/23/2013

c. Nursing: "Physician Orders for Life Sustaining Treatment" 6/14/2012;

d. Pharmacy: "Non-Formulary Drugs" 7/07/2011; "Securing Medications" 12/01/2013; "Emergency Medication List" 3/20/2013; "Emergency Crash Cart " 3/20/2013

e. Dietary: "Nutrition Assessment for Residents" 2/27/2009; "Issuance of Importance Message for Medicare and Detailed Notice of Discharge" 1/15/2010

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Based on interview and document review, the hospital failed to demonstrate that it evaluated the quality of services provided to patients and residents for 4 of 5 patient care contractors.

Failure to do so creates risk that patients may receive substandard services as provided by contractors.

Findings:

Surveyor #1 requested to review the evaluations of patient care services provided by hospital contractors. Vendor services provided by contractors that did not have quality evaluations completed included physical rehabilitation, mobile imaging, medical transcription, blood services and interpreter services.

This finding was verified by the Administrative Executive Assistant (Staff Member #2) on 3/18/2015 at 12:10 PM.

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Based on record review and interview the hospital failed to provide 7 of 7 swing bed residents with a copy of the resident rights, including written acknowledgment of receipt of such information.

Failure to do so creates a risk that resident and/or surrogate decision makers may be unable to exercise their rights due to lack of information.

Findings:

1.In review of hospital policy titled, "RESIDENT RIGHTS" (REVIEWED AND REVISED May 23, 2013) item 1 stated, "Each resident and/or Durable Power of Attorney is informed during the admission process of his/her rights and is given a copy of the Resident Handbook, which includes the 'Residents Rights' handout. Resident or their DPOA will sign a copy indicating that they understand the information presented. The signed copy of the 'Residents Rights' is kept in the facility records ..."

2. In review of the records of swing bed residents, there was not evidence that residents had been provided a copy of their resident rights for Patients #1- #7.
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Based on interview, record review and review of policy and procedure, the hospital failed to provide 2 of 2 residents written notice of their discharge plan including, but not limited to, information about rights to appeal the plan.

Failure to do so creates risk that patients will not be informed of their discharge rights and then would be unable to exercise those rights.

Findings:

1. In review of facility policy titled, "SWING BED TRANSFER OR DISCHARGE" (Revised 05/03/2013) under section B.2. it stated, "The facility will notify the resident in writing, and if known a family member of, surrogate or representative, of the transfer and the reasons, and record the reasons in the medical record. The effective date of transfer/discharge and the location will be included in the notice."

2. Review of the following medical records for swing bed residents who were discharged to a nursing home indicated that the patient/surrogate decision maker did not receive written notice to inform them of discharge plans accordingly:

a. Patient #4 was admitted on 7/4/2014 after a fall and was discharged to a nursing home on 7/16/2014.

b. Patient #5 was admitted on 6/8/2014 with Parkinson's disease and was discharged to a nursing home on 6/12/2014.

3. On 3/18/2015 at 4:00 PM Surveyor #1 discussed the above findings with the Director of Nursing (Staff Member #4). S/he stated that hospital staff were not currently aware of the requirement to provide all residents (and specifically for those discharged to a nursing home) with written notification of rights about the discharge plan. S/he stated that the Social Services Director (Staff Member #5) was not aware of that either.

On the next day at 9:00 AM, the Social Services Director acknowledged that s/he located a document on the nursing unit that had previously been used to provide residents of written notice of their discharge rights. S/he further acknowledged that it had not been utilized by staff members with residents for several months.
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Based on interview, review of documents and medical records, the hospital failed to demonstrate that it provided therapeutic activities program services to 3 of 3 hospital swing bed patients.

Failure to do so creates risk that the quality of life benefits of therapeutic activities would be omitted from patient care.

Findings:

1.In review of the job description of the Activities Coordinator (revised 8/22/14) it stated that position was responsible for activities that were "individualized to the interests of the individual residents" and included "supervision of all activities within the facility including ...swing beds ..." It also stated that the Activities Coordinator "Plans and monitors leisure activities for recreational and therapeutic purposes ..." and item 6 stated, "Documents on all resident charts ..."

2. On 3/18/2015 at 8:45 AM Surveyor #1 interviewed the hospital Activities Coordinator (Staff Member #3). S/he stated that s/he reviewed assessments on swing bed residents on the "Activity Profile/Screening" form that was completed by the Activities Assistant. However, no staff person developed an individualized plan or monitored the delivery of leisure activities to swing bed residents. Additionally, the hospital Activities Coordinator did not ensure that the medical record indicated whether or not those services were delivered to swing bed residents.

3. In review of the medical records of 3 of 3 swing bed Patients #1, #2 and #3, the records indicated that the form titled "Activity Profile/Screening" was completed. However, the record did not indicate that a leisure activities plans were developed or that leisure activities services were delivered to the residents. The respective lengths of stay for the residents were 43 days, 35 days and 15 days.